RESUMEN
OBJECTIVE: Renal transplantation is the most successful therapy to improve survival and quality of life for patients with end-stage renal disease. Living donors have been used as an alternative to reduce the stay on the waiting list. Laparoscopic living donor nephrectomy has become the standard procedure for renal transplantation. Minimally invasive surgery involves less postoperative pain with less analgesic requirements allowing shorter hospital stay for the donor. MATERIAL AND METHODS: We retrospectively analyzed demographic and intraoperative data and surgical complications for 46 patients who underwent laparoscopic living donor nephrectomy between March 2001 and March 2011. RESULTS: Mean donor age was 41 years. Mean operative time was 170 ± 45 minutes. The average cold ischemic time was 40 minutes and warm ischemic time was 26 minutes. Twenty-one patients were donors for pediatric receptors. Fourty patients underwent left laparoscopic nephrectomy, the other 6 patients underwent right laparoscopic nephrectomy due to vascular anatomic variant. Right laparoscopic nephrectomy was converted in 1 case (2.2%) due to renal vein laceration without donor morbidity and without compromise of graft function. Renal function at the second day post donor nephrectomy was measured using serum creatinine averaged 1.2 mg/dL with a mean increase of 0.4 mg/dL from baseline, with normalization after 30 days. No patient required blood transfusion, and there were no immediate surgical complications, infections, or mortality. One patient developed an incisional hernia in relation to the site of kidney removal. The mean hospital stay was 5 ± 1 days. CONCLUSIONS: Laparoscopic nephrectomy in our experience is a safe technique without postoperative morbidity or mortality. It is associated with low levels of pain, early discharge and early return to physical activity and work, good sense of aesthetic results, and long-term graft function comparable to traditional nephrectomy and cadaveric grafts.
Asunto(s)
Trasplante de Riñón/métodos , Laparoscopía , Donadores Vivos , Nefrectomía/métodos , Adulto , Biomarcadores/sangre , Chile , Isquemia Fría , Creatinina/sangre , Femenino , Humanos , Trasplante de Riñón/efectos adversos , Laparoscopía/efectos adversos , Tiempo de Internación , Masculino , Nefrectomía/efectos adversos , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Isquemia TibiaRESUMEN
Low-risk renal transplant recipients treated with standard immunosuppressive therapy including interleukin-2 receptor (IL-2R) antagonist show a low incidence of early rejection episodes but few reports have examined the incidence and severity of late rejection processes. This study evaluated retrospectively cellular and antibody-mediated rejection (AMR) among 42 recipients selected because they showed low panel-reactive-antibodies, short cold ischemia time, no delayed graft function, and therapy including basiliximab (Simulect) induction. The mean observation time was 6.6 years. Sixty-seven percent of donors were deceased. Ten-year patient and death-censored graft survivals were 81% and 78%, respectively. Seven patients lost their kidneys due to nonimmunologic events. The seven recipients who experienced cellular rejection episodes during the first posttransplant year had them reversed with steroids. Five patients displayed late acute AMR causing functional deterioration in four cases including 1 graft loss. De novo sensitization occurred in 48% of recipients including patients without clinical rejection. In conclusion, long-term follow-up of kidney transplant recipients selected by a low immunologic risk showed a persistent risk of de novo sensitization evolving to acute AMR in 11% of cases. Although immunologic events were related to late immunosuppressive reduction, most graft losses were due to nonimmunologic factors.
