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Santos DW, Proença H, Medina-Pestana JO, Rangel ÉB. Fungal sinusitis in simultaneous pancreas-kidney transplant. J Clin Pathol 2019; 72:720. [PMID: 31358535 DOI: 10.1136/jclinpath-2018-205258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 05/28/2018] [Accepted: 06/26/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Daniel W Santos
- Nephrology Department, Federal University of São Paulo/Hospital do Rim e Hipertensão, Sao Paulo, SP, Brazil
| | - Henrique Proença
- Nephrology Department, Federal University of São Paulo/Hospital do Rim e Hipertensão, Sao Paulo, SP, Brazil
| | - Jose O Medina-Pestana
- Nephrology Department, Federal University of São Paulo/Hospital do Rim e Hipertensão, Sao Paulo, SP, Brazil
| | - Érika B Rangel
- Nephrology Department, Federal University of São Paulo/Hospital do Rim e Hipertensão, Sao Paulo, SP, Brazil.,Instituto de Ensino e Pesquisa, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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Hiramoto LL, Tedesco-Silva H, Medina-Pestana JO, Felipe CR. Tolerability of mycophenolate sodium in renal transplant recipients. Int J Clin Pharm 2018; 40:1548-1558. [DOI: 10.1007/s11096-018-0727-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 09/11/2018] [Indexed: 11/25/2022]
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Mine KL, Tedesco-Silva H, Mourão TB, Campos EF, Salzedas LA, Aguiar B, Felipe CR, Medina-Pestana JO, Gerbase-DeLima M. Heightened expression of HLA-DQB1 and HLA-DQB2 in pre-implantation biopsies predicts poor late kidney graft function. Hum Immunol 2018; 79:594-601. [DOI: 10.1016/j.humimm.2018.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/02/2018] [Accepted: 05/16/2018] [Indexed: 10/16/2022]
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Ruppel P, Felipe CR, Medina-Pestana JO, Hiramoto LL, Viana L, Ferreira A, Aguiar W, Ivani M, Bessa A, Cristelli M, Gaspar M, Tedesco-Silva H. The influence of clinical, environmental, and socioeconomic factors on five-year patient survival after kidney transplantation. ACTA ACUST UNITED AC 2018; 40:151-161. [PMID: 29927458 PMCID: PMC6533991 DOI: 10.1590/2175-8239-jbn-3865] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 09/04/2017] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The risk of death after kidney transplant is associated with the age of the recipient, presence of comorbidities, socioeconomic status, local environmental characteristics and access to health care. OBJECTIVE To investigate the causes and risk factors associated with death during the first 5 years after kidney transplantation. METHODS This was a single-center, retrospective, matched case-control study. RESULTS Using a consecutive cohort of 1,873 kidney transplant recipients from January 1st 2007 to December 31st 2009, there were 162 deaths (case group), corresponding to 5-year patient survival of 91.4%. Of these deaths, 25% occurred during the first 3 months after transplant. The most prevalent cause of death was infectious (53%) followed by cardiovascular (24%). Risk factors associated with death were history of diabetes, dialysis type and time, unemployment, delayed graft function, number of visits to center, number of hospitalizations, and duration of hospital stay. After multivariate analysis, only time on dialysis, number of visits to center, and days in hospital were still associated with death. Patients who died had a non-significant higher number of treated acute rejection episodes (38% vs. 29%, p = 0.078), higher mean number of adverse events per patient (5.1 ± 3.8 vs. 3.8 ± 2.9, p = 0.194), and lower mean eGFR at 3 months (50.8 ± 25.1 vs. 56.7 ± 20.7, p = 0.137) and 48 months (45.9 ± 23.8 vs. 58.5 ± 20.2, p = 0.368). CONCLUSION This analysis confirmed that in this population, infection is the leading cause of mortality over the first 5 years after kidney transplantation. Several demographic and socioeconomic risk factors were associated with death, most of which are not readily modifiable.
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Affiliation(s)
| | | | | | | | - Laila Viana
- Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | | | - Wilson Aguiar
- Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Mayara Ivani
- Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Adrieli Bessa
- Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | | | - Melissa Gaspar
- Universidade Federal de São Paulo, São Paulo, SP, Brasil
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Neves Neto JF, Palomino Z, Mizuno Watanabe IK, Aguiar WF, Medina-Pestana JO, Soler R. Pretransplant defunctionalized bladder-overrated condition? Neurourol Urodyn 2018; 37:1559-1566. [PMID: 29357104 DOI: 10.1002/nau.23495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 12/19/2017] [Indexed: 11/11/2022]
Abstract
AIMS The objective of this study was to evaluate the expression of bladder receptors in patients with defunctionalized bladder (DB) and to assess voiding behavior after refunctionalization. METHODS A total of 68 pretransplant patients were divided in two groups: DB (diuresis <300 mL/24 h; n = 33) and NDB (non-DB; diuresis ≥300 mL/24 h; n = 35). A sample of mucosa and detrusor at the site of the future ureteral implantation was collected. The following receptors were assessed by real-time polymerase chain reaction (qRT-PCR): M2 , M3 , α1D , β3 , P2X2 , P2X3 , TRPV1, TRPV4, TRPA1, and TRPM8. At 3, 6, and 12 months after transplant patients answered IPSS and ICIQ-OAB questionnaires and filled a 3-day 24 h frequency/volume chart (FVC) at 6 and 12 months. RESULTS The expression of all receptors in the mucosa and in the detrusor was similar in both groups, except from α1D , which was overexpressed in the detrusor of DB relatively to NDB group. ICIQ-OAB symptom score was similar between the groups at 3, 6, and 12 months. There was a reduction of this score in both groups with time. The same pattern was found for IPSS score. Bother scores were similar between groups. No difference was observed for all FVC parameters between DB and NDB patients. CONCLUSION Gene expression of bladder receptors involved in micturition control was similar in patients with or without DB. Bladder behavior had a similar pattern independently of pretransplant residual diuresis. These findings question the relevance of the term DB in pretransplant patients.
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Affiliation(s)
- João F Neves Neto
- Division of Urology, Universidade Federal de São Paulo, São Paulo, Brazil.,Hospital do Rim, Fundação Oswaldo Ramos, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Zaira Palomino
- Hospital do Rim, Fundação Oswaldo Ramos, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Wilson F Aguiar
- Division of Urology, Universidade Federal de São Paulo, São Paulo, Brazil.,Hospital do Rim, Fundação Oswaldo Ramos, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose O Medina-Pestana
- Hospital do Rim, Fundação Oswaldo Ramos, Universidade Federal de São Paulo, São Paulo, Brazil.,Division of Nephrology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Roberto Soler
- Division of Urology, Universidade Federal de São Paulo, São Paulo, Brazil
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de Oliveira NI, Paula MI, Felipe CR, Tedesco-Silva H, Medina-Pestana JO. Limitations of the interpretation and extrapolation of clinical trial data in kidney transplant recipients. Clin Transplant 2017; 31. [PMID: 28665496 DOI: 10.1111/ctr.13046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The risks and benefits of the participation of kidney transplant recipients in randomized clinical trials (RCTs) investigating new immunosuppressive therapies are unknown. DESIGN AND SETTING We included patients from 12 prospective phase II/III RCTs randomized to the experimental (G1, n=319) or standard-of-care internal control group (G2, n=118). We constructed two additional external control groups with (G3, n=319) or without (G4, n=319) matching inclusion/exclusion criteria based on transplant date. The primary outcome analysis was the composite clinical efficacy failure, defined as biopsy-proven acute rejection (BPAR), graft loss, death, or loss to follow-up 12 months after kidney transplantation. RESULTS Survival free of composite clinical efficacy failure was higher among participants in RCT, without difference between experimental or standard-of-care therapy (80∙3 vs 78∙0 vs 69∙9 vs 66∙1%, P<.001), respectively. Patient (98.1 vs 99.2 vs 96.9 vs 91.8 P<.001) and graft (94.0 vs 98.3 vs 90.9 vs 82.4) survivals were also higher in G1 compared to G4, but no differences in survival free of BPAR were observed (85.3 vs 78.8 vs 82.8 vs 81.2 P>.05), respectively. CONCLUSION These findings suggested that new treatments investigated in kidney transplant recipients are not associated with detectable harm compared to standard of care.
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Cristelli MP, Cofán F, Tedesco-Silva H, Trullàs JC, Santos DWCL, Manzardo C, Agüero F, Moreno A, Oppenheimer F, Diekmann F, Medina-Pestana JO, Miro JM. Regional differences in the management and outcome of kidney transplantation in patients with human immunodeficiency virus infection: A 3-year retrospective cohort study. Transpl Infect Dis 2017; 19. [PMID: 28508573 DOI: 10.1111/tid.12724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 02/06/2017] [Accepted: 03/05/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND In the developed world, kidney transplantation (KT) in patients with human immunodeficiency virus (HIV) infection is well established. Developing countries concentrate 90% of the people living with HIV, but their experience is underreported. Regional differences may affect outcomes. OBJECTIVES We compared the 3-year outcomes of patients with HIV infection receiving a KT in two different countries, in terms of incomes and development. METHODS This was an observational, retrospective, double-center study, including all HIV-infected patients >18 years old undergoing KT. RESULTS Between 2005 and 2015, 54 KTs were performed (39 in a Brazilian center, and 15 in a Spanish center). Brazilians had less hepatitis C virus co-infection (5% vs 27%, P=.024). Median cold ischemia time was higher in Brazil (25 vs 18 hours, P=.001). Biopsy-proven acute rejection (AR) was higher in Brazil (33% vs 13%, P=.187), as were the number of AR episodes (22 vs 4, P=.063). Patient survival at 3 years was 91.3% in Brazil and 100% in Spain; P=.663. All three cases of death in Brazil were a result of bacterial infections within the first year post transplant. At 3 years, survival free from immunosuppressive changes was lower in Brazil (56% vs 90.9%, P=.036). Raltegravir-based treatment to avoid interaction with calcineurin inhibitor was more prevalent in Spain (80% vs 3%; P<.001). HIV infection remained under control in all patients, with undetectable viral load and no opportunistic infections. CONCLUSION Important regional differences exist in the demographics and management of immunosuppression and antiretroviral therapy. These details may influence AR and infectious complications. Non-AIDS infections leading to early mortality in Brazil deserve special attention.
