RESUMO
In the United States, >100 000 patients are waiting for a kidney transplant. Given the paucity of organs available for transplant, expansion of eligibility criteria for deceased donation is of substantial interest. Sickle cell disease (SCD) is viewed as a contraindication to kidney donation, perhaps because SCD substantially alters renal structure and function and thus has the potential to adversely affect multiple physiological processes of the kidney. To our knowledge, transplantation from a donor with SCD has never been described in the literature. In this paper, we report the successful transplantation of two kidneys from a 37-year-old woman with SCD who died from an intracranial hemorrhage. Nearly 4 mo after transplant, both recipients are doing well and are off dialysis. The extent to which kidneys from donors with SCD can be safely transplanted with acceptable outcomes is unknown; however, this report should provide support for the careful expansion of kidneys from donors with SCD without evidence of renal dysfunction and with normal tissue architecture on preimplantation biopsies.
Assuntos
Anemia Falciforme , Falência Renal Crônica/cirurgia , Transplante de Rim/métodos , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/métodos , Adulto , Cadáver , Feminino , Humanos , Pessoa de Meia-Idade , Nefrectomia , PrognósticoRESUMO
The direct-acting antivirals (DAAs) constitute an emerging group of small molecule inhibitors that effectively treat hepatitis C virus (HCV) infection, a common comorbidity in end-stage renal disease patients. To date, there are no data to guide use of these agents in kidney transplant patients. The authors collected data from 20 consecutive kidney recipients treated with interferon-free treatment regimens for HCV at their center: 88% were infected with genotype 1; 50% had biopsy-proved advanced hepatic fibrosis on their most recent liver biopsy preceding treatment (Metavir stage 3 fibrosis [F3] or F4); and 60% had failed treatment pretransplantation with interferon-based therapy. DAA treatment was initiated a median of 888 days after renal transplantation. All patients cleared the virus while on therapy, and 100% have achieved a sustained virologic response at 12 weeks after completion of DAA therapy. The most commonly used regimen was sofosbuvir 400 mg daily in combination with simeprevir 150 mg daily. However, four different treatment approaches were used, with comparable results. The DAAs were well tolerated, and less than half of patients required calcineurin inhibitor dose adjustment during treatment. Eradication of HCV infection with DAAs is feasible after kidney transplantation with few treatment-related side effects.
Assuntos
Antivirais/uso terapêutico , Sobrevivência de Enxerto/efeitos dos fármacos , Hepacivirus/efeitos dos fármacos , Hepatite C/tratamento farmacológico , Falência Renal Crônica/complicações , Transplante de Rim/efeitos adversos , Idoso , DNA Viral/genética , Feminino , Seguimentos , Taxa de Filtração Glomerular , Hepacivirus/genética , Hepatite C/virologia , Humanos , Falência Renal Crônica/cirurgia , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Prognóstico , Fatores de Risco , Carga ViralRESUMO
Organ transplantation is an acceptable option for human immunodeficiency virus (HIV)-infected patients with end-stage kidney or liver disease. With worse outcomes on the waitlist, HIV-infected patients may actually be disproportionately affected by the organ shortage in the United States. One potential solution is the use of HIV-infected deceased donors (HIVDD), recently legalized by the HIV Organ Policy Equity (HOPE) Act. This is the first analysis of patient-specific data from potential HIVDD, retrospectively examining charts of HIV-infected patients dying in care at six HIV clinics in Philadelphia, Pennsylvania from January 1, 2009 to June 30, 2014. Our data suggest that there are four to five potential HIVDD dying in Philadelphia annually who might yield two to three kidneys and three to five livers for transplant. Extrapolated nationally, this would approximate 356 potential HIVDD yielding 192 kidneys and 247 livers annually. However, several donor risk indices raise concerns about the quality of kidneys that could be recovered from HIVDD as a result of older donor age and comorbidities. On the other hand, livers from these potential HIVDD are of similar quality to HIV-negative donors dying locally, although there is a high prevalence of positive hepatitis C antibody.