Asunto(s)
Anticuerpos Monoclonales/administración & dosificación , Rechazo de Injerto/prevención & control , Supervivencia de Injerto/efectos de los fármacos , Inmunidad Humoral/efectos de los fármacos , Inmunosupresores/administración & dosificación , Trasplante de Riñón , Receptores de Interleucina-2/antagonistas & inhibidores , Proteínas Recombinantes de Fusión/administración & dosificación , Enfermedad Aguda , Adulto , Basiliximab , Chile , Enfermedades Transmisibles/etiología , Femenino , Rechazo de Injerto/inmunología , Rechazo de Injerto/mortalidad , Antígenos HLA/inmunología , Humanos , Isoanticuerpos/sangre , Estimación de Kaplan-Meier , Trasplante de Riñón/efectos adversos , Trasplante de Riñón/inmunología , Trasplante de Riñón/mortalidad , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
Alemtuzumab (ALT), a humanized monoclonal anti-CD52 antibody, was introduced in solid organ transplantation as an induction agent. ALT associated with anticalcineurins has provided a low incidence of acute rejection episodes (ARE) and potential tolerogenic properties. We analyzed the clinical outcomes and effects on peripheral Treg of renal transplant recipients treated with ALT. Six-month data on kidney alone or kidney combined with pancreas or liver patients treated with ALT and tacrolimus (TAC) in standard doses were compared with those on renal transplant recipients of similar demography who were not treated with ALT. We evaluated patient and graft survivals, ARE incidence, hematological parameters, renal function, adverse events, and CD4+CD25+FoxP3+ T cells in peripheral blood. Demographics of recipients, donors, and transplants were similar in both groups. Mean HLA mismatch was slightly greater among ALT-treated patients (3.5 vs 2.5). No combined transplantation was performed in the ALT-untreated group. Patient and graft survivals were 100% without rejection or serious infections in both groups. ALT-treated recipients showed anemia and leukopenia in 3 patients as well as severe lymphopenia in 5 recipients, who partially recovered on day 90. Final mean plasma creatinine was 1.4 mg/dL, while calculated creatinine clearance was approximately 65 mL/min in both groups. Mean Treg cell percentage was higher among ALT-treated recipients than the comparative group or healthy controls (P < .05). In conclusion, renal transplantation results obtained using ALT with rigorous immunosuppressive therapy were excellent; serious adverse events and acute rejection were absent. The effect of the increased proportion of Treg cells must be evaluated with longer observation.
Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Anticuerpos Antineoplásicos/uso terapéutico , Rechazo de Injerto/prevención & control , Inmunosupresores/uso terapéutico , Trasplante de Riñón/inmunología , Linfocitos T Reguladores/inmunología , Adulto , Alemtuzumab , Anticuerpos Monoclonales Humanizados , Antígenos CD/inmunología , Antígenos de Neoplasias/inmunología , Autoanticuerpos/sangre , Recuento de Linfocito CD4 , Antígeno CD52 , Femenino , Glicoproteínas/inmunología , Rechazo de Injerto/epidemiología , Supervivencia de Injerto/efectos de los fármacos , Supervivencia de Injerto/inmunología , Antígenos HLA/inmunología , Humanos , Enfermedades Renales/clasificación , Enfermedades Renales/cirugía , Trasplante de Hígado/inmunología , Masculino , Persona de Mediana Edad , Trasplante de Páncreas/inmunología , Tacrolimus/uso terapéutico , Resultado del TratamientoRESUMEN
Between 1989 and 2002, 178 renal transplants were performed in 168 pediatric patients in Chile. The mean age was 10.9 +/- 3.7 years (range 1 to 17.9). End-state renal disease etiologies were: congenital renal hypoplasia/dysplasia, chronic glomerulonephritis, and reflux nephropathy. Seventy received a graft from a living donor (LD), and 108 from a cadaveric donor (CD). Only 9% received antibody induction. Acute rejection episodes were reported in 76 patients: 38% in LD recipients and 48% in CD recipients (P = NS). One-, 3-, and 5-year graft survivals were 88%, 84%, and 76%, respectively, for LD and 86%, 79%, and 68% for CD recipients. Actuarial graft survival was significantly better among those patients with serum creatinine < 1 mg/dL at 1 year posttransplant compared with those with creatinine > 1 mg/dL (P < .05). The graft survival rate has improved from the first period (1989 to 1996) to the second period (1997 to 2002); (P = .05). Patient survival rates at 1, 3, and 5 years were 98%, 98%, and 98%, respectively, for LD, and 95%, 94%, and 94% for CD. Global height/age Z-score decreased from -0.7 at birth to -1.5 when dialysis started, and to -2.4 at the time of transplantation. The Z-score height/age at 1, 3, and 5 years posttransplantation was -2.25, -2.24, and -2.5. No significant differences were observed in transplant outcomes comparing patients younger than 7 years with those older ones. In conclusion, pediatric renal transplant has been performed in Chile with acceptable morbidity. The patient and graft survivals are similar to the reported international experience. In the last period there was a significant improvement in graft survival.
