RESUMEN
BACKGROUND: In Human immunodeficiency virus (HIV)-positive patients undergoing kidney transplantation, outcomes and immunosuppression (IS) protocol are not yet established due to infectious and neoplastic risks as well as to pharmacokinetic interactions with antiretroviral therapy (TARV). METHODS: We report a retrospective, 1-center study on 18 HIV+ patients undergoing, between October 2007 and September 2015, kidney transplantation (13 cases) or combined kidney-liver transplant (5 cases). Inclusion criteria for transplant were based on the Italian National Transplant Center protocol. IS regimen was based on quick tapering of steroids and the use of mTOR inhibitors (mTORi) with low dose of calcineurin inhibitors (CNI). In the early post-transplant period, TARV was based on enfuvirtide, raltegravir, plus 1 or more nucleoside analogues. RESULTS: In a mean follow-up of 3.1 years, patient survival rate at 1 and 3 years was, respectively, 86.6% and 84.6%, whereas graft survival was 81.2% and 78.6%. Cumulative rejection rate was 20.0% and 26.6% (1- and 3-year results). Median eGFR (MDRD) was 58.8 mL/min and 51.9 mL/min at 1 and 3 years. We had 9 cases of clinically relevant infections (2 Pneumocystis jirovecii pneumonia, 1 pulmonary aspergillosis, 2 severe sepsis, and 4 HCV reactivation) as well as 1 case (5.5%) of HIV reactivation. CONCLUSIONS: IS therapy based on mTORi and low CNI dose ensures good graft survival, low rate of acute rejection, limited drug toxicity, and control of HIV disease. TARV has no significant interaction with IS therapy.
Asunto(s)
Infecciones por VIH/complicaciones , Fallo Renal Crónico/cirugía , Trasplante de Riñón , Adulto , Antivirales/uso terapéutico , Inhibidores de la Calcineurina/uso terapéutico , Femenino , Supervivencia de Injerto , Infecciones por VIH/tratamiento farmacológico , Humanos , Terapia de Inmunosupresión , Inmunosupresores/uso terapéutico , Fallo Renal Crónico/virología , Trasplante de Hígado , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Serina-Treonina Quinasas TOR/antagonistas & inhibidores , Resultado del TratamientoRESUMEN
Although human immunodeficiency virus (HIV) infection has been a major global health problem for almost 3 decades, with the introduction of highly active antiretroviral therapy in 1996 and effective prophylaxis and management of opportunistic infections, mortality from acquired immunodeficiency syndrome has decreased markedly. In developed countries, this condition is now being treated as a chronic condition. As a result, rates of morbidity and mortality from other medical conditions leading to end-stage liver, kidney, and heart disease are steadily increasing in individuals with HIV. Because the definitive treatment for end-stage organ failure is transplantation, the demand for it has increased among HIV-infected patients. For these reasons, many transplant centers have eliminated HIV infection as a contraindication to transplantation, as a result of better patient management and demand.
Asunto(s)
Infecciones por VIH/complicaciones , Trasplante de Riñón , Trasplante de Hígado , Adulto , Fármacos Anti-VIH/administración & dosificación , Fármacos Anti-VIH/uso terapéutico , Terapia Antirretroviral Altamente Activa , Infecciones por VIH/tratamiento farmacológico , Humanos , Fallo Hepático/terapia , Masculino , Persona de Mediana Edad , Selección de Paciente , Insuficiencia Renal/terapia , Resultado del TratamientoRESUMEN
Marginal donors (advanced age, comorbidities, and so on) provide an increasing contribution to the kidneys used to alleviate the relative organ shortage. We describe the evaluation process and clinical outcome of two kidneys with hemosiderosis used as a double graft. The donor was a 59-year-old hypertensive man, known to have a mechanical mitral valve, who died from a cerebral hemorrhage, with a normal serum creatinine (SCr) and kidneys with normal appearances at sonography. A protocol donor biopsy showed a Karpinsky score of 5 for both kidneys. A double graft was therefore scheduled. The recipient was a 59-year-old man, on dialysis because of chronic glomerulonephritis. HLA match was incompatibility 4/6; immunosuppression was based on steroids, cyclosporine, and mycophenolate mofetil with basiliximab as induction therapy. The grafts showed delayed function with dialysis treatments performed from postoperative day (POD) 1. On POD 2, a magnetic resonance imaging (MRI) study showed the typical appearance of siderosis. Pearl's staining performed on a protocol biopsy confirmed the presence of widespread iron deposits. On POD 5, a recipient renal biopsy showed a superimposed severe acute tubular necrosis. Renal function recovered slowly; SCr at discharge on POD 22 was still 4.2 mg/dL. Two months later, the SCr was 2.2 mg/dL. A second MRI performed at 3 years and 6 months after transplantation confirmed a progressive removal of iron overload while the patient had stable renal function (glomerular filtration rate) of 33 mL/min and SCr: 2.3 mg/dL. We concluded that donors with hemosiderosis should be treated as marginal donors and may be grafted based on a pretransplant biopsy.
Asunto(s)
Hemosiderosis/patología , Trasplante de Riñón/fisiología , Cadáver , Humanos , Masculino , Persona de Mediana Edad , Donantes de Tejidos , Resultado del TratamientoRESUMEN
Ureteral catheters represent essential devices in the management of upper urinary tract obstruction; complications are unusual. Knotting of the stent at its proximal coiled end is a very rare but potentially dangerous event that should be promptly recognized.
Asunto(s)
Hidronefrosis/etiología , Hidronefrosis/terapia , Cálculos Renales/complicaciones , Stents/efectos adversos , Uréter , Falla de Equipo , Humanos , Cálculos Renales/terapia , Litotricia , Masculino , Persona de Mediana EdadRESUMEN
Androgen deprivation based on hormone manipulation is the treatment of choice in advanced prostatic cancer. The unequivocal role of adrenal androgens in the growth of prostatic cancer after medical or surgical castration requires a new logical approach (complete androgen blockade) in the treatment of advanced prostate cancer. One hundred and fifty patients with biopsy-proven advanced prostatic cancer were randomized into two groups. One group (74 patients) received leuprolide + flutamide (complete androgen blockade); the second group (76 patients) received only leuprolide and, during the first 3 weeks of treatment, cyproterone acetate (150 mg/day) to prevent flare-up phenomena. The aim of the study was to evaluate the differences between the two groups on overall survival and time to progression (log-rank test). One hundred and twenty-five patients were evaluable, 62 in the leuprolide-only group and 63 in the leuprolide + flutamide group. Median duration of follow-up was 102 weeks. No statistical difference between the two groups was observed in overall survival, in time to disease progression, and in time to treatment failure. In the combination (leuprolide + flutamide) treatment group, a positive trend for overall survival and in time to progression was observed in a subgroup of patients with good performance status and no bone metastases. We observed mild gastrointestinal toxicity (diarrhea, nausea) in the group treated with leuprolide + flutamide. The aim of this study was to compare the effectiveness of total androgen withdrawal with medical testicular suppression in advanced prostatic cancer. No significant statistical difference was observed between the two groups in overall survival and in time to progression, but probably too few patients were enrolled in each treatment arm to give a statistical interpretation of our results. We conclude that there is a positive trend in the combination treatment arm in patients with good prognostic factors.
Asunto(s)
Antagonistas de Andrógenos/uso terapéutico , Antineoplásicos Hormonales/uso terapéutico , Flutamida/uso terapéutico , Leuprolida/uso terapéutico , Neoplasias de la Próstata/tratamiento farmacológico , Distribución por Edad , Anciano , Anciano de 80 o más Años , Antagonistas de Andrógenos/administración & dosificación , Antineoplásicos Hormonales/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Acetato de Ciproterona/administración & dosificación , Acetato de Ciproterona/uso terapéutico , Flutamida/administración & dosificación , Estudios de Seguimiento , Humanos , Leuprolida/administración & dosificación , Masculino , Persona de Mediana Edad , Neoplasias de la Próstata/mortalidad , Tasa de SupervivenciaRESUMEN
The therapeutic activity of a single dose of 150 mg of tobramycin, parenteral administration, was studied in the prophylaxis of urinary tract infection (UTI) postoperative or postendoscopic. This study incorporated 85 patients of both sexes ranging in age from 18-91 years; 20 had had previous UTI. Duration of therapy ranged from 5 to 15 days and was determined by clinical response; 70 of 85 patients clinically observed achieved excellent results, 10 good and 5 moderate. In 5 cases persistent asymptomatic bacteriuria recurred, indicating incomplete eradication of the microorganism. Results of data showed the clinical efficacy, safety and tolerance of tobramycin, in one dose only, in the prophylaxis of UTI posturological surgery, as well as its easy administration and limited cost.