Assuntos
Infecções por HIV/mortalidade , Obtenção de Tecidos e Órgãos , População Urbana , Feminino , Infecções por HIV/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados UnidosRESUMO
Over the past two decades, live kidney donation by older individuals (≥55 years) has become more common. Given the strong associations of older age with cardiovascular disease (CVD), nephrectomy could make older donors vulnerable to death and cardiovascular events. We performed a cohort study among older live kidney donors who were matched to healthy older individuals in the Health and Retirement Study. The primary outcome was mortality ascertained through national death registries. Secondary outcomes ascertained among pairs with Medicare coverage included death or CVD ascertained through Medicare claims data. During the period from 1996 to 2006, there were 5717 older donors in the United States. We matched 3368 donors 1:1 to older healthy nondonors. Among donors and matched pairs, the mean age was 59 years; 41% were male and 7% were black race. In median follow-up of 7.8 years, mortality was not different between donors and matched pairs (p = 0.21). Among donors with Medicare, the combined outcome of death/CVD (p = 0.70) was also not different between donors and nondonors. In summary, carefully selected older kidney donors do not face a higher risk of death or CVD. These findings should be provided to older individuals considering live kidney donation.
Assuntos
Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/mortalidade , Transplante de Rim , Doadores Vivos , Insuficiência Renal/cirurgia , Fatores Etários , Idoso , Feminino , Seguimentos , Humanos , Estudos Longitudinais , Masculino , Medicare , Pessoa de Meia-Idade , Nefrectomia , Qualidade de Vida , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
An exploratory, post hoc analysis was performed using data from a prospective, multicenter, open-label, randomized, two-period (14 d per period), two-sequence, crossover, steady-state pharmacokinetic study comparing generic tacrolimus (Sandoz) vs. reference tacrolimus in stable renal transplant patients receiving their pre-study twice-daily dose. Pharmacokinetic parameters were compared in 68 patients according to gender, African American ethnicity, the presence or absence of diabetes, and use of steroids. The ratios of tacrolimus AUC0-12 h , Cmax , and C12 with generic vs. reference tacrolimus were calculated using the geometric mean (GM) of dose-normalized values at days 14 and 28. Mean (SD) tacrolimus dose at baseline was 5.7 (4.2) mg/d. There were no consistent differences in dose-normalized AUC0-12 h , C12 , Cmax, or tmax between the generic and reference preparations within subpopulations. The 90% confidence intervals (CI) for the ratios of dose-normalized AUC0-12 h and C12 with generic vs. reference tacrolimus were within 80-125% for all subpopulations, as were 90% CIs for Cmax other than for females, African Americans, and non-diabetics, which is not unexpected given the wide variability of tacrolimus Cmax and the small subpopulation sizes. These exploratory results suggest that this generic tacrolimus preparation would be expected to offer comparable bioavailability to the reference drug in these patient subpopulations.
Assuntos
Medicamentos Genéricos , Imunossupressores/farmacocinética , Transplante de Rim , Rim/metabolismo , Tacrolimo/farmacocinética , Área Sob a Curva , Estudos Cross-Over , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Equivalência Terapêutica , Distribuição TecidualRESUMO
Early rehospitalization after kidney transplantation (KT) is common and may predict future adverse outcomes. Previous studies using claims data have been limited in identifying preventable rehospitalizations. We assembled a cohort of 753 adults at our institution undergoing KT from January 1, 2003 to December 31, 2007. Two physicians independently reviewed medical records of 237 patients (32%) with early rehospitalization and identified (1) primary reason for and (2) preventability of rehospitalization. Mortality and graft failure were ascertained through linkage to the Scientific Registry of Transplant Recipients. Leading reasons for rehospitalization included surgical complications (15%), rejection (14%), volume shifts (11%) and systemic and surgical wound infections (11% and 2.5%). Reviewer agreement on primary reason (85% of cases) was strong (kappa = 0.78). Only 19 rehospitalizations (8%) met preventability criteria. Using logistic regression, weekend discharge (odds ratio [OR] 1.59, p = 0.01), waitlist time (OR 1.10, p = 0.04) and longer initial length of stay (OR 1.42, p = 0.03) were associated with early rehospitalization. Using Cox regression, early rehospitalization was associated with mortality (hazard ratio [HR] 1.55; p = 0.03) but not graft loss (HR 1.33; p = 0.09). Early rehospitalization has diverse causes and presents challenges as a quality metric after KT. These results should be validated prospectively at multiple centers to identify vulnerable patients and modifiable processes-of-care.
