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Freire MP, Camargo CH, Yamada AY, Nagamori FO, Reusing Junior JO, Spadão F, Cury AP, Rossi F, Nahas WC, David-Neto E, Pierrotti LC. Critical points and potential pitfalls of outbreak of IMP-1-producing carbapenem-resistant Pseudomonas aeruginosa among kidney transplant recipients: a case-control study. J Hosp Infect 2021; 115:83-92. [PMID: 34033889 DOI: 10.1016/j.jhin.2021.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 03/10/2021] [Revised: 05/05/2021] [Accepted: 05/16/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Carbapenem-resistant Pseudomonas aeruginosa (CRPA) infection after kidney transplantation (KT) is associated with high mortality. AIM To analyse an outbreak of infection/colonization with IMP-1-producing CRPA on a KT ward. METHODS A case-control study was conducted. Cases were identified through routine surveillance culture and real-time polymerase chain reaction for carbapenemase performed directly from rectal swab samples. Controls were randomly selected from patients hospitalized on the same ward during the same period, at a ratio of 3:1. Strain clonality was analysed through pulsed-field gel electrophoresis (PFGE), and whole-genome sequencing was performed for additional strain characterization. FINDINGS CRPA was identified in 37 patients, in 51.4% through surveillance cultures and in 49.6% through clinical cultures. The median persistence of culture positivity was 42.5 days. Thirteen patients (35.1%) presented a total of 15 infections, of which seven (46.7%) were in the urinary tract; among those, 30-day mortality rate was 46.2%. PFGE analysis showed that all of the strains shared the same pulsotype. Multilocus sequence typing analysis identified the sequence type as ST446. Risk factors for CRPA acquisition were hospital stay >10 days, retransplantation, urological surgical reintervention after KT, use of carbapenem or ciprofloxacin in the last three months and low median lymphocyte count in the last three months. CONCLUSION KT recipients remain colonized by CRPA for long periods and could be a source of nosocomial outbreaks. In addition, a high proportion of such patients develop infection. During an outbreak, urine culture should be added to the screening protocol for KT recipients.
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Affiliation(s)
- M P Freire
- Working Committee for Hospital Epidemiology and Infection Control, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil.
| | - C H Camargo
- Bacteriology Division, Instituto Adolfo Lutz, São Paulo, Brazil
| | - A Y Yamada
- Bacteriology Division, Instituto Adolfo Lutz, São Paulo, Brazil
| | - F O Nagamori
- Bacteriology Division, Instituto Adolfo Lutz, São Paulo, Brazil
| | - J O Reusing Junior
- Renal Transplantation Unit, Department of Urology, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - F Spadão
- Working Committee for Hospital Epidemiology and Infection Control, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - A P Cury
- Microbiology Laboratory, Central Laboratory, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - F Rossi
- Microbiology Laboratory, Central Laboratory, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - W C Nahas
- Renal Transplantation Unit, Department of Urology, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - E David-Neto
- Renal Transplantation Unit, Department of Urology, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - L C Pierrotti
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
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Ramalho J, Bacelar Marques ID, Aguirre AR, Pierrotti LC, de Paula FJ, Nahas WC, David-Neto E. Pneumocystis jirovecii pneumonia with an atypical granulomatous response after kidney transplantation. Transpl Infect Dis 2014; 16:315-9. [PMID: 24621124 DOI: 10.1111/tid.12198] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [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: 03/12/2013] [Revised: 05/09/2013] [Accepted: 10/12/2013] [Indexed: 12/11/2022]
Abstract
Pneumocystis jirovecii pneumonia (PCP) continues to be a leading cause of morbidity and mortality in kidney transplant recipients. Granulomatous PCP is an unusual histological presentation that has been described in a variety of immunosuppressive conditions. Previous studies have demonstrated an association between granulomatous disorders and hypercalcemia, the purported mechanism of which is extrarenal production of 1,25-dihydroxyvitamin D by activated macrophages. Here, we report a case of granulomatous formation in a kidney transplant recipient with PCP who presented with hypercalcemia and suppressed parathyroid hormone, both of which resolved after successful treatment of the pneumonia. In immunocompromised patients, pulmonary infection associated with hypercalcemia should raise the suspicion of PCP and other granulomatous disorders.