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Affiliation(s)
| | - Federico Cofán
- Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Joan Carles Trullàs
- Hospital d'Olot, Medical Science Department, University of Girona, Girona, Spain
| | | | | | - Fernando Agüero
- Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Asunción Moreno
- Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Fritz Diekmann
- Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Jose Maria Miro
- Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
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Tamashiro EY, Felipe CR, Genvigir FDV, Rodrigues AC, Campos AB, Hirata RDC, Tedesco-Silva H, Medina-Pestana JO. Influence of CYP3A4 and CYP3A5 polymorphisms on tacrolimus and sirolimus exposure in stable kidney transplant recipients. Drug Metab Pers Ther 2017; 32:89-95. [PMID: 28593920 DOI: 10.1515/dmpt-2016-0036] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 03/07/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Polymorphisms in genes encoding for drug-metabolizing enzymes and drug transporters are among multiple factors that modulate the pharmacokinetic variability of tacrolimus (TAC) and sirolimus (SRL). This study aimed to evaluate the influence of single nucleotide polymorphisms (SNPs) on TAC and SRL dose-adjusted concentrations (C0/D) in stable kidney transplant recipients. METHODS This is an exploratory and prospective study, which includes 46 stable kidney transplant recipients. These patients were monitored from the 3rd to the 24th month after transplantation. The SRL group consisted of 25 patients receiving TAC, prednisone (PRED), and mycophenolate sodium (MPS), which were converted from TAC to SRL at 3rd month after transplantation. The TAC group consisted of 21 patients who underwent treatment with TAC, PRED, and MPS. Both groups were genotyped for CYP3A4 rs2242480 (g.20230G>A), CYP3A5 rs15524 (g.31611C>T), CYP2C8 rs10509681 (c.1196A>G) and ABCB1 rs1045642 (c.3435C>T), rs1128503 (c.1236C>T), and rs2032582 (c.2677G>T/A) polymorphisms. RESULTS In the TAC group, CYP3A4 rs2242480 A allele carriers were associated with lower TAC C0/D. For CYP3A5 rs15524 SNP, C0/D was higher among patients carrying TT genotype when compared with CT and CC genotype carriers in the SRL and, more consistently, in the TAC groups. For ABCB1 rs1045642 SNP, TT genotype was associated with reduced SRL C0/D, but only at month 15. CONCLUSIONS CYP3A4 rs2242480 and CYP3A5 rs15524 SNPs resulted in significant changes in SRL and TAC C0/D at different times after transplantation.
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Genvigir FDV, Nishikawa AM, Felipe CR, Tedesco-Silva H, Oliveira N, Salazar ABC, Medina-Pestana JO, Doi SQ, Hirata MH, Hirata RDC. Influence of ABCC2, CYP2C8, and CYP2J2 Polymorphisms on Tacrolimus and Mycophenolate Sodium-Based Treatment in Brazilian Kidney Transplant Recipients. Pharmacotherapy 2017; 37:535-545. [PMID: 28316087 DOI: 10.1002/phar.1928] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
STUDY OBJECTIVE To investigate the influence of single nucleotide polymorphisms (SNPs) in genes encoding metabolizing enzymes (CYP2C8, CYP2J2, and UGT2B7) and transporters (ABCC2 and ABCG2) on dose and dose-adjusted trough blood concentrations (C:D ratio), clinical outcomes, and occurrence of adverse events of tacrolimus and mycophenolate sodium in Brazilian kidney transplant recipients. DESIGN Pharmacogenetic analysis of patients enrolled in a previously published study. PATIENTS One hundred forty-eight adult kidney transplant recipients treated with tacrolimus, enteric-coated mycophenolate sodium, and prednisone for 90 days posttransplantation. MEASUREMENTS AND MAIN RESULTS ABCC2 c.-24C>T and c.3972C>T, ABCG2 c.421C>A, CYP2C8*3, CYP2J2 c.-76G>T, and UGT2B7 c.372A>G SNPs were determined by real-time polymerase chain reaction. The CYP3A5*3C SNP data were used to eliminate the confounding effect of this variant on the results. ABCC2 c.3972T allele carriers showed higher tacrolimus C:D values than did carriers of the c.3972CC genotype. The CYP2C8*3 variant was also associated with slightly higher tacrolimus C:D values and higher estimated glomerular filtration rate but only in CYP3A5-nonexpressing patients (CYP3A5*3C/*3C carriers). None of the SNPs were associated with mycophenolate sodium dose or episodes of biopsy-confirmed acute rejection or delayed graft function. The CYP2J2 c.-76T allele was associated with increased risk for treatment-induced nausea and/or vomiting (OR: 5.30, 95% confidence interval 1.49-18.79, p<0.05). CONCLUSION The ABCC2 c.3972C >T polymorphism affected tacrolimus C:D in Brazilian kidney transplant recipients. Further, CYP2C8*3 and CYP2J2 c.-76G>T SNPs influenced the renal function of these patients and the occurrence of adverse events during treatment with tacrolimus and mycophenolate sodium.
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Affiliation(s)
- Fabiana D V Genvigir
- Department of Clinical and Toxicological Analysis, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo, Brazil
| | - Alvaro M Nishikawa
- Department of Clinical and Toxicological Analysis, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo, Brazil
| | - Claudia R Felipe
- Nephrology Division, Hospital do Rim, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Helio Tedesco-Silva
- Nephrology Division, Hospital do Rim, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Nagilla Oliveira
- Nephrology Division, Hospital do Rim, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Antony B C Salazar
- Department of Clinical and Toxicological Analysis, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo, Brazil
| | - Jose O Medina-Pestana
- Nephrology Division, Hospital do Rim, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Sonia Q Doi
- School of Medicine, Uniformed Services University, Bethesda, Maryland
| | - Mario H Hirata
- Department of Clinical and Toxicological Analysis, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo, Brazil
| | - Rosario D C Hirata
- Department of Clinical and Toxicological Analysis, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo, Brazil
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Salgado PC, Genvigir FD, Felipe CR, Tedesco-Silva H, Medina-Pestana JO, Doi SQ, Hirata MH, Hirata RD. Association of the PPP3CA c.249G>A variant with clinical outcomes of tacrolimus-based therapy in kidney transplant recipients. Pharmgenomics Pers Med 2017; 10:101-106. [PMID: 28435308 PMCID: PMC5386607 DOI: 10.2147/pgpm.s131390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The effects of genetic variants related to the pharmacodynamic mechanisms of immunosuppressive drugs on their therapeutic efficacy and safety have been poorly explored. This study was performed to investigate the influence of the PPP3CA c.249G>A variant on the clinical outcomes of kidney transplant recipients. PATIENTS AND METHODS A total of 148 Brazilian patients received tacrolimus (TAC)-based immunosuppressive therapy for 90 days post-kidney transplantation. The PPP3CA rs3730251 (c.249G>A) polymorphism was determined by real-time polymerase chain reaction. Single-nucleotide polymorphism (SNP) data for CYP3A5 rs776746 (CYP3A5*3C; g.6986A>G) were used to eliminate the confounding effects of this variant. RESULTS The PPP3CA c.249G>A SNP did not influence early TAC exposure, renal function, or other laboratory parameters, including levels of urea, creatinine, glucose, and lipids, and blood counts. This variant also did not account for the cumulative incidence of biopsy-confirmed acute rejection or delayed graft function. Regarding adverse events, PPP3CA c.249A allele carriers initially had a 3.05-fold increased probability of treatment-induced blood and lymphatic system disorders compared with c.249GG genotype individuals (95% confidence interval: 1.10-8.48, p=0.032). However, this result was not maintained after adjusting for body weight and CYP3A5*3C SNP status (p=0.086). CONCLUSION The PPP3CA c.249G>A variant does not influence the clinical outcomes of Brazilian patients in the early phase of TAC-based immunosuppressive regimen.
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Affiliation(s)
- Patricia C Salgado
- Department of Clinical and Toxicological Analysis, School of Pharmaceutical Sciences, University of Sao Paulo
| | - Fabiana Dv Genvigir
- Department of Clinical and Toxicological Analysis, School of Pharmaceutical Sciences, University of Sao Paulo
| | - Claudia R Felipe
- Division of Nephrology, Hospital do Rim, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Helio Tedesco-Silva
- Division of Nephrology, Hospital do Rim, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Jose O Medina-Pestana
- Division of Nephrology, Hospital do Rim, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Sonia Q Doi
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Mario H Hirata
- Department of Clinical and Toxicological Analysis, School of Pharmaceutical Sciences, University of Sao Paulo
| | - Rosario Dc Hirata
- Department of Clinical and Toxicological Analysis, School of Pharmaceutical Sciences, University of Sao Paulo
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Santos DW, Camargo LF, Gonçalves SS, Ogawa MM, Tomimori J, Enokihara MM, Medina-Pestana JO, Colombo AL. Melanized fungal infections in kidney transplant recipients: contributions to optimize clinical management. Clin Microbiol Infect 2017; 23:333.e9-333.e14. [PMID: 28062320 DOI: 10.1016/j.cmi.2016.12.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 12/15/2016] [Accepted: 12/22/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This is a retrospective and observational study addressing clinical and therapeutic aspects of melanized fungal infections in kidney transplant recipients. METHODS We retrospectively reviewed medical records of all patients admitted between January 1996 and December 2013 in a single institution who developed infections by melanized fungi. RESULTS We reported on 56 patients aged between 30 and 74 years with phaeohyphomycosis or chromoblastomycosis (0.54 cases per 100 kidney transplants). The median time to diagnosis post-transplant was 31.2 months. Thirty-four (60.8%) infections were reported in deceased donor recipients. Fifty-one cases of phaeohyphomycosis were restricted to subcutaneous tissues, followed by two cases with pneumonia and one with brain involvement. Most dermatological lesions were represented by cysts (23/51; 45.1%) or nodules (9/51; 17.9%). Exophiala spp. (34.2%) followed by Alternaria spp. (7.9%) were the most frequent pathogens. Graft loss and death occurred in two patients and one patient, respectively. Regarding episodes of subcutaneous phaeohyphomycosis, a complete surgical excision without antifungal therapy was possible in 21 of 51 (41.2%) patients. Long periods of itraconazole were required to treat the other 30 (58.8%) episodes of subcutaneous disease. All four cases of chromoblastomycosis were treated only with antifungal therapy. CONCLUSIONS Melanized fungal infections should be considered in the differential diagnosis of all chronic skin lesions in transplant recipients. It is suggested that the impact of these infections on graft function and mortality is low. The reduction in immunosuppression should be limited to severely ill patients.