Assuntos
Falência Renal Crônica/terapia , Transplante de Rim/efeitos adversos , Readmissão do Paciente , Adolescente , Adulto , Estudos de Coortes , Feminino , Rejeição de Enxerto , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Complicações Pós-Operatórias , Prognóstico , Modelos de Riscos Proporcionais , Sistema de Registros , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Infecção dos Ferimentos , Adulto JovemAssuntos
Vírus BK/genética , Genótipo , Infecções por Polyomavirus/virologia , Viremia/virologia , Humanos , Terapia de Imunossupressão/métodos , Transplante de Rim/efeitos adversos , Transplante de Rim/métodos , Infecções por Polyomavirus/complicações , Reação em Cadeia da Polimerase em Tempo Real , Insuficiência Renal/complicações , Reprodutibilidade dos Testes , Viremia/complicaçõesRESUMO
En el año de 1989 la Academia de Ciencias de Nueva York organizó el simposio titulado "Bajo el Volcán. La investigación biomédica y el Tercer Mundo" en el que participaron expertos de diferentes disciplinas y países: biólogos moleculares, epidemiólogos, expertos en economía de la salud, investigadores clínicos, entre otros. La conferencia estuvo orientada hacia el análisis del impacto futuro de las nuevas tecnologías para la investigación biomédica sobre la provisión de recursos para la salud y el control de varias enfermedades que aquejan a los pobladores del tercer mundo: la meta a corto o largo plazo es elevar su calidad de vida y de salud. La presente publicación reúne y resume los trabajos y las contribuciones que fueron presentadas: 1) Enfermedades: problema en el tercer mundo; 2) Investigación para la salud en Africa: prioridades, promesa y desempeño; 3) Perspectivas sobre la investigación y las enfermedades desde los trópicos: un punto de vista asiático; 4) La investigación biomédica en América Latina: viejos retos, nuevas oportunidades; 5) Programa ampliado de inmunización de la Organización Mundial de la Salud: progreso e informe de evaluación; 6) El plan de acción de la Organización Mundial de la Salud para la erradicación global de la poliomielitis en el año 2000; 7) Vectores de expresión del virus de vaccinia; 8) Estrategias para la modificación genética de los parásitos; 9) Estrategias para el control de la malaria: realidades, magia y ciencia; 10) Variación antigénica en relación con vacunas; 11) Estrategias para el desarrollo de vacunas: esquistosomiasis; 12) Estrategias para el desarrollo de vacunas para la fiebre tifoidea, la shigelosis y el cólera; 13) Nuevas estrategias para el desarrollo del bacilo de calmette-guérin como un vehículo multivacunal para la lepra y la tuberculosis; 14) Aspectos moleculares de theileria parva y enfoques para el desarrollo de vacunas para animales; 15) Leishmaniasis y malaria: sondas de DNA para el diagnóstico y el análisis epidemiológico; 16) Problemas epidemiológicos y perspectivas; 17) Las ciencias sociales y la mejoría de los programas de control de enfermedades tropicales; 18) Inversiones en la mujeres, el desarrollo económico y las mejoras en la salud de los países de bajos ingresos; 19) Expectativas de avances científicos redituables; 20) Papel de la Organización Mundial de la Salud en la investigación de las enfermedades tropicales; 21) Biotecnología y el Tercer Mundo: estrategias de desarrollo en Cuba