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Affiliation(s)
- J Ramalho
- Nephrology Division, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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3
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Marques IB, Silva RDM, Moraes CE, Azevedo LS, Nahas WC, David-Neto E, Furmanczyk-Zawiska A, Baczkowska T, Chmura A, Szmidt J, Durlik M, Joslin J, Blaker P, White B, Marinaki A, Sanderson J, Goldsmith DJ, Medani S, Traynor C, Mohan P, Little D, Conlon P, Molina M, Gonzalez E, Gutierrez E, Sevillano A, Polanco N, Morales E, Hernandez A, Praga M, Morales JM, Andres A, Park SJ, Kim TH, Kim YW, Kim YH, Kang SW, Kujawa-Szewieczek A, Szotowska M, Kuczera P, Chudek J, Wiecek A, Kolonko A, Mahrova A, Svagrova K, Bunc V, Stollova M, Teplan V, Hundt F, van Heteren P, Woitas R, Cavallo MC, Sepe V, Conte F, Albrizio P, Bottazzi A, Geraci PM, Alpay N, Gumber MR, Kute VB, Vanikar AV, Patel HV, Shah PR, Engineer DP, Trivedi HL, Golebiewska JE, Debska-Slizien A, Rutkowski B, Matias P, Martins AR, Raposo L, Jorge C, Weigert A, Birne R, Bruges M, Adragao T, Almeida M, Mendes M, Machado D, Masin-Spasovska J, Dohcev S, Stankov O, Stavridis S, Saidi S, Dejanova B, Rambabova-Busletic I, Dejanov P, Spasovski G, Nho KW, Kim YH, Han DJ, Park SK, Kim SB, Fenoglio R, Lazzarich EE, Cagna D, Cena T, Conti N, Quaglia M, Radin E, Izzo C, Stratta P, Oh IH, Park JS, Lee CH, Kang CM, Kim GH, Leone F, Lofaro D, Gigliotti P, Lupinacci S, Toteda P, Vizza D, Perri A, Papalia T, Bonofiglio R, di Loreto P, de Silvestro L, Montanaro D, Martino F, Sandrini S, Minetti E, Cabiddu G, Yildirim T, Yilmaz R, Turkmen E, Abudalal A, Altindal M, Ertoy-Baydar D, Erdem Y, Panuccio V, Tripepi R, Parlongo G, Versace MC, Politi R, Zoccali C, Mallamaci F, Porrini E, Silva I, Diaz J, Ibernon M, Moreso F, Benitez R, Delgado Mallen P, Osorio J, Lauzurica R, Torres A, Ersoy A, Koca N, Gullu Koca T, Kirhan E, Sarandol E, Ersoy C, Dirican M, Milne J, Suter V, Mikhail A, Akalin H, Dizdar O, Ersoy A, Pascual J, Torio A, Garcia C, Hernandez J, Perez-Saez MJ, Mir M, Anna F, Crespo M, Carta P, Zanazzi M, Antognoli G, Di Maria L, Caroti L, Minetti E, Dizdar O, Ersoy A, Akalin H, Ray DS, Mukherjee K, Bohidar NP, Pattanaik A, Das P, Thukral S, Kimura T, Yagisawa T, Ishikawa N, Sakuma Y, Fujiwara T, Nukui A, Gavela EE, Sancho AA, Kanter JJ, Avila AA, Beltran SS, Pallardo LL, Dawoud FG, Aithal V, Mikhail A, Majernikova M, Rosenberger J, Prihodova L, Nagyova I, Jarcuskova M, Roland R, Groothoff JW, van Dijk JP, van Agteren M, de Weerd A, van de Wetering J, IJzermans J, Betjes M, Weimar W, Popoola J, Reed A, Tavarro R, Chryssanthopoulou C, MacPhee I, Mayor M, Franco S, Jara P, Ayala R, Orue MG, Martinez A, Martinez M, Wasmouth N, Arik G, Yasar A, Turkmen E, Yildirim T, Altindal M, Abudalal A, Yilmaz S, Arici M, Bihari Bansal S, Pokhariyal S, Jain S, Sethi S, Ahlawat R, Kher V, Martins LS, Aguiar P, Dias L, Fonseca I, Henriques AC, Cabrita A, Davide J, Sparkes TM, Trofe-Clark J, Reese PP, Jakobowski D, Goral S, Doll SL, Abt PL, Sawinski D, MBloom RD, Knap B, Lukac J, Lukin M, Majcen I, Pavlovec F, Kandus A, Bren AF, Kong JM, Jeong JH, Ahn J, Lee DR, Son SH, Kim BC, Choi WY, Whang EJ, Czajka B, Malgorzewicz S, Debska-Slizien A, Rutkowski B, Panizo N, Rengel MA, Vega A, Abad S, Tana L, Arroyo D, Rodriguez-Ferrero M, Perez de Jose A, Lopez-Gomez JM, Koutroutsos K, Sackey J, Paolini L, Ramkhelawon R, Tavarro R, Chowrimootoo M, Whelan D, Popoola J, Szotowska M, Kuczera P, Chudek J, Wiecek A, Kolonko A, Slatinska J, Honsova E, Wohlfahrtova M, Slimackova E, Rajnochova SB, Viklicky O, Yankovoy A, Smith ISJ, Wylie E, Ruiz-Esteban P, Lopez V, Garcia-Frias P, Cabello M, Gonzalez-Molina M, Vozmediano C, Hernandez D, Pavlovic J, Radivojevic D, Lezaic V, Simic-Ogrizovic S, Lausevic M, Naumovic R, Ersoy A, Koca N, Kirhan E, Gullu Koca T, Ersoy C, Sarandol E, Dirican M, Sakhuja V, Gundlapalli S, Rathi M, Jha V, Kohli HS, Sharma A, Minz M, Nimgirova A, Esayan A, Kayukov I, Zuyeva E, Bilen Y, Cankaya E, Keles M, Gulcan E, Turkeli M, Albayrak B, Uyanik A, Yildirim R, Molitor N, Praktiknjo M, Woitas R, Abeygunaratne TN, Balasubramanian S, Baker R, Nicholson T, Toprak O, Sari Y, Keceli S, Kurt H, Rocha A, Malheiro J, Martins LS, Fonseca I, Dias L, Pedroso S, Almeida M, Henriques A, Nihei C, Bacelar Marques I, Seguro CA, David-Neto E, Mate G, Martin N, Colon L, Casellas L, Garangou D, de la Torre M, Torguet P, Garcia I, Calabia J, Valles M, Pruthi R, Calestani M, Leydon G, Ravanan R, Roderick P, Korkmaz S, Ersoy A, Gulten S, Koca N. Transplantation - clinical studies II. Nephrol Dial Transplant 2013. [DOI: 10.1093/ndt/gft155] [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: 11/14/2022] Open
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Caires RA, Marques IDB, Repizo LP, Sato VAH, Carmo LPF, Machado DJB, de Paula FJ, Nahas WC, David-Neto E. De novo thrombotic microangiopathy after kidney transplantation: clinical features, treatment, and long-term patient and graft survival. Transplant Proc 2013; 44:2388-90. [PMID: 23026601 DOI: 10.1016/j.transproceed.2012.07.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Posttransplant thrombotic microangiopathy (TMA)/hemolytic uremic syndrome (HUS) can occur as a recurrent or de novo disease. METHODS A retrospective single-center observational study was applied in order to examine the incidence and outcomes of de novo TMA/HUS among transplantations performed between 2000 and 2010. Recurrent HUS or antibody-mediated rejections were excluded. RESULTS Seventeen (1.1%) among 1549 kidney transplant recipients fulfilled criteria for de novo TMA. The mean follow-up was 572 days (range, 69-1769). Maintenance immunosuppression was prednisone, tacrolimus (TAC), and mycophenolic acid in 14 (82%) patients. Mean age at onset was 40 ± 15 years, and serum creatinine was 6.1 ± 4.1 mg/dL. TMA occurred at a median of 25 days (range, 1-1755) after transplantation. Nine (53%) patients developed TMA within 1 month of transplantation and only 12% after 1 year. Clinical features were anemia (hemoglobin < 10 g/dL) in 9 (53%) patients, thrombocytopenia in 7 (41%), and increased lactate dehydrogenase in 12 (70%). Decreased haptoglobin was observed in 64% and schistocytes in 35%. Calcineurin inhibitor (CNI) withdrawal or reduction was the first step in the management of 10/15 (66%) patients, and 6 (35%) received fresh frozen plasma (FFP) and/or plasmapheresis. TAC was successfully reintroduced in six patients after a median of 17 days. Eight (47%) patients needed dialytic support after TMA diagnosis and 75% remained on dialysis. At 4 years of follow-up, death-censored graft survival was worse for TMA group (43.0% versus 85.6%, log-rank = 0.001; hazard ratio = 3.74) and there was no difference in patient survival (53.1% versus 82.2%, log-rank = 0.24). CONCLUSION De novo TMA after kidney transplantation is a rare but severe condition with poor graft outcomes. This syndrome may not be fully manifested, and clinical suspicion is essential for early diagnosis and treatment, based mainly in CNI withdrawal and FFP infusions and/or plasmapheresis.
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Affiliation(s)
- R A Caires
- Nephrology Division, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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5
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Falci R, Torricelli FC, Antonopoulos IM, Piovesan AC, Kanashiro H, Saito F, Ebaid GX, Nahas WC. Single center experience with elective surgical patients as living kidney donors. Transplant Proc 2012. [PMID: 23194997 DOI: 10.1016/j.transproceed.2012.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE To report a single center experience with elective surgical patients as living kidney donors. METHODS We retrospectively analyzed a prospective database of 458 living kidney donors from September 2005 to May 2011. Fifteen (3.2%) of them were elective surgical patients simultaneously undergoing living donor nephrectomy. We reviewed age, gender, operative time, intraoperative blood transfusion, intra- and postoperative complications, as well as length of hospital stay. Recipients were evaluated for delayed graft function. Four hundred forty-three patients undergoing living donor nephrectomy alone composed the control group. RESULTS Among the elective surgical patients group, the mean (range) operative time was 155 (90 to 310) minutes and mean (range) length of hospital stay was 3 (2 to 9) days. One (6.7%) recipient displayed delayed graft function. Among the regular living kidney donors group, the mean (range) operative time was 100 (70 to 150) minutes, mean (range) length of hospital stay was 3 (2 to 5) days, and delayed graft function was observed in 5.6% of recipients. Only operative time (P = .03) was significantly different between the groups. CONCLUSIONS Elective surgical patients are potential donors who may be treated at the same time as the living donor nephrectomy.
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Affiliation(s)
- R Falci
- Renal Transplantation Unit, Division of Urology, Department of Surgery, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
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David-Neto E, David DSR, Ginani GF, Rodrigues H, Souza PS, Castro MCR, Kanashiro H, Saito F, Falci R, Antonopoulos IM, Piovesan AC, Nahas WC. C4d staining in post-reperfusion renal biopsy is not useful for the early detection of antibody-mediated rejection when CDC crossmatching is negative. Nephrol Dial Transplant 2010; 26:1388-92. [DOI: 10.1093/ndt/gfq549] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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7
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Ribeiro-David DS, David-Net E, Castro MCR, Souza NA, Reis M, Saldanha L, Sabbaga E, Nahas WC, Ianhez IE. Contribution of the expression of ICAM-1, HLA-DR and IL-2R to the diagnosis of acute rejection in renal allograft aspirative cytology. Transpl Int 2008. [DOI: 10.1111/j.1432-2277.1998.tb01112.x] [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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8
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Britto ZML, David-Neto E, Lemos FC, Pereira LM, Castro MCR, Fonseca JA, Alves CF, Nahas WC, Ianhez LE, David-Neto E. Identifying cyclosporine blood levels associated with the prevention of renal transplant rejection: a single-center, randomized prospective study. Transplant Proc 2004; 36:2649-55. [PMID: 15621114 DOI: 10.1016/j.transproceed.2004.10.015] [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: 11/29/2022]
Abstract
Multiple-drug therapy may allow reduced individual drug doses with fewer side effects. Blood levels of cyclosporine (CsA) necessary to avoid rejection may vary with different drug combinations. Fifty-eight kidney transplant patients were randomized into two groups: 25 subjects were assigned to the 4-hour area under the curve (AUC(0-4)) Cohort-the "high arm" (4500 to 5500 ng . h/mL)--1 and 33 to the AUC(0-4) "low arm" (2400 to 3400 ng . h/mL). After CsA introduction, AUC(0-4) was drawn on days 4, 7, 14, 21, 28, 42, 56, 70, 84, 90. We compared the proportion of rejection versus rejection-free patients, according to the CsA exposure. Logistic regression analysis showed that an AUC(0-4) of > or =4000 ng . h/mL or a 2-hour cyclosporine level (C(2)) of > or =1450 ng/mL predicted a rejection-free course among patients not receiving induction therapy. When either basiliximab or thymoglobulin was administered, a C(2) and AUC(0-4) of 1043 +/- 151 ng/mL or 3146 +/- 262 ng . h/mL, respectively, were associated with a rejection-free course. Our findings confirm the need for different CsA levels to prevent rejection according to induction therapy. Induction with either basiliximab or thymoglobulin allows reduced CsA levels during the first 3 months after renal transplantation.
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Affiliation(s)
- Z M L Britto
- Universidade de São Paulo, São Paulo 01246-903 , Brazil
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9
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Castro MCR, Araujo LMP, Nahas WC, Arap S, David-Neto E, Ianhez LE. Induction versus noninduction therapy in kidney transplantation: considering different PRA levels and different induction therapies. Transplant Proc 2004; 36:874-6. [PMID: 15194299 DOI: 10.1016/j.transproceed.2004.03.084] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [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: 10/26/2022]
Abstract
To evaluate the rate of acute cellular rejection (ACR) and long-term results in different levels of anti-HLA sensitization, using noninduction or different induction therapies, 763 patients who underwent transplantation from January 1995 to December 2001 were evaluated: 213 patients received induction therapy, 71 received Thymoglobulin (Thymo), 66 Simulect, and 44 OKT3. Follow-up time was at least 1 year for all groups. The Simulect group included older recipients and the OKT3 group had more female patients. Simulect and OKT3 groups had more black patients; Thymo and OKT3 groups had more retransplantations. PRA was low in the noninduction group (mean, 7%) and about the same in the Simulect and Thymo groups (mean, 30%). OKT3 was the most sensitized group (mean = 59%). Dialysis during the first posttransplantation week was more frequent among the induction groups (43% vs 65%; P <.005). Fewer patients experienced rejection episodes in the Thymo group (20% vs 50%; P =.02). Patients were classified according to their level of sensitization, and the Thymo group showed the lower rejection rates in all levels (mean, 20%; P =.001). When analyzing PRA >50%, the Thymo group showed lower rejection rates (12% vs 50%; P =.02). At this level of sensitization, there was no significant difference on graft loss and death with a functioning graft. There was a trend to more cytomegalovirus (CMV) disease in the Thymo group (33% vs 23%; P =.08). Two PTLD were diagnosed, both in the noninduction group. Renal function was better in the Thymo group (1.3 mg/dL). In conclusion, Thymo showed lower ACR rates in all PRA groups. No significant differences in CMV infection, tumors, and patient survival were observed.
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Affiliation(s)
- M C R Castro
- Renal Transplantation Unit, São Paulo Medical School, Sao Paulo-SP, Brazil.
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Nahas WC, Mazzucchi E, Arap MA, Antonopoulos IM, Piovesan AC, Neto ED, Arap S. How to deal with children with end-stage renal disease and severe bladder dysfunction. Transplant Proc 2003; 35:849-50. [PMID: 12644162 DOI: 10.1016/s0041-1345(02)04025-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- W C Nahas
- Hospital das Clinicas, Universidade of São Paulo School of Medicine, São Paulo, Brazil
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Affiliation(s)
- W C Nahas
- Renal Transplantation Unit, Division of Urology, School of Medicine, Hospital das Clínicas of the University of São Paulo, 288 Apt 61, R. Fernandes de Abreu, São Paulo, SP 04543-070, Brazil
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Antonopoulos IM, Nahas WC, Mazzucchi E, Ianhez LE, Saldanha LB, Arap S. Comparison of palpation-guided and ultrasound-guided biopsies in transplanted kidneys. Clin Transplant 2001; 15:393-6. [PMID: 11737115 DOI: 10.1034/j.1399-0012.2001.150605.x] [Citation(s) in RCA: 5] [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: 12/17/2022]
Abstract
UNLABELLED Biopsy is the gold standard for the diagnosis of conditions affecting the function of renal allografts. Obtaining representative tissue in biopsies is critical but these procedures are associated with up to 9% of complications and 20% of inadequate material. Although ultrasound guidance allows perfect control of depth and location of the graft, there is controversy regarding the cost-benefit of its use and reports of unsuitable material in ultrasound-guided biopsies are still high. PURPOSE To compare ultrasound with the palpation method to guide biopsies in order to see if there is any difference between both methods and which one is better. PATIENTS AND METHODS The casuistic consisted of 82 renal transplant patients (32 female and 50 male patients, age ranging between 5 and 64 yr; m=31.2 yr) randomized into two groups: GI, palpation-guided; GII, ultrasound-guided. Fifty-six biopsies were performed in GI and 66 in GII. RESULTS Number of glomeruli, arcuate, and interlobar arteries and arterioles were compared in the two groups and were 503 (m=10) vs. 801 (m=12.9), 24 (m=0.5) vs. 38 (m=0.6), 104 (m=2.1) vs. 154 (m=2.5), and 174 (m=3.5) vs. 264 (4.3), respectively (p<0.05). Inadequate material for analysis in GI and GII was 7.1 and 7.6%, respectively (p=0.72). CONCLUSIONS Although ultrasound guidance improves the number of glomeruli, arcuate, and interlobar arteries, as well as arterioles, compared with palpation-guided biopsies, there is no difference in the rate of adequate material between the two methods.
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Affiliation(s)
- I M Antonopoulos
- Division of Urology, University of Sao Paulo School of Medicine Hospital, Rua Jaragua, 192, 01129-000 Sao Paulo, Brazil.
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Abstract
CONTEXT There is still controversy as to the use and dosage of antimicrobial prophylaxis of the urinary infection associated with urethral catheterization in the post renal transplant period. OBJECTIVE To determine whether patients develop urinary infection during short-term urethral catheterization after renal transplant without routine antimicrobial prophylaxis. DESIGN Prospective study. SETTING Kidney Transplantation Unit. SAMPLE 20 patients submitted to non-complicated kidney transplant, with a normal urinary tract and no risk factors present regarding urinary infection. Aged 15 to 65 years. MAIN MEASUREMENTS Before the transplant, material from the urethral meatus and urine were collected for culture. After the transplant, in the period during which the patient was with short-term urethral catheterization (4 to 5 days), material from the urethral meatus and urine from the bladder and the collecting bag were taken daily from all recipients for culture. RESULTS There was a predominance of coagulase-negative Staphylococcus and S. viridans in the normal urethral meatus flora and in the first two days of urethral catheterization. After the second day, there was a predominance of E. coli and E. faecalis. Urinary infection did not occur during the period of urethral catheterization. In the follow up only one female patient (7%) had asymptomatic bacteriuria caused by E.coli after the withdrawal of the urethral catheter. CONCLUSIONS Infection urinary does not occur during the period of urethral catheterization in kidney post-transplant patients. Thus, antimicrobial prophylaxis is not recommended for these patients to prevent urinary infection.
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Affiliation(s)
- L C de Oliveira
- Kidney Transplantation Unit, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil.
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Nahas WC, Mazzucchi E, Antonopoulos I, Denes FT, David-Neto E, Ianhez LE, Arap S. End-stage renal disease and bladder dysfunction: algorithm for renal transplantation. Transplant Proc 2001; 33:2984-5. [PMID: 11543821 DOI: 10.1016/s0041-1345(01)02281-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- W C Nahas
- Division of Urology, University of Sao Paulo School of Medicine Hospital, Sao Paulo, Brazil
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Mazzucchi E, Nahas WC, Antonopoulos I, Ianhez LE, Arap S. Incisional hernia and its repair with polypropylene mesh in renal transplant recipients. J Urol 2001; 166:816-9. [PMID: 11490225] [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: 02/21/2023]
Abstract
PURPOSE We evaluate the incidence of incisional hernia after kidney transplantation, predisposing factors and the results of surgical repair with polypropylene mesh. MATERIALS AND METHODS We reviewed the records of 371 consecutive kidney transplants performed between April 1995 and February 2000. Patients with clinical signs of hernia at the transplant incision site were included in the study. Predisposing factors for incisional hernia were also reviewed. A prospective protocol of surgical correction was established using polypropylene mesh and patient outcome was studied. RESULTS We identified 14 patients (3.8%) with an incisional hernia at the transplant incision site. Hernias developed 3 to 840 days after transplant surgery and were significantly more common in white (p = 0.019) and cadaveric graft (p = 0.02) recipients. Predisposing factors in 11 cases included complications of transplant surgery in 7, bladder obstruction in 2, large polycystic kidneys in 1 and chronic pulmonary disease in 1. Surgical repair was performed by primary fascial approximation and polypropylene mesh reinforcement in 13 cases and by pre-peritoneal mesh placement in 1. Minor subcutaneous wound infection developed in 1 patient. No relapses were noted at a mean followup of 17.8 months. CONCLUSIONS In the majority of cases incisional hernia develops in the first 3 months after transplant surgery. The incidence is significantly higher in white patients and after cadaveric donor transplantation. Surgical complications of transplant surgery are important predisposing factors for incisional hernia after kidney transplantation. Surgical repair using polypropylene mesh is safe and effective in this group of patients.
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Affiliation(s)
- E Mazzucchi
- Renal Transplantation Unit, Division of Urology, University of São Paulo Medical School, São Paulo, Brazil
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David-Neto E, Araujo LM, Lemos FC, David DS, Mazzucchi E, Nahas WC, Arap S, Ianhez LE. Introduction of mycophenolate mofetil and cyclosporin reduction in children with chronic transplant nephropathy. Pediatr Transplant 2001; 5:302-9. [PMID: 11472611 DOI: 10.1034/j.1399-3046.2001.00007.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Chronic transplant nephropathy (CTN) is the most important cause of kidney graft dysfunction. Studies in adult populations have reported a beneficial effect of non-nephrotoxic mycophenolate mofetil (MMF) on graft function in this setting. However, few studies were reported in children in this setting. We therefore reviewed the charts/medical records of renal transplanted patients < 18 yr of age at a single center who had switched from azathioprine to MMF as a result of progressive loss in graft function, for which vascular, infectious, and urological causes were excluded. Serum creatinine (SCr) and calculated creatinine clearance were compared prior to and after MMF introduction. Thirteen patients (nine male/four female), followed-up for 59.3 +/- 35.4 months after transplantation, were analyzed. Age at MMF introduction was 14.2 +/- 3.6 yr. In 11 patients a previous biopsy had shown features of CTN and four patients also presented signs of chronic cyclosporin A (CsA) nephrotoxicity. MMF was started at a dose of 1211 +/- 351 mg/day, and the CsA dose was decreased from 6.69 +/- 3.15 mg/kg/day 6 months before MMF to 4.8 +/- 2.3 mg/kg/day at the time of MMF introduction. CsA was withdrawn in four patients. The median (25-75%) SCr value increased from 1.60 mg/dL (range 1.3 to 1.87 mg/dL) 6 months before MMF to 2.2 mg/dL (range 1.87-2.32 mg/dL) when MMF was introduced. Six months after introduction of MMF, the SCr level had decreased to 1.5 mg/dL (range 1.2-1.8 mg/dL) and remained stable until the last follow-up (17.5 +/- 9.2 months after MMF was started). A similar pattern occured with calculated SCr clearance. There were no acute rejections after changes in immunosuppression. The safety of MMF was also analyzed and in only one patient was the drug stopped as a result of intractable diarrhea. These findings suggest that MMF is sufficiently powerful to allow a decrease/withdrawal of CsA without the burden of acute rejection in a pediatric population with CTN.
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Affiliation(s)
- E David-Neto
- Renal Transplantation Unit, Hospital das Clínicas, University of São Paulo School of Medicine, 01250-040-São Paulo, Brazil.
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David-Neto E, Ballarati CA, Freitas OJ, Lemos FC, Nahas WC, Arap S, Kalil J. Comparison of the fluorescent polarization (TDx) and the enzymatic competitive (EMIT 2000) immune assays for the measurement of cyclosporin A blood concentration. Rev Hosp Clin Fac Med Sao Paulo 2000; 55:207-12. [PMID: 11313660 DOI: 10.1590/s0041-87812000000600003] [Citation(s) in RCA: 9] [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] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Evaluation of Cyclosporin A (CyA) blood concentration is imperative in solid organ transplantation in order to achieve maximal immunosuppression with the least side effects. We compared the results of whole blood concentrations of CyA in 50 blood samples simultaneously evaluated by the fluorescent polarization immune assay (TDx) and the enzymatic competitive immune assay (EMIT 2000). There was a strong correlation between both kits for any range of CyA blood concentration (R=0.99, p<0.001). The within-run and between-days coefficient of variation were less than 4% for both assays. The cost for each CyA measurement was 50% lower for the EMIT assay when compared to the TDx assay. We concluded that the EMIT is as accurate as the TDx in measuring CyA blood concentration and has the advantage of a lower cost, as well as the possibility of widespread access to the EMIT methodology in contrast to the TDx equipment, allowing the laboratory to perform several routines within a working day.
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18
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Nahas WC, Mazzucchi E, Scafuri AG, Antonopoulos I, Neto ED, Ianhez LE, Arap S. Extraperitoneal access for kidney transplantation in children weighing 20 kg. or less. J Urol 2000; 164:475-8. [PMID: 10893626] [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: 02/17/2023]
Abstract
PURPOSE We present our experience with kidney transplantation in children weighing 20 kg. or less. Surgery was done via extraperitoneal access while preserving the peritoneal cavity intact with special attention given to technical feasibility and the complication rate. MATERIALS AND METHODS Included in our study were 46 children with a median age of 7 years weighing 20 kg. or less (mean 16.6), of whom 16 weighed less than 15 kg. (median 13.2). The 25 boys and 21 girls underwent a total of 49 kidney transplants, including 2 in 3 during the study. Donors were living related in 44 cases and cadaveric in 5. Surgical access was obtained by making a J-shaped pararectal incision in a curvilinear fashion from the symphysis pubis to near the costal border. RESULTS Mean hospital stay was 22.9 days (range 6 to 83) and mean followup was 55.8 months (range 12 to 131). All patients received water on day 1 and food on day 2 postoperatively. In 6 patients 7 surgical complications developed, including urinary fistula in 2, superficial wound infection in 2 and vascular complications in 3 (renal vein thrombosis, stenosis and renal artery kinking in 1 each). Only 1 graft was lost due to a surgical complication. CONCLUSIONS There are many advantages to using extraperitoneal access without an increase in surgical complications or technical difficulty. Absent gastrointestinal complications, an easier way to perform percutaneous biopsy, treatment of any surgical complication with no need for repeat laparotomy and the possibility of using the peritoneal cavity when dialysis is needed postoperatively are attractive justifications for extraperitoneal access.
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Affiliation(s)
- W C Nahas
- Unidade de Transplantes Renais do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Nahas WC, Hakim NS, Mazzucchi E, Antonopoulos LM, Eltayar AR, Labruzzo C, Chocair PR, Arap S. Transplantation of horseshoe kidney en bloc. Int Surg 2000; 85:272-4. [PMID: 11325010] [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: 02/19/2023] Open
Abstract
Horseshoe kidney is probably the most common renal fusion anomaly. With the continuous donor shortage, transplant surgeons tend to accept donors previously considered unsuitable. We present a successful case of en bloc horseshoe kidney transplant in a single recipient. The literature is reviewed. The use of horseshoe kidneys in transplantation is recommended in selected cases.
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Affiliation(s)
- W C Nahas
- Department of Urology, Hospital das Clinicas, University São Paolo Medical School, Brazil
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20
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Mazzucchi E, Lucon AM, Nahas WC, Neto ED, de Castro MC, Saldanha LB, Sabbaga E, Ianhez LE, Arap S. Histologic outcome of acute cellular rejection in kidney transplantation after treatment with methylprednisolone. Transplant Proc 2000; 32:784-5. [PMID: 10856584 DOI: 10.1016/s0041-1345(00)00981-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- E Mazzucchi
- Renal Transplantation Unit, Division of Urology, Cl¿inicas Hospital, University of Såo Paulo Medical School, Såo Paulo, Brazil
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21
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Nahas WC, Scafuri AG, Mazzucchi E, Antonopoulos I, Neto ED, Ianhez LE, Arap S. Extraperitoneal access for kidney transplantation in children weighing less than 20 KG. Transplant Proc 2000; 32:776-7. [PMID: 10856580 DOI: 10.1016/s0041-1345(00)00978-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- W C Nahas
- Unidade de Transplante Renal do Hospital das Cl¿inicas da Faculdade de Medicina da Universidade de São Paulo, Såo Paulo, Brazil
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22
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Machado DJ, Cocuzza CS, Nahas WC, Ianhez LE. Sclerosing encapsulating peritonitis after renal transplantation. Does it make sense? Perit Dial Int 2000; 20:341-3. [PMID: 10898054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Affiliation(s)
- D J Machado
- Renal Transplant Unit, Hospital das Clínicas, University of São Paulo, Brazil
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David-Neto E, Americo da Fonseca J, Jota de Paula F, Nahas WC, Sabbaga E, Ianhez LE. The impact of azathioprine on chronic viral hepatitis in renal transplantation: a long-term, single-center, prospective study on azathioprine withdrawal. Transplantation 1999; 68:976-80. [PMID: 10532537 DOI: 10.1097/00007890-199910150-00013] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [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
BACKGROUND In transplanted patients, viral hepatitis progresses to chronic liver disease and patient's death after many years of transplantation. Also, it is well known that azathioprine (AZA) is harmful to the liver of these patients. However, it is unclear whether a low dose of AZA still represents a threat to the viral liver disease. METHODS A total of 79 patients with hepatitis C, B, or both, transplanted between 1973 and 1990, were grouped according to whether they had AZA either withdrawn from the immunosuppressive regimen [group (G) I, n=45] or a dosage reduction only (group II, n=34). The decision to remove or to keep AZA was restricted to the patient's doctor. Patients records were reviewed by April 1997. RESULTS After an equal time of follow-up, after the AZA changing (64+/-26 vs. 58+/-29 months), patients in GI showed a significant decrease in the serum liver parameters when compared to baseline [alanine aminotransferase (ALT): P=0.001; gamma-glutamyl transferase (gamma-GT): P=0.001 and total bilirubin: P=0.002], whereas in GII only ALT decreased (P=0.04) although gamma-GT and total bilirubin did not. Compared to baseline, serum creatinine (SCr) increased only in GI (P=0.001) but, at last follow-up, did not differ from GII. The intention-to-perform liver biopsies was equal in GI and GII (16 vs. 14) but the hystological findings of severe chronic liver disease (either chronic active hepatitis or cirrhosis) were more frequent in GII (P=0.004). Death with a functioning graft was much more frequent in GII than in GI (P=0.001). Infection and cirrhosis were more common as a cause of death in GII than in GI. CONCLUSIONS The use AZA is harmful to renal transplantation patients with both chronic hepatitis C and B and, therefore, should be avoided. AZA withdrawal, but not dose adjustments, diminishes the serum liver enzymes and the progression rate of the chronic viral liver disease as well as the rate of death secondary to infection and cirrhosis.
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Affiliation(s)
- E David-Neto
- Renal Transplantation Unit, Hospital das Clinicas of the University of São Paulo School of Medicine, Brazil
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24
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Nahas WC, Iizuka FH, Mazzucchi E, Antonopoulos IM, Lucon AM, Arap S. Adenocarcinoma of an augmented bladder 25 years after ileocecocystoplasty and 6 years after renal transplantation. J Urol 1999; 162:490-1. [PMID: 10411067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- W C Nahas
- Unidade de Transplante Renal do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
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25
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Mazzucchi E, Lucon AM, Nahas WC, Neto ED, Saldanha LB, Sabbaga E, Ianhez LE, Arap S. Histological outcome of acute cellular rejection in kidney transplantation after treatment with methylprednisolone. Transplantation 1999; 67:430-4. [PMID: 10030291 DOI: 10.1097/00007890-199902150-00016] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [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: 11/26/2022]
Abstract
BACKGROUND Several studies comparing the response of acute cellular rejection (ACR) episodes to different corticosteroid regimens have been conducted. However, in most of them, the histological evaluation of the infiltrate and its correlation with clinical response was not studied. The clinical and histological outcomes of 37 episodes of ACR treated with methylprednisolone (MP) were studied, with the aim to determine how long the infiltrate takes to be cleared after therapy. METHODS A total of 37 patients with biopsy-proven ACR were treated with 8 or 16 mg of MP/kg/day. Allograft biopsies were repeated at 5 and 10 days after the end of corticotherapy. Clinical and histological outcomes were compared. RESULTS Six patients were excluded; 15 (48.4%) patients responded to therapy; the mean serum creatinine of these patients reached normal levels in the 2 weeks that followed treatment. Nine patients (60%) of this group had signs of ACR on biopsies done 5 days after corticotherapy, and four (26.7%) maintained them on the 10th day. Among 16 patients with no clinical response, none reached normal serum creatinine levels; 15 (93.7%) had signs of rejection 5 days after treatment and maintained them on the 10th day. Histological signs of ACR disappeared in 73.3% of patients with clinical response 10 days after therapy, but in only 6.3% of patients with no response (P=0.001). CONCLUSIONS Biopsies performed 5 days after treatment show a high incidence of features of ACR; such features take on average 10 days to disappear in nearly 75% of cases with successful therapy with MP.
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Affiliation(s)
- E Mazzucchi
- Division of Urology, Clínicas Hospital, University of São Paulo Medical School, Brazil
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26
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David-Neto E, da Fonseca JA, de Paula FJ, Nahas WC, Sabbaga E, Ianhez LE. Is azathioprine harmful to chronic viral hepatitis in renal transplantation? A long-term study on azathioprine withdrawal. Transplant Proc 1999; 31:1149-50. [PMID: 10083514 DOI: 10.1016/s0041-1345(98)01941-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- E David-Neto
- Renal Transplantation Unit, Hospital das Clínicas of the University of São Paulo, School of Medicine, Brazil
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Abstract
PURPOSE A shortage of organs for transplantation has forced surgeons to optimize the use of marginal organs, such as kidneys with arterial disease. We present a retrospective study of the outcome of donors with renal artery disease and recipients of kidneys from living related and unrelated donors. MATERIALS AND METHODS Kidneys with vascular abnormalities from healthy living donors were grafted into 11 recipients. These kidney transplants comprised 1.8% of those performed at our institution. The vascular abnormalities were aneurysms in 3 cases, atherosclerotic lesions in 4 and fibromuscular dysplasia in 4. After nephrectomy all abnormalities were corrected under hypothermic conditions during bench surgery except in 3 cases of ostial atherosclerotic plaque, which was left in the donors. The renal artery was anastomosed to the external iliac artery in 5 cases and to the internal iliac artery in 6. The ureter was reimplanted using an extravesical technique. RESULTS