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Affiliation(s)
- D W Santos
- Special Mycology Laboratory-LEMI, Division of Infectious Diseases, Federal University of São Paulo, São Paulo, SP, Brazil; Division of Infectious Diseases, Hospital do Rim, São Paulo, SP, Brazil
| | - L F Camargo
- Division of Infectious Diseases, Federal University of São Paulo, São Paulo, SP, Brazil
| | - S S Gonçalves
- Special Mycology Laboratory-LEMI, Division of Infectious Diseases, Federal University of São Paulo, São Paulo, SP, Brazil
| | - M M Ogawa
- Department of Dermatology, Federal University of São Paulo, São Paulo, SP, Brazil
| | - J Tomimori
- Department of Dermatology, Federal University of São Paulo, São Paulo, SP, Brazil
| | - M M Enokihara
- Department of Dermatology, Federal University of São Paulo, São Paulo, SP, Brazil
| | | | - A L Colombo
- Special Mycology Laboratory-LEMI, Division of Infectious Diseases, Federal University of São Paulo, São Paulo, SP, Brazil; Division of Infectious Diseases, Federal University of São Paulo, São Paulo, SP, Brazil.
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Vicari AR, Spuldaro F, Sandes-Freitas TV, Cristelli MP, Requião-Moura LR, Reusing JO, Pierrotti LC, Oliveira ML, Girão CM, Gadonski G, Kroth LV, Deboni LM, Ferreira GF, Tedesco-Silva H, Esmeraldo R, David-Neto E, Saitovitch D, Keitel E, Garcia VD, Pacheco-Silva A, Medina-Pestana JO, Manfro RC. Renal transplantation in human immunodeficiency virus-infected recipients: a case-control study from the Brazilian experience. Transpl Infect Dis 2016; 18:730-740. [PMID: 27503081 DOI: 10.1111/tid.12592] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 05/27/2016] [Accepted: 06/24/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Highly active antiretroviral therapy has turned human immunodeficiency virus (HIV)-infected patients with end-stage renal disease into suitable candidates for renal transplantation. We present the Brazilian experience with kidney transplantation in HIV-infected recipients observed in a multicenter study. METHODS HIV-infected kidney transplant recipients and matched controls were evaluated for the incidence of delayed graft function (DGF), acute rejection (AR), infections, graft function, and survival of patients and renal grafts. RESULTS Fifty-three HIV-infected recipients and 106 controls were enrolled. Baseline characteristics were similar, but a higher frequency of pre-transplant positivity for hepatitis C virus and cytomegalovirus infections was found in the HIV group. Immunosuppressive regimens did not differ, but a trend was observed toward lower use of anti-thymocyte globulin in the group of HIV-infected recipients (P = 0.079). The HIV-positive recipient group presented a higher incidence of treated AR (P = 0.036) and DGF (P = 0.044). Chronic Kidney Disease Epidemiology Collaboration estimated that glomerular filtration rate was similar at 6 months (P = 0.374) and at 12 months (P = 0.957). The median number of infections per patient was higher in the HIV-infected group (P = 0.018). The 1-year patient survival (P < 0.001) and graft survival (P = 0.004) were lower, but acceptable, in the group of HIV-infected patients. CONCLUSIONS In the Brazilian experience, despite somewhat inferior outcomes, kidney transplantation is an adequate therapy for selected HIV-infected recipients.
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Affiliation(s)
- A R Vicari
- Renal Transplant Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - F Spuldaro
- Renal Transplant Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - M P Cristelli
- Hospital do Rim, Federal University of São Paulo, São Paulo, SP, Brazil
| | - L R Requião-Moura
- Renal Transplant Unit, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - J O Reusing
- Renal Transplant Unit, Hospital das Clínicas de São Paulo, University of São Paulo, São Paulo, SP, Brazil
| | - L C Pierrotti
- Renal Transplant Unit, Hospital das Clínicas de São Paulo, University of São Paulo, São Paulo, SP, Brazil
| | - M L Oliveira
- Renal Transplant Unit, Hospital Geral de Fortaleza, Fortaleza, CE, Brazil
| | - C M Girão
- Renal Transplant Unit, Hospital Geral de Fortaleza, Fortaleza, CE, Brazil
| | - G Gadonski
- Renal Transplant Unit, Hospital São Lucas, Catholic University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - L V Kroth
- Renal Transplant Unit, Hospital São Lucas, Catholic University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - L M Deboni
- Hospital Municipal São José e Fundação Pró-Rim, Joinville, SC, Brazil
| | - G F Ferreira
- Hospital Santa Casa de Misericórdia de Juiz de Fora, Juiz de Fora, MG, Brazil
| | - H Tedesco-Silva
- Hospital do Rim, Federal University of São Paulo, São Paulo, SP, Brazil
| | - R Esmeraldo
- Renal Transplant Unit, Hospital Geral de Fortaleza, Fortaleza, CE, Brazil
| | - E David-Neto
- Renal Transplant Unit, Hospital das Clínicas de São Paulo, University of São Paulo, São Paulo, SP, Brazil
| | - D Saitovitch
- Renal Transplant Unit, Hospital São Lucas, Catholic University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - E Keitel
- Renal Transplant Unit, Hospital Santa Casa de Porto Alegre, Federal University of Medical Sciences of Porto Alegre, Porto Alegre, RS, Brazil
| | - V D Garcia
- Renal Transplant Unit, Hospital Santa Casa de Porto Alegre, Federal University of Medical Sciences of Porto Alegre, Porto Alegre, RS, Brazil
| | - A Pacheco-Silva
- Renal Transplant Unit, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | - R C Manfro
- Renal Transplant Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.
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Mourão TB, Mine KL, Campos EF, Medina-Pestana JO, Tedesco-Silva H, Gerbase-DeLima M. Predicting delayed kidney graft function with gene expression in preimplantation biopsies and first-day posttransplant blood. Hum Immunol 2016; 77:353-7. [PMID: 26851369 DOI: 10.1016/j.humimm.2016.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 11/25/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
The purpose of this study was to investigate possible markers for predicting delayed graft function (DGF). To this end we analyzed, in pre-implantation biopsies (PIB) and in first-day post-Tx peripheral blood mononuclear cells (PBMC), the expression of five genes (ACSL4, CUBN, DEFB1, FABP3, GK) through real-time TaqMan PCR assays. These genes were selected from a large scale gene expression study in PIB. DEFB1, FABP3 and GK expression levels in PIB were lower in cases with DGF and, in a multivariate analysis which included these genes and clinical variables, only FABP3 expression remained independently associated with DGF. FABP3 expression lower than -1.32 units of relative expression conferred an odds ratio for DGF of 41.1. Compared to the PBMC of recipients without DGF, recipients with prolonged DGF (pDGF) had lower ACSL4 and higher DEFB1 expression levels. In a multivariate analysis, including PBMC gene expression levels of ACSL4, DEFB1 and TLR4 (data from a previous study with the same patients) and clinical variables, only TLR4 remained independently associated with pDGF. In summary, this study revealed FABP3 expression in PIB as a marker for DGF and disclosed new genes possibly involved in the pathogenesis of DGF.
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Affiliation(s)
- Tuíla B Mourão
- Instituto de Immunogenética - AFIP, São Paulo, SP, Brazil; Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Karina L Mine
- Instituto de Immunogenética - AFIP, São Paulo, SP, Brazil
| | - Erika F Campos
- Instituto de Immunogenética - AFIP, São Paulo, SP, Brazil; Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Jose O Medina-Pestana
- Universidade Federal de São Paulo, São Paulo, SP, Brazil; Hospital do Rim e Hipertensão, São Paulo, SP, Brazil
| | | | - Maria Gerbase-DeLima
- Instituto de Immunogenética - AFIP, São Paulo, SP, Brazil; Universidade Federal de São Paulo, São Paulo, SP, Brazil.
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15
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Goncalves-Primo A, Campos EF, Medina-Pestana JO, Tedesco-Silva H, Gerbase-DeLima M. OR46. Hum Immunol 2014. [DOI: 10.1016/j.humimm.2014.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Assis-Borba L, Cristelli MP, Paula MI, Franco MF, Tedesco-Silva H, Medina-Pestana JO. Expanding the use of expanded criteria donors in kidney transplantation. Int Urol Nephrol 2014; 46:1663-71. [PMID: 24677001 DOI: 10.1007/s11255-014-0695-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 03/17/2014] [Indexed: 01/16/2023]
Abstract
PURPOSE Although the use of kidney allografts from expanded criteria donors (ECD) has increased in recent years, the reported discard rates are also growing. The influence of ECD characteristics on transplant outcomes is still underevaluated. METHODS This retrospective study investigated the influence of preimplantation biopsy findings and delayed graft function (DGF) on patient and graft survivals and renal function at 36 months in a cohort of 372 ECD kidney transplant recipients. RESULTS Patient and graft survivals were 91.6 and 68.9 %. The incidence of biopsy-proven acute rejection was 31 %. There were no differences in patient (88.6 vs. 91.1 vs. 94.7 vs. 78.6 %, p = 0.10) or graft (78.1 vs. 72.2 vs. 60.5 vs. 62.6 %, p = 0.14) survivals and renal function (41.7 ± 25.6 vs. 39.9 ± 29.9 vs. 38.1 ± 30.6 vs. 37.4 ± 29.2 mL/min, p = 0.79) comparing ECD kidneys with mild, moderate, and severe histological changes or with no preimplantation biopsy, respectively. However, severe scored transplants had the worst death-censored graft survival (OR 3.1, 95 % CI 1.4-6.9, p = 0.007). No significant differences in patient (86.2 vs. 83.4 %, p = 0.17) or graft (73.7 vs. 65.9 %, p = 0.06) survivals and renal function (38.9 ± 28.6 vs. 39.9 ± 28.4 mL/min, p = 0.72) were observed comparing patients with or without DGF. Multivariable analysis found diabetes history as the only independent risk factor for graft loss (OR 2.1, 95 % CI 1.3-3.3, p = 0.003) or patient death (OR 3.1, 95 % CI 1.5-5.8, p < 0.001). CONCLUSIONS Within the limitations of sample size and short follow-up time, in this cohort of ECD kidney transplant recipients the severity of histological changes observed in preimplantation biopsies was independently associated with graft loss.
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Affiliation(s)
- Luciana Assis-Borba
- Transplant Division, Hospital do Rim e Hipertensão, UNIFESP, São Paulo, SP, Brazil
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Oliveira N, Felipe CR, De Paula MI, Tamashiro EY, Tedesco-Siva H, Medina-Pestana JO. OHP-037 Benefits of clinical research in a single kidney transplant centre. Eur J Hosp Pharm 2014. [DOI: 10.1136/ejhpharm-2013-000436.489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Felix M, Felipe CR, Tedesco-Silva H, Medina-Pestana JO, Spinelli GA. DI-033 Safety profile study of planned randomised conversion from tacrolimus to sirolimus-based immunosuppressive regimen in de novokidney transplant recipients. Eur J Hosp Pharm 2014. [DOI: 10.1136/ejhpharm-2013-000436.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Holanda-Cavalcanti A, Campos ÉF, Grenzi PC, De Marco R, Rampim GF, Tedesco-Silva H, Medina-Pestana JO, Gerbase-DeLima M. 21-P. Hum Immunol 2012. [DOI: 10.1016/j.humimm.2012.07.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Souza LO, Perez RM, Carvalho-Filho RJ, Matos CA, Moutinho RS, Silva IS, Medina-Pestana JO, Silva AE, Ferraz ML. Unexpected distribution of Hepatitis B genotypes in patients with kidney disease: Comparison with immunocompetent subjects. J Med Virol 2012; 84:1548-52. [DOI: 10.1002/jmv.23357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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21
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Goncalves-Primo A, Mourão TB, Andrade-Oliveira V, Campos EF, Medina-Pestana JO, Tedesco-Silva H, Gerbase-DeLima M. 40-OR: Low BCl2 mRNA levels in pre-implantation biopsies are associated with delayed graft function after deceased donor kidney transplantation. Hum Immunol 2011. [DOI: 10.1016/j.humimm.2011.07.285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Santoro A, Felipe CR, Tedesco-Silva H, Medina-Pestana JO, Struchiner CJ, Ojopi EB, Suarez-Kurtz G. Pharmacogenetics of calcineurin inhibitors in Brazilian renal transplant patients. Pharmacogenomics 2011; 12:1293-303. [PMID: 21806386 DOI: 10.2217/pgs.11.70] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
AIM Polymorphisms in the CYP3A5 and ABCB1 genes have been investigated as modulators of the pharmacokinetics and clinical effects of cyclosporine (CSA) and tacrolimus (TAC) in European, North American and Asian populations, with controversial results. The extensive variation in worldwide frequency distribution of CYP3A5 and ABCB1 polymorphisms is a caveat against the extrapolation of these data to the heterogeneous and admixed Brazilian population. We investigated the effect of CYP3A5 and ABCB1 polymorphisms on CSA and TAC dose-adjusted trough concentration (C₀/dose) in Brazilian renal transplant recipients, during the first 3 months post-transplantation. MATERIALS & METHODS Patients receiving CSA (n = 150) or TAC (n = 151) were genotyped for CYP3A5*3 (rs776746, 6986A>G), *6 (rs10264272, 14690G>A) and *7 (rs41303343, 27131-27132insT) and for ABCB1 1236C>T (rs1128503), 2677G>T/A (rs2032582) and 3435C>T (rs1045642) polymorphisms. We explored the effects of CYP3A5 and ABCB1 polymorphisms, clinical and demographical characteristics on CSA and TAC C₀/dose under a two-step data analysis strategy by fitting a longitudinal mixed-effects model to the data; first to select the important covariates under a univariate setting and then to fit the final multivariate model. RESULTS C₀/dose of TAC was associated with the number of CYP3A5-defective alleles, in a gene-dose manner, throughout the observation period, whereas C₀/dose of CSA was associated with body surface area and prednisone dosing. No other significant associations were detected. CONCLUSION Individual adjustment of the initial TAC dose according to the CYP3A5 haplotypes comprising the CYP3A5*3, *6 and *7 defective alleles might prove beneficial to Brazilian renal transplant recipients and should be further investigated in prospective trials.
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Affiliation(s)
- Ana Santoro
- Divisão de Farmacologia, Coordenação de Pesquisa, Instituto Nacional de Câncer, Rio de Janeiro, RJ 20231-050, Brazil
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Abstract
Brazil is a country with over 190 000 000 inhabitants and a health system composed of a large public, government managed system. Between 1999 and 2010 the number of deceased donors increased by 161%, from 3.8 to 9.9 pmp, and the number of solid organ transplants increased by 121%, from 2891 to 6402. This growth was a consequence of the creation of a well-organized national transplant program. Government funding, decentralization and educational investment in transplant coordinators and related professional were decisive. In 2009 Brazil was the second largest country in the absolute number of kidney transplants (n = 4259). There are significant region disparities in performance which are mainly due to the development status. Improvements in transplant and research regulations resulted in an increasing participation of Brazilian transplant centers in multicenter trials, reaching over 44 studies during the last 11 years. Brazilian centers have been involved in clinical trials using everolimus, sirolimus, fingolimod, mycophenolate mofetyl, mycophenolate sodium, tacrolimus modified-release, sotrastaurin, belatacept, JAK3 inhibitor CP690,550 and valganciclovir. The still increasing number of transplants performed every year along with more efficient regulatory and sanitary analysis, organized clinical research programs and reduction in region performance disparities will eventually increase even more the participation of Brazil in trials worldwide.
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Affiliation(s)
- H Tedesco Silva
- Hospital do Rim e Hipertensão-Universidade Federal de São Paulo-SP-Brazil.
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Rangel EB, Melaragno CS, Gonzalez AM, Linhares MM, de Sá JR, Salzedas A, Medina-Pestana JO. Delayed kidney allograft function after simultaneous pancreas-kidney transplantation. Transplant Proc 2011; 42:3655-9. [PMID: 21094834 DOI: 10.1016/j.transproceed.2010.06.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2009] [Revised: 03/28/2010] [Accepted: 06/10/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND Simultaneous pancreas-kidney transplantation (SPKT) is one of the treatments for insulin-dependent chronic renal failure patients. METHODS One-year patient and kidney allograft survival rates of 150 patients undergoing SPKT were subjected to Cox regression and Kaplan-Meier analyses. Uni- and multivariate methods identified risk factors involved in allograft and patient survival. RESULTS One-year patient and kidney allograft survival rates were 82% and 80%, respectively. Delayed graft function (DGF) (P = .001; hazard ratio [HR]5.41) and acute kidney rejection episodes (P = .016; HR 3.36) were related to 1 year patient survival as well as intra-abdominal infection (IAI) rates. (IAI). One-year kidney allograft survival was related to DGF (P = .013; odds ratio [OR] 3.39), acute rejection (P = .001; OR 4.74), and IAI (P = .003, OR 6.29). DGF was related to a time on dialysis >27 months (P = .046; OR 2.59), cold kidney ischemia time >14 hours (P = .027; OR 2.94), donor age >25 years (P = .03; OR 2.82), and donor serum sodium concentration >155 mEq/L (P < .0001; OR 1.09). Female kidney to male recipient in 17% of the cases did not increase the risk of DGF. We observed an important correlation between donor serum sodium and creatinine (P < .0001), which suggested undertreatment of diabetes insipidus secondary to brain death. CONCLUSIONS DGF, acute rejection, and IAI were the main determinants of survival after SPKT. Improving the care of deceased donors may reduce DGF occurrence.
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Affiliation(s)
- E B Rangel
- Division of Nephrology, Universidade Federal de São Paulo, São Paulo, Brazil.
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Guimarães-Souza N, Dalboni MA, Canziani ME, Tedesco-Silva H, Batista MC, Sesso R, Câmara NO, Medina-Pestana JO, Pacheco-Silva A, Cendoroglo M. Clinical implications of initial renal function after deceased donor transplant. Transplant Proc 2010; 42:1084-9. [PMID: 20534229 DOI: 10.1016/j.transproceed.2010.03.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to investigate whether slow graft function (SGF) after transplantation of deceased-donor kidneys affected the prevalence of anemia or the glomerular filtration rate (GFR). We retrospectively evaluated the records of 534 kidney transplant patients who were classified based on their initial renal function, namely, immediate graft function (IGF), slow graft function (SGF), or delayed graft function (DGF). Among the 534 kidney transplant patients studied, the occurrences of each condition were IGF 104, SGF 133, and DGF 297. Six months after transplantation, a greater percentage of DGF patients were anemic compared with the others (P = .028). However, at 12 months after transplantation, SGF patients showed more anemia than the IGF group. DGF and SGF patients displayed similar GFR values at 18 and 24 months after transplantation. However, IGF patients displayed higher GFRs, even when subjects who experienced acute rejection episodes were censored (P = .004). The incidence of acute rejection episodes was similar among SGF and DGF patients. Patients displaying SGF after deceased-donor transplantation showed a greater tendency to be anemic than those displaying IGF. This study also suggested that SGF patients were at risk for acute rejection episodes and/or significantly reduced kidney function as measured by GFR.
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Tedesco-Silva H, Garcia VD, Contieri FLC, De Boni Monteiro de Carvalho D, Noronha IL, Gonçalves RT, de Paula FJ, Abbud-Filho M, Manfro RC, David-Neto E, Alfieri F, Ikehara E, Jiang Q, Tai SS, Medina-Pestana JO. Comparison of the safety and efficacy of cyclosporine minimization versus cyclosporine elimination in de novo renal allograft patients receiving sirolimus. Transplant Proc 2010; 42:1659-66. [PMID: 20620495 DOI: 10.1016/j.transproceed.2010.02.083] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Revised: 01/12/2010] [Accepted: 02/02/2010] [Indexed: 12/30/2022]
Abstract
The safety and efficacy of concentration-controlled use of sirolimus (SRL) and cyclosporine (CsA) followed by CsA minimization (CsAm) or elimination (CsAe) beginning at week 13 was compared in a phase 4, open-label, randomized (1:1) trial of renal transplant recipients enrolled between March 2004 and November 2005. The primary endpoint was renal function, measured at 12 months using the Nankivell formula, in patients remaining on therapy. Though a total enrollment of 140 patients in each group was planned to provide an 80% power to detect a difference in means, only 207 subjects were enrolled in this study. Demographic characteristics were similar between groups, with 98.1% recipients of first grafts, 69.1% from living donors, and 7.2% diabetics. At 12 months, there were no differences in renal function (61.08 vs 65.24 mL/min, P = .132); incidence of biopsy-confirmed acute rejection (14.3% vs 22.5%, P = .152); and patient (89.5% vs 92.2%, P = .632), graft (87.6% vs 88.2%, P = .999), and death-censored graft (98.1% vs 94.1%, P = .166) survivals between CsAm and CsAe groups, respectively. There were no differences in the overall rate of study-drug discontinuation (32.4% vs 36.3%, P = .562) but more patients discontinued because of lack of efficacy/graft loss in the CsAe group (4.8% vs 14.7%, P = .018). This study was underpowered to demonstrate the superiority of one regimen over the other. In summary, SRL immunotherapy combined with CsA minimization or elimination showed comparative safety and efficacy. Both regimens offer potential treatment options for de novo renal allograft recipients.
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Guimarães-Souza NK, Dalboni MA, Câmara NC, Medina-Pestana JO, Paheco-Silva A, Cendoroglo M. Infectious complications after deceased kidney donor transplantation. Transplant Proc 2010; 42:1137-41. [PMID: 20534244 DOI: 10.1016/j.transproceed.2010.03.074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Despite improvements in immunosuppressive therapy, infections remain a complication of renal transplantation that is associated with increased morbidity and graft rejection. The aim of this study was to evaluate the relationship between initial renal function after deceased donor transplantation and viral infections. METHODS We included patients 18 years and older who received a deceased donor transplantation between January 1995 and December 2004. They were divided into 2 groups: cases from 1994 to 1999, versus from 2000 to 2004. Initial renal function was classified as immediate (IGF), slow (SGF), or delayed (DGF). Infections were classified according to Centers for Disease Control and prevention standards. RESULTS Among 534 patients, SGF and DGF patients who underwent immunosuppression between 2000 and 2004 show a higher infection rate than IGF patients (P = .005). SGF patients showed a higher incidence of tissue-invasive cytomegalovirus disease (P < .001). Second episodes of viral infections were more common among all patients in this period. However, DGF patients were more susceptible to second episodes of viral infection. In the first group, OKT3 use (P = .013) and donor age (P = .012) were the major risk factors associated with viral infections whereas in the second group, thymoglobulin use (P = .002), acute rejection episode (P = .003), and anemia (P = .044) were the risk factors for viral infection. CONCLUSION Initial renal function after deceased donor transplantation was correlated with viral infection. DGF patients had a higher risk for second infection episodes. SGF patients had a higher risk for tissue-invasive cytomegalovirus infection.
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Tedesco-Silva H, Felipe CR, Park SI, Pinheiro-Machado PG, Garcia R, Slade A, Schmouder R, Medina-Pestana JO. Randomized crossover study to assess the inter- and intrasubject variability of morning mycophenolic acid concentrations from enteric-coated mycophenolate sodium and mycophenolate mofetil in stable renal transplant recipients. Clin Transplant 2010; 24:E116-23. [DOI: 10.1111/j.1399-0012.2009.01183.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rangel EB, Melaragno CS, Sá JR, Gonzalez AM, Linhares MM, Salzedas A, Medina-Pestana JO. Mycophenolate mofetil versus enteric-coated mycophenolate sodium after simultaneous pancreas-kidney transplantation. Transplant Proc 2010; 41:4265-9. [PMID: 20005381 DOI: 10.1016/j.transproceed.2009.09.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2009] [Revised: 08/15/2009] [Accepted: 09/02/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Adverse gastrointestinal events are frequent after mycophenolate use. The objectives of the present study were to report the incidence of acute noninfectious diarrhea, to determine the risk factors, and to compare the severity of reactions between mycophenolate mofetil (MMF) and enteric-coated mycophenolate sodium (EC-MPS) after simultaneous pancreas kidney transplantation (SPKT). METHODS We included 165 SPKT patients from December 2000 to May 2007. Uni- and multivariate analyses were performed, using acute noninfectious diarrhea as the dependent variable. P < .05 was considered significant. RESULTS Mean age and duration of dialysis and of diabetes were 34.9 +/- 8.2 years, 27.3 +/- 18.3 months, and 21.9 +/- 16.2 years, respectively. Sixty-three percent used MMF, 36.4% used EC-MPS, and 0.6% used azathioprine. Multivariate analysis showed that the duration of diabetes (P = .049, confidence interval [CI] 1.0- 1.13) and MMF use (P = .013, 95% CI 0.2-0.82) were the main determinants of acute diarrhea after SPKT. MMF dose reduction (79.2% vs 62.3%, P = .024) and severity of diarrhea associated with orthostatic hypotension were more pronounced among MMF than EC-MPS patients (42.4% vs 15.1%, P = .001). There was no difference between MMF and EC-MPS after dose reduction in relation to the occurrence of acute kidney rejection (30.8% vs 26.7%, P = .53). CONCLUSIONS Acute noninfectious diarrhea after SPKT was related to the duration of diabetes and to prescription of MMF. Preferential use of EC-MPS was associated with a lower necessity of dose reduction and less severe episodes of acute diarrhea compared with MMF, although dose reduction was equally associated with acute episodes of kidney rejection.
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Affiliation(s)
- E B Rangel
- Nephrology Division, Universidade Federal de São Paulo, Rua Botucatu, 740 VilaClementino, 04023-900 São Paulo, Brazil.
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Grenzi P, Campos EF, Tedesco-Silva H, Franco M, Medina-Pestana JO, Gerbase-deLima M. 81-P: Post-transplant anti-MICA antibodies and long-term kidney allograft survival. Hum Immunol 2009. [DOI: 10.1016/j.humimm.2009.09.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Felipe CR, Park SI, Pinheiro-Machado PG, Garcia R, Casarini DE, Moreira S, Tedesco-Silva Jr H, Medina-Pestana JO. Cyclosporine and sirolimus pharmacokinetics and drug-to-drug interactions in kidney transplant recipients. Fundam Clin Pharmacol 2009; 23:625-31. [DOI: 10.1111/j.1472-8206.2009.00699.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Park SI, Felipe CR, Pinheiro-Machado PG, Garcia R, Fernandes FB, Casarini DE, Tedesco-Silva H, Medina-Pestana JO. Tacrolimus pharmacokinetic drug interactions: effect of prednisone, mycophenolic acid or sirolimus. Fundam Clin Pharmacol 2009; 23:137-45. [PMID: 19267777 DOI: 10.1111/j.1472-8206.2008.00644.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study was conducted to evaluate time-dependent pharmacokinetic changes and drug interactions over the first 6 months after transplantation in kidney transplant recipients receiving tacrolimus (TAC), prednisone (PRED) and mycophenolate mofetil (MMF) or sirolimus (SRL). Pharmacokinetic assessments were carried out at day 7 and months 1, 3, and 6 in kidney transplant recipients receiving TAC plus PRED with either MMF (2 g/day, n = 13) or SRL (15 mg loading dose, 5 mg for 7 days followed by 2 mg/day, n = 12). There were no differences in the main demographic characteristics or in mean PRED doses during the first 6 months after transplant. From day 7 to month 6, there was a 65% increase in TAC dose corrected exposure (dose corrected area under the curve; AUC) in patients receiving MMF (P = 0.005) and a 59% increase in TAC dose corrected exposure in patients receiving SRL (P = 0.008). From day 7 to month 6, there was a 72% increase in mycophenolate dose corrected exposure (P = 0.001) and a 65% increase in SRL dose corrected exposure (P = 0.008). TAC dose corrected exposure was 23% lower in patients receiving SRL compared with MMF (P = 0.012) on average over the study period. PRED dose reduction was associated with increase in TAC (in patients receiving SRL, P = 0.040) and mycophenolic acid (MPA) (P = 0.070) drug exposures. Tercile distribution of TAC drug exposure showed a positive correlation with mean SRL exposures (P = 0.016). Conversely, tercile distribution of SRL drug exposure showed a positive correlation with mean TAC exposures (P = 0.004). Time-dependent increases in TAC, MPA and SRL drug exposures occur up to 6 months after transplantation. Drug-to-drug interactions indicate that intense therapeutic drug monitoring is required to avoid under- or over-immunosuppression.
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Affiliation(s)
- Sung-In Park
- Nephrology Division, Hospital do Rim e Hipertensão, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Rangel EB, Melaragno CS, Gonzalez AM, Linhares MM, de Sa JR, Salzedas A, Medina-Pestana JO. Impact of pancreatic allograft function on 1-year survival rates after simultaneous pancreatic-renal transplant. EXP CLIN TRANSPLANT 2008; 6:301-306. [PMID: 19338493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Simultaneous pancreatic-renal transplant is an effective treatment for insulin-dependent patients with chronic renal failure. We sought to identify the main influences on pancreatic and patient survival rates after simultaneous pancreas-kidney transplants. PATIENTS AND METHODS The 1-year patient and pancreas survival rates of 150 patients who had undergone simultaneous pancreas-kidney transplant were analyzed by the Cox proportional hazards regression model and the Kaplan-Meier method. Uni and multivariate analyses were performed in terms of transplant-, recipient-, and donor-related risk factors. RESULTS At 1 year, patient and pancreatic allograft survival rates were 82% and 76.7%, respectively. Delayed graft function in the kidney (P = .001, HR 5.41), acute kidney rejection (P = .016, HR 3.36), and intra-abdominal infection (P < .0001, HR 4.15) were the main factors related to 1-year patient survival. Pancreatic allograft survival at 1 year was related to intra-abdominal infection (P < .0001, OR 12.83), vascular thrombosis (P = .002, OR 40.55), acute kidney rejection (P = .027, OR 3.06), donor sodium greater than 155 mEq/L (P = .02, OR 3.27), and dopamine administration exceeding 7.6 microg/kg/min (P = .046, OR 2.85). CONCLUSIONS Delayed kidney allograft function and intra-abdominal infection had an important effect on both patient and pancreatic allograft survival rates.
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Schiavon LL, Narciso-Schiavon JL, Carvalho Filho RJ, Sampaio JP, Medina-Pestana JO, Lanzoni VP, Silva AEB, Ferraz MLG. Serum levels of YKL-40 and hyaluronic acid as noninvasive markers of liver fibrosis in haemodialysis patients with chronic hepatitis C virus infection. J Viral Hepat 2008; 15:666-74. [PMID: 18482283 DOI: 10.1111/j.1365-2893.2008.00992.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hepatitis C virus (HCV) infection is highly prevalent among end-stage renal disease (ESRD) patients undergoing haemodialysis and it is an important cause of morbidity and mortality in this population. The aim of this study was to evaluate the diagnostic value of YKL-40 and hyaluronic acid (HA) as noninvasive markers of liver fibrosis in 185 ESRD HCV-infected patients. Significant liver fibrosis was defined as METAVIR F2, F3 or F4 stages. Significant fibrosis was observed in 45 patients (24%). By univariate analysis, higher levels of YKL-40, HA, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyltransferase (GGT) as well as reduced platelet count were associated with fibrosis. However, by multivariate analysis, only AST (P = 0.001), platelet count (P = 0.004) and HA (P = 0.042) were independently associated with significant fibrosis. For the prediction of significant fibrosis, the areas under receiver operating characterictic curve (AUROC) of the regression model (0.798) was significantly higher than the AUROC of YKL-40 (0.607) and HA (0.650). No difference was noted between the AUROC of the regression model and AST to platelet ratio index (APRI) (0.787). Values <8.38 of the regression model showed a negative predictive value of 94% and scores >or=9.6 exhibited a positive predictive value of 65%. If biopsy indication was restricted to scores in the intermediate range of the regression model, it could have been correctly avoided in 61% of the cases. In conclusion, APRI and a model based on AST, platelet count and HA showed better accuracy than YKL-40 and HA (when used solely) for the prediction of significant fibrosis in ESRD HCV-infected patients.
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Affiliation(s)
- L L Schiavon
- Division of Gastroenterology, Federal University of Sao Paulo, Sao Paulo, Brazil.
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Sampaio EL, Pinheiro-Machado PG, Garcia R, Felipe CR, Park SI, Casarini DE, Moreira S, Franco MF, Tedesco-Silva H, Medina-Pestana JO. Mycophenolate mofetil vs. sirolimus in kidney transplant recipients receiving tacrolimus-based immunosuppressive regimen. Clin Transplant 2008; 22:141-9. [PMID: 18339132 DOI: 10.1111/j.1399-0012.2007.00756.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Mycophenolate mofetil (MMF) and sirolimus (SRL) are effective immunosuppressive drugs with distinct safety profile. METHODS Kidney transplant recipients receiving tacrolimus (TAC)-based immunosuppressive regimen were randomized to receive fixed daily doses of MMF (2 g/d, n = 50) or SRL (one loading dose of 15 mg, 5 mg/d till day 7 and 2 mg/d thereafter, n = 50) without induction therapy. RESULTS No differences were observed in the incidence of the composite (biopsy-confirmed acute rejection, graft loss or death) end-point (18% vs. 16%, p = 1.000), biopsy confirmed acute rejection (12% vs. 14%, p = 1.000), one-yr patient (94% vs. 98%, p = 0.308), graft (92% vs. 98%, p = 0.168), and death-censored graft survival (98% vs. 100%, p = 0.317) comparing patients receiving MMF or SRL respectively. Patients receiving SRL showed worse safety outcomes, higher mean creatinine (1.6 +/- 0.5 mg/dL vs. 1.4 +/- 0.3 mg/dL, p = 0.007), higher proportion of patients with proteinuria (52.0% vs. 10.7%, p = 0.041), higher mean urinary protein concentrations (0.3 +/- 0.5 g/L vs. 0.1 +/- 0.2 g/L, p = 0.012), higher mean cholesterol concentration (217 mg/dL vs. 190 mg/dL, p = 0.030), and higher proportion of patients prematurely discontinued from randomized therapy (26% vs. 8%, p = 0.031). CONCLUSION In patients receiving TAC, MMF produced similar efficacy but superior safety profile compared with SRL.
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Affiliation(s)
- Edison L Sampaio
- Nephrology Division, Hospital do Rim e Hipertensão, UNIFESP, São Paulo, Brazil
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Garcia R, Machado PG, Felipe CR, Park SI, Spinelli GA, Franco MF, Tedesco-Silva H, Medina-Pestana JO. Exploratory calcineurin inhibitor-free regimens in living-related kidney transplant recipients. Braz J Med Biol Res 2008; 40:457-65. [PMID: 17401488 DOI: 10.1590/s0100-879x2007000400003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2006] [Accepted: 01/19/2007] [Indexed: 11/21/2022] Open
Abstract
Chronic allograft nephropathy is among the major causes of graft loss even in low-risk kidney transplant recipients and correlates with acute nephrotoxic events during the first year post-transplant. Therefore, calcineurin inhibitor-free regimens may improve patient and graft survival among recipients of living-related kidney transplants. To confirm this hypothesis, we evaluated the efficacy and safety of two calcineurin inhibitor-free regimens in 92 low-risk recipients of one-haplotype living-related kidney transplants. Immunosuppression consisted of tacrolimus, azathioprine and prednisone (group I, GI, N = 38), 2 doses of daclizumab, mycophenolate mofetil (MMF), and prednisone (GII, N = 33) and 2 doses of daclizumab, MMF, sirolimus and prednisone (GIII, N = 21). At 12 months, treatment failure (biopsy-confirmed acute rejection, graft loss or death) was higher in GII compared to GIII and GI (54.5 vs 24.0 vs 13.1%, P < 0.01, respectively). In patients of black ethnicity the incidence of acute rejection was 25 vs 83.3 vs 20% (P = 0.055), respectively. Patient and graft survival was comparable. There were no differences in mean creatinine or calculated creatinine clearance at 12 months. Overall incidence of post-transplant diabetes mellitus (3.3%) and cytomegalovirus disease (4.3%) was similar in all groups. Further development of effective calcineurin inhibitor-free regimens should exclude patients of black ethnicity and may need full-induction therapy, perhaps with depleting agents, and concentration-controlled use of sirolimus and MMF.
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Affiliation(s)
- R Garcia
- Divisão de Nefrologia, Hospital do Rim e Hipertensão, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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Clesca P, Dirlando M, Park SI, García R, Ferraz E, Pinheiro-Machado PG, Kushnaroff L, Tedesco-Silva H, Medina-Pestana JO. Thymoglobulin and rate of infectious complications after transplantation. Transplant Proc 2007; 39:463-4. [PMID: 17362760 DOI: 10.1016/j.transproceed.2007.01.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
UNLABELLED Thymoglobulin is used as an induction agent in kidney transplantation, but the optimal dose is not well established. However, its use may be associated with increased infectious complications after transplantation. METHODS This retrospective study of 61 high-risk renal recipients of transplants from deceased donors performed between June 2001 and April 2004 included patients treated with thymoglobulin. Patients were divided into two groups according to the total thymoglobulin dose (G1, n = 30, <7 mg/kg; G2, n = 31, >7 mg/kg) and followed for at least 1 year. RESULTS Mean recipient age was 43 +/- 14 years; 41% were males; 63% non-Whites. Mean cold ischemia time was 26.3 +/- 7 hours. Mean PRA was 23% (0-100%). Second transplantation was performed in 18 (29.5%) patients. Mean donor age was 42.1 +/- 16 years, and 59% had a cerebral vascular accident as the cause of death. Patient- and death-censored graft survival at 12 months were 86% and 88%, respectively. There were 149 infectious episodes among 47 (78%) patients. The incidence of infection was 1.7 +/- 0.24 infections per patient per year in G1 (lower dose) vs 3.12 +/- 0.23 in G2 (P < .001). Bacterial (0.66 +/- 1.0 vs 1.48 +/- 1.26 infections per patient per year, P = .009) and viral infections (0.9 +/- 0.71 vs 1.41 +/- 0.71; P = .006) were more frequent in the higher dose group. CONCLUSION This study suggested that a greater number of infectious episodes were present when the total dose of thymoglobulin was higher than 7 mg/kg.
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Affiliation(s)
- P Clesca
- Hospital do Rim e Hipertensao - Nephrology Division, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
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Carneiro-Roza F, Medina-Pestana JO, Moscoso-Solorzano G, Franco M, Ozaki K, Mastroianni-Kirsztajn G. Initial response to immunosuppressive and renoprotective treatment in posttransplant glomerulonephritis. Transplant Proc 2007; 38:3491-7. [PMID: 17175313 DOI: 10.1016/j.transproceed.2006.10.109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Indexed: 01/28/2023]
Abstract
UNLABELLED The current studies on posttransplant glomerulonephritis (PTxGN) do not establish when, how, or how long we must treat these patients. This study sought to compare the initial response to immunosuppressive treatment and renoprotection in PTxGN. PATIENTS AND METHODS This prospective study was performed in 23 patients with a histological diagnosis of PTxGN. RESULTS Mean follow-up was 12 months (3-18); 91% received immunosuppressants, and 56.5% just renoprotective drugs. The best results (reduction of serum creatinine [SCr] and proteinuria) with immunosuppression were observed in patients with recurrent membranous PTxGN using the scheme of Ponticelli (IV + PO corticosteroid [CS] + PO cyclophosphamide [CPP]). A similar response was also seen in subjects with recurrent or de novo focal glomerulosclerosis treated with PO CS or CPP, except when the initial SCr > 2.5 mg/dL. In de novo IgA nephropathy, reduction of proteinuria occurred with use of PO CS, with or without CPP, but without improvement in SCr. Patients with recurrent or de novo crescentic PTxGN used renoprotective drugs and always immunosuppressants. In this group, good results were seen with IV + PO CS, with or without CPP, when there was less than 50% of glomeruli with crescents, or more than 50% with crescents but an initial SCr < 2.5 mg/dL. CONCLUSION Immunosuppression seemed to give a better initial response than renoprotection in cases of membranous, IgA, and focal segmental glomulerulosclerosis PTxGN. Patients with an initial SCr > or = 2.5 mg/dL displayed worse outcomes.
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Affiliation(s)
- F Carneiro-Roza
- Glomerulopathy Section, Escola Paulista de Medicina- Federal University of São Paulo (UNIFESP), São Paulo, Brazil
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Park SI, Felipe CR, Pinheiro-Machado PG, Garcia R, Tedesco-Silva H, Medina-Pestana JO. Circadian and time-dependent variability in tacrolimus pharmacokinetics. Fundam Clin Pharmacol 2007; 21:191-7. [PMID: 17391292 DOI: 10.1111/j.1472-8206.2007.00468.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Tacrolimus (TAC) is considered a critical dose drug. The purpose of our study was to investigate circadian and time-dependent changes in TAC pharmacokinetics over the first year after kidney transplantation. Pharmacokinetic (PK) studies were performed in 26 recipients of first living donor kidney transplants at day 7 after morning (a.m.) and evening (p.m.) doses of TAC. Additional serial PK studies were carried out in nine patients at month 6 (M6) and month 12 (M12). Blood samples were collected before 1, 1.5, 2, 2.5, 3, 4, 6, 8 and 12 h after TAC administration. Demographics, TAC and adjunctive immunosuppressive doses, hematology, and biochemistry were recorded in each PK study. Mean age was 37 years, body mass index 23 kg/m(2), 58% males, and 85% Caucasian. Higher AUC (231.4 vs. 220 ng.h/mL, P = 0.06) and C(max) (34.1 +/- 12.6 vs. 24.4 +/- 9.8 ng/mL, P < 0.001), and lower T(max) (1.6 +/- 0.8 vs. 2.7 +/- 2.0 h, P = 0.05) values were observed comparing a.m. and p.m. administrations. Comparing D7, M6 and M12, there was a significant increase in dose-normalized AUC (31.4 +/- 22.2 vs. 50.1 +/- 33 vs. 39.2 +/- 24.4 ng.h/mL/mg, P = 0.005), C(max) (4.4 +/- 2.4 vs. 7.8 +/- 3.5 vs. 6.0 +/- 3.3 ng/mL/mg, P < 0.001) and T(max) (1.6 +/- 1.1 vs. 1.7 +/- 0.4 vs. 1.8 +/- 0.8 h, P = 0.006), respectively. Over the first year the intraindividual variability of dose-normalized AUC, C(max) and C(0) were 82%, 72%, and 90%, respectively. No significant changes were observed comparing inter-individual variability of dose-normalized AUC (21%, 24%, 33%), C(max) (46%, 45%, 55%), C(0) (49%, 83%, 81%) at D7, M6 and M12, respectively. We observed a good correlation between a.m. and p.m. TAC AUC (r(2) = 0.90) and C(0) (r(2) = 0.88). Tacrolimus pharmacokinetics display circadian variation suggesting a slower and delayed absorption phase at nighttime. Tacrolimus also showed time-dependent PK changes, suggesting an improvement in absorption during the first 6 months. Despite circadian variation we observed good correlations between a.m. and p.m. TAC AUC (r(2) = 0.90) and C(0) (r(2) = 0.88) and between C(0) and total daily TAC exposure (a.m. + p.m. AUC) suggesting that trough-guided therapeutic monitoring is still a reliable and simple strategy to optimize the clinical use of TAC.
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Affiliation(s)
- Sung-In Park
- Hospital do Rim e Hipertensão Nephrology Division, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Abstract
METHODS We retrospectively analyzed the registry data from one organ procurement organization obtained between January 1 and December 31, 2005. RESULTS Among the 378 potential deceased donors, 182 (48.2%) were lost, mainly due to clinical conditions (27%) or cardiac arrest (19.3%). Of the remaining 196 (51.8%) potential donors, family consent was obtained in 94 cases (48%). Family refusal was higher for potential donors aged between 18 and 59 years (70%). Of the 94 donors, 72 (77%) had their organs harvested. Cardiac arrest before harvesting (56.5%) and positive viral serology (26%) were the main reasons for further losses. The mean donor age was 40 years and 51% were men. Causes of death were cerebral vascular accidents (55.5%), cranium encephalic traumas (29%), and gun shot wounds (8%). The rate of organ donation was 100% for kidneys and livers, 96% for hearts, 86% for pancreatas, 76% for lungs, and 74% for corneas. After assessment of organ viability, 94% of corneas, 91% of kidneys, and 88% of livers were transplanted, but only 52% of pancreata and 42% of hearts. The most frequent causes of discarded organs were age and concomitant donor infection. CONCLUSION Areas for potential improvements are: (1) earlier identification and adequate maintenance of potential donors; (2) campaigns for organ donation; and (3) careful evaluation of donated organs and selection of a suitable population to increase utilization of expanded criteria organs.
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Affiliation(s)
- J O Medina-Pestana
- Hospital do Rim e Hipertensao - Nephrology Division, Universidade Federal de Sao Paulo, Sao Paulo, Brazil.
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Medina-Pestana JO, Sampaio EM, Vaz MLS, Pinheiro-Machado PG, Tedesco-Silva H. Worse Renal Transplant Outcomes Observed Among Afro-Brazilian Patients on Prospective Registry Data of 2461 Renal Transplants at Least 1 Year Follow-up. Transplant Proc 2007; 39:435-6. [PMID: 17362750 DOI: 10.1016/j.transproceed.2007.01.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We present prospective registry data of 2461 (live donor = 1753 and deceased donor = 08) renal transplants performed between 1999 and 2003. All subjects were followed for more than 1 year after transplantation and most were treated with a calcineurin inhibitor and azathioprine. Afro-Brazilian, white, and mixed patients constituted 11% (272), 67.1% (1651), and 14.9% (367) of the population respectively. Mean dialysis time was 42.3 +/- 32.9 months and delayed graft function, occurred in more than 60%. Three-year patient survival rates were 96.3%, 92.8%, and 86.7% for living-related, living-unrelated, and deceased donors, respectively. Corresponding 3-year graft survival rates were 87.3%, 82.1%, and 71.3% and functional graft survival rates were 90.2%, 88.8%, and 81.5%. The poorer transplant outcome observed among Afro-Brazilian patients has been mainly attributed to differences in absorption of cyclosporine, tacrolimus, and mycophenolate mofetil.
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Affiliation(s)
- J O Medina-Pestana
- Hospital do Rim e Hipertensao - Nephrology Division, Universidade Federal de Sao Paulo, Sao Paulo, Brazil.
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Garcia R, Pinheiro-Machado PG, Felipe CR, Park SI, Silva LA, Franco MF, Tedesco-Silva H, Medina-Pestana JO. Conversion from azathioprine to mycophenolate mofetil followed by calcineurin inhibitor minimization or elimination in patients with chronic allograft dysfunction. Transplant Proc 2007; 38:2872-8. [PMID: 17112853 DOI: 10.1016/j.transproceed.2006.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2005] [Indexed: 11/29/2022]
Abstract
UNLABELLED The purpose of this study was to evaluate the effects of the conversion from azathioprine (AZA) to mycophenolate mofetil (MMF) followed by calcineurin inhibitor (CNI) elimination or minimization in patients with progressive chronic allograft dysfunction (CAD). METHODS Between November 6, 1999 and February 12, 2003, 169 patients receiving CNI/AZA/prednisone (153 CsA; 14 tacrolimus) were included in this study. Demographics, immunosuppression, graft function, hematology, and biochemistry were obtained before (-6, -3, and -1 month) and 1, 3, 6, 9 and 12 months after and at last follow-up visit after conversion. RESULTS Mean age was 34 +/- 12 years, 66% males, 51% Caucasian, and 72% living allograft recipients. Mean follow-up times before and after conversion were 32.4 and 19.4 months; 10 patients completed 3 years of follow-up. CNI elimination was performed in 39% and minimization in 61% of patients. Overall there was significantly improved graft function at 1 year after conversion (2.6 +/- 1.0 vs 2.1 +/- 0.6 mg/dL, P = .038). The slopes of the regression lines of 1/Cr vs time were significantly improved from preconversion to after conversion (-0.026 vs +0.007 mg(-1)/dL per day(-1), P = .001). There was a significant decrease in mean systolic (141 +/- 21 vs 135 +/- 22 mm Hg, P = .015) and diastolic (89 +/- 15 vs 84 +/- 14 mm Hg, P = .005) blood pressure values at 1 year. There were four episodes of acute rejection (Banff IA) treated with steroids. Three years after conversion, patient and graft survivals were 95% and 79%, respectively. One patient developed posttransplant lymphoproliferative disease. CONCLUSION Among patients with CAD, conversion from AZA to MMF followed by CNI minimization or elimination was a safe and effective strategy to preserve or improve graft function.
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Affiliation(s)
- R Garcia
- Nephrology Division, Hospital do Rim e Hipertensão, Universidade Federal de São Paulo, São Paulo, Brazil
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Campos EF, Tedesco-Silva H, Machado PG, Franco M, Medina-Pestana JO, Gerbase-DeLima M. Post-transplant anti-HLA class II antibodies as risk factor for late kidney allograft failure. Am J Transplant 2006; 6:2316-20. [PMID: 16925566 DOI: 10.1111/j.1600-6143.2006.01503.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The purpose of this study was to prospectively analyze the relationship between the post-transplant anti-HLA class I and/or class II panel reactive antibodies and graft failure due to chronic allograft nephropathy (CAN). We studied 512 first kidney recipients transplanted at a single center, with a graft functioning for at least 3 years. A single blood sample was collected from each patient for antibody evaluation. The median posttransplant time after blood collection was 4.4 years and did not differ between patients with (n = 91) or without anti-HLA antibodies (n = 421). Female gender, pregnancies and blood transfusions were associated with the presence of anti-HLA class I antibodies. Graft function deterioration was associated with anti-HLA class II antibodies. Multivariate analysis showed independent association for creatinine levels (RR = 7.5), acute rejection (RR = 2.6), recipient male gender (RR = 3.6) and anti-HLA class II antibodies (RR = 2.9) and CAN-associated graft loss. In conclusion, the presence of anti-HLA class II antibodies conferred a risk for graft loss before a decline in renal function and increased the risk of graft failure in patients who already had a decline in graft function. Thus, anti-HLA class II antibody monitoring is a useful tool for the management of long-term kidney recipients.
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Affiliation(s)
- E F Campos
- Nephrology Division/Hospital do Rim e Hipertensão, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
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Spinelli GA, Felipe CR, Machado PG, Garcia R, Casarini DE, Moreira SR, Park SI, Tedesco-Silva H, Medina-Pestana JO. Relationship of cyclosporin and sirolimus blood concentrations regarding the incidence and severity of hyperlipidemia after kidney transplantation. Braz J Med Biol Res 2006; 39:19-30. [PMID: 16400461 DOI: 10.1590/s0100-879x2006000100003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The influence of drug concentrations on the development of persistent posttransplant hyperlipidemia was investigated in 82 patients who received cyclosporin A (CsA) and prednisone plus sirolimus (SRL) (52) or azathioprine (AZA) (30) during the first year after transplantation. Blood levels of CsA and SRL, daily doses of AZA and prednisone, and cholesterol, triglyceride, and glucose concentrations were determined during each visit (pretransplant and 30, 60, 90, 120, 180, and 360 days posttransplant). Persistent hyperlipidemia was defined as one-year average steady-state cholesterol (CavCHOL) or triglyceride (CavTG) concentrations above 240 and 200 mg/dL, respectively. Mean cholesterol and triglyceride concentrations increased after transplantation (P < 0.01) and were higher in patients receiving SRL compared to AZA (P < 0.001). Patients receiving SRL showed a significantly higher number of cholesterol (> 229 or > 274 mg/dL) and triglyceride (> 198 or > 282 mg/dL) determinations in the upper interquartile ranges. CsA and SRL interquartile ranges correlated with cholesterol concentrations (P = 0.001) whereas only SRL interquartile ranges correlated with triglyceride concentrations (P < 0.0001). Only pretransplant cholesterol concentration > 205 mg/dL was independently associated with development of persistent hypercholesterolemia (CavCHOL > 240 mg/dL, relative risk (RR) = 20, CI 3.8-104.6, P = 0.0004) whereas pretransplant triglyceride concentration > 150 mg/dL (RR = 7.2, CI 1.6-32.4, P = 0.01) or > 211 mg/dL (RR = 19.8, CI 3.6-107.9, P = 0.0006) and use of SRL (RR = 3, CI 1.0-8.8, P = 0.0049) were independently associated with development of persistent hypertriglyceridemia (CavTG > 200 mg/dL). Persistent hypercholesterolemia was more frequent among patients with higher pretransplant cholesterol concentrations and was dependent on both CsA and SRL concentrations. Persistent hypertriglyceridemia was more frequent among patients with higher pretransplant triglyceride concentrations and was dependent on SRL concentrations.
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Affiliation(s)
- G A Spinelli
- Divisão de Nefrologia, Hospital do Rim e Hipertensão, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Baptista-Silva JC, Medina-Pestana JO, Verissimo MJM, Castro MJ, Demuner MS, Signorelli MF. Right renal vein elongation with the inferior vena cava for cadaveric kidney transplants: an old neglected surgical approach. Int Braz J Urol 2005; 31:519-25; discussion 525. [PMID: 16386119 DOI: 10.1590/s1677-55382005000600002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2005] [Accepted: 07/07/2005] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Short right renal vein is a frequent and well-known technical inconvenience that is commonly observed during transplantation of the right kidney. We present our experience with the elongation of short cadaveric right renal veins using the contiguous vena cava during cadaveric renal transplants. METHODS We performed 34 kidney transplantations with a short right renal vein requiring elongation using the inferior vena cava, to make the venous anastomosis technically feasible. The elongated right renal vein was anastomosed end to side to the external iliac vein in 24 patients, to the common iliac vein in 8 patients and to the inferior vena cava in 2 patients. The right renal artery with an aortic patch was implanted end to side in 33 patients, and end to end without aortic patch to the internal iliac artery in one patient. RESULTS In all cases, the vascular anastomoses were easily performed in the recipient and no thrombosis was observed. CONCLUSION Elongation of a short right renal vein with the inferior vena cava is a feasible mean to overcome technical problems that may compromise the results of cadaveric renal transplantation.
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Campos EF, Temin J, Paiva RF, Miyamoto Y, Dantas LV, Machado PG, Medina-Pestana JO, Gerbase-DeLima M. Pre-transplant anti-HLA class I or II panel reactive antibodies are associated with poor kidney graft survival. Hum Immunol 2005. [DOI: 10.1016/j.humimm.2005.08.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Campos EF, Tedesco H, Medina-Pestana JO, Park SI, Gerbase-DeLima M. Anti-HLA class II post-transplant antibodies are associated with graft loss due to chronic allograft nephropathy. Hum Immunol 2005. [DOI: 10.1016/j.humimm.2005.08.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Moutinho RS, Perez RM, Pace FHL, Ferreira ASP, Cendoroglo M, Medina-Pestana JO, Lanzoni VP, Silva AEB, Ferraz MLG. Lack of Impact of Hepatitis C Virus Coinfection in End-Stage Renal Disease Patients With Hepatitis B Virus Infection. Transplant Proc 2005; 37:2080-2. [PMID: 15964344 DOI: 10.1016/j.transproceed.2005.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2004] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Hepatitis B virus (HBV) and hepatitis C virus (HCV) coinfection results in more severe forms of liver disease in nonuremic patients; however, the impact of HCV coinfection is not clearly known in end-stage renal disease (ESRD) patients with HBV infection. We sought to determine the impact of HCV coinfection in HBV-infected ESRD patients. PATIENTS AND METHODS The HBsAg-positive ESRD patients evaluated between March 1999 and May 2003 were divided into two groups: group B, HBV infection alone, and group BC, HBV-HCV coinfection (anti-HCV-positive). Both groups were compared regarding epidemiological, laboratory, and histological findings. A liver biopsy was obtained in cases with evidence of viral replication and/or elevated alanine aminotransferase. RESULTS One hundred patients (73% men) with mean age of 42 +/- 11 years (55 patients in group B and 45 in group BC) were studied. Comparison between groups showed a difference in time on hemodialysis and duration of infection, which were higher in group BC (P < .001 and P = .001, respectively) and in history of blood transfusion, which was also more frequent in group BC (P = .04). Liver biopsies, obtained from 15 patients in group B and 28 patients in group BC, showed no difference in frequency of septal fibrosis (60% in group B vs 48% in group BC, P = .46) or interface hepatitis (73% vs 71%, P = .99). CONCLUSIONS HBV-HCV coinfection was related to a longer time on hemodialysis, longer duration of infection, and history of blood transfusion. Contrary to nonuremic patients, HCV coinfection was not associated with more severe forms of liver disease in ESRD patients.
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Affiliation(s)
- R S Moutinho
- Universidade Federal de São Paulo, São Paulo, Brazil
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Park SI, Felipe CR, Machado PG, Garcia R, Skerjanec A, Schmouder R, Tedesco-Silva H, Medina-Pestana JO. Pharmacokinetic/pharmacodynamic relationships of FTY720 in kidney transplant recipients. Braz J Med Biol Res 2005; 38:683-94. [PMID: 15917949 DOI: 10.1590/s0100-879x2005000500005] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
FTY720 is a new and effective immunosuppressive agent, which produces peripheral blood lymphopenia through a lymphocyte homing effect. We investigated the relationship between the dose of FTY720 or blood concentration (pharmacokinetics, PK) and peripheral lymphopenia (pharmacodynamics, PD) in 23 kidney transplant recipients randomized to receive FTY720 (0.25-2.5 mg/day) or mofetil mycophenolate (2 mg/day) in combination with cyclosporine and steroids. FTY720 dose, blood concentrations and lymphocyte counts were determined weekly before and 4 to 12 weeks after transplantation. The effect of PD was calculated as the absolute lymphocyte count or its reductions. PK/PD modeling was used to find the best-fit model. Mean FTY720 concentrations were 0.36 +/- 0.05 (0.25 mg), 0.73 +/- 0.12 (0.5 mg), 3.26 +/- 0.51 (1 mg), and 7.15 +/- 1.41 ng/ml (2.5 mg) between 4 and 12 weeks after transplantation. FTY720 PK was linear with dose (r(2) = 0.98) and showed low inter- and intra-individual variability. FTY720 produced a dose-dependent increase in mean percent reduction of peripheral lymphocyte counts (38 vs 42 vs 56 vs 77, P < 0.01, respectively). The simple Emax model [E = (Emax * C)/(C + EC50)] was the best-fit PK/PD modeling for FTY720 dose (Emax = 87.8 +/- 5.3% and ED50 = 0.48 +/- 0.08 mg, r(2) = 0.94) or concentration (Emax = 78.3 +/- 2.9% and EC50 = 0.59 +/- 0.09 ng/ml, r(2) = 0.89) vs effect (% reduction in peripheral lymphocytes). FTY720 PK/PD is dose dependent and follows an Emax model (EC50 = 0.5 mg or 0.6 ng/ml). Using lymphopenia as an FTY720 PD surrogate marker, high % reductions (~80%) in peripheral lymphocytes are required to achieve best efficacy to prevent acute allograft rejection.
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Affiliation(s)
- S I Park
- Divisão de Nefrologia, Hospital do Rim e Hipertensão, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil.
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Machado PGP, Felipe CR, Park SI, Garcia R, Moreira S, Casarini D, Franco M, Alfieri F, Tedesco-Silva H, Medina-Pestana JO. Preservation of graft function in low-risk living kidney transplant recipients treated with a combination of sirolimus and cyclosporine. Braz J Med Biol Res 2004; 37:1303-12. [PMID: 15334195 DOI: 10.1590/s0100-879x2004000900004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The use of sirolimus (SRL) in combination with full doses of cyclosporin A (CsA) results in reduced one-year kidney allograft function, which is associated with shorter long-term allograft survival. We determined the effect of reduced CsA exposure on graft function in patients receiving SRL and prednisone. Ninety recipients of living kidney transplants receiving SRL (2 mg/day, po) were compared to 35 recipients receiving azathioprine (AZA, 2 mg kg-1 day-1, po). All patients also received CsA (8-10 mg kg-1 day-1, po) and prednisone (0.5 mg kg-1 day-1). Efficacy end-point was a composite of biopsy-confirmed acute rejection, graft loss, or death at one year. Graft function was measured by creatinine, creatinine clearance, and graft function deterioration between 3 and 12 months (delta1/Cr). CsA concentrations in patients receiving SRL were 26% lower. No differences in one-year composite efficacy end-point were observed comparing SRL and AZA groups (18 vs 20%) or in the incidence of biopsy-proven acute rejection (14.4 and 14.3%). There were no differences in mean +/- SD creatinine (1.65 +/- 0.46 vs 1.60 +/- 0.43 mg/dl, P = 0.48) or calculated creatinine clearances (61 +/- 15 vs 62 +/- 13 ml/min, P = 0.58) at one year. Mean +/- SD delta1/Cr (-11 +/- 17 vs -14 +/- 15%, P = 0.7) or the percentage of patients with >20% (26 vs 31%, P = 0.6) or >30% delta1/Cr (19 vs 17%, P = 1) did not differ between the two groups. The use of 2-mg fixed oral doses of SRL and reduced CsA exposure was effective in preventing acute rejection and preserving allograft function.
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Affiliation(s)
- P G P Machado
- Divisão de Nefrologia, Hospital do Rim e Hipertensão, Universidade Federal de São Paulo, Brasil
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