Asunto(s)
Trasplante de Hígado/fisiología , Adolescente , Cadáver , Niño , Preescolar , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Lactante , Enfermedades Renales/cirugía , Trasplante de Hígado/mortalidad , Donadores Vivos , Masculino , Reoperación , Estudios Retrospectivos , Análisis de Supervivencia , Factores de Tiempo , Donantes de TejidosRESUMEN
Desde septiembre de 1981 a enero de 1995 se han trasplantado 52 niiíos, 22 hombres (42.3 por ciento) y 30 mujeres (57.7 por ciento), cuyas edades fluctúan entre 4 y 15 años (edad promedio 12.1 años). Complicaciones de tipo quirúrgico encontramos en 6 pacientes, la mayoría de ellas de tipo vascular y urológico, sólo una de ellas llevó a la pérdida del injerto. A los 2 meses de seguimiento 51 pacientes se encuentran vivos, 50 de ellos con el injerto funcionando con un promedio de creatinina plasmática de 1.0 mg/dl. A los 5 aiíos la sobrevida actuarial para los pacientes es de un 90 por ciento y para los injertos de un 50 por ciento. Al comparar este grupo de pacientes con un grupo seleccionado de trasplantes en edad adulta, nos encontramos que sus complicaciones son similares, al igual que la sobrevida de pacientes, aunque la sobrevida actuarial de injertos es más pobre. Las diferencias principales de ambos grupos se encuentran en la etiología de origen de la Insuficiencia renal crónica, donde en el grupo pediátrico las de tipo urológico alcanzan al 36 por ciento y en el grupo adulto sólo al 5 por ciento y respecto a la relación donante receptor, en que recibieron un órgano de uno de sus padres 42 (80.7 por ciento) de los niños y sólo 10 (19,2 por ciento) de los adultos, en cambio estos últimos lo recibieron de un hermano en un 67.3 por ciento de los casos lo que conlleve a ser un grupo de mejor histocompatibilidad. De hecho el promedio de crisis de rechazo agudo fue de 2.3 en niños y 1.5 para grupo de pacientes adultos
Asunto(s)
Humanos , Masculino , Femenino , Preescolar , Adolescente , Insuficiencia Renal Crónica/cirugía , Trasplante de Riñón/efectos adversos , Factores de Edad , Rechazo de Injerto , Supervivencia de Injerto , Histocompatibilidad , Terapia de Inmunosupresión , Insuficiencia Renal Crónica/etiología , Trasplante de Riñón/estadística & datos numéricosRESUMEN
BACKGROUND: Renal transplantation can be done in patients with neurogenic bladder and clean intermittent self catheterization maintains renal function AIM: To retrospective assess the results of renal transplantation in patients with neurogenic bladder. PATIENTS AND METHODS: The medical records of seven patients aged 10 to 22 years old (3 female) followed during 7 to 32 months were reviewed. All patients had urinary tract infection, prior to transplantation, were instructed on self catheterization and received tri-associated immunosuppression. RESULTS: Grafts came from alive related donors in 5 patients and from cadavers in two. Prior to transplantation, three patients were subjected to nephrectomy and three to bladder enlargement, leaving a pigtail catheter. After transplantation, one lymphocele was drained, one uretherostomy due to an impacted lithiasis and one nephrectomy plus vesical enlargement due to intravesical pressures over 40 cm H2O, were done. One uretheral stricture was treated with dilatation. Seven episodes of pyelonephritis, 19 urinary tract infections and 77 asymptomatic bacteriurias were documented. Serum creatinine at the end of follow up ranged from 0.7 to 2.1 mg/dl. There were 0.7 acute rejection episodes per patient and all grafts survived. CONCLUSIONS: Renal transplantation in patients with neurogenic bladder is feasible, performing a vesical enlargement. There is however a high frequency of infectious episodes.
Asunto(s)
Trasplante de Riñón/rehabilitación , Complicaciones Posoperatorias , Pielonefritis , Vejiga Urinaria Neurogénica/cirugía , Cateterismo Urinario/métodos , Enfermedad Aguda , Adolescente , Adulto , Niño , Creatinina/sangre , Femenino , Estudios de Seguimiento , Humanos , Inmunosupresores/uso terapéutico , Masculino , Cuidados Posoperatorios , Estudios Retrospectivos , Vejiga Urinaria Neurogénica/tratamiento farmacológicoRESUMEN
We report two insulin dependent diabetic patients with a past history of 21 and 30 years complicated with retinopathy, neuropathy and nephropathy with arterial hypertension and kidney failure. Simultaneous pancreas-kidney transplantation was done 8 and 18 months after starting hemodialysis, performing a double intraperitoneal implant with pancreato-duodeno-vesical anastomosis and contralateral kidney grafting with uretero vesical anastomosis using antireflux techniques. In the second case, a second kidney transplant from the same donor was needed, due to a thrombosis of renal vein. There was one rejection episode in each case but renal or pancreatic function was not impaired. Other observed complications were metabolic acidosis and hyperkalemia due to urine loss of bicarbonate, moderate arterial hypertension and bacterial and fungal infections. There was a graft dysfunction due to the association of vancomycin and cyclosporin. In conclusion, in the two presented patients, simultaneous pancreas-kidney transplantations were successful and they remain free of insulin or dialytic therapy 4 and 9 months after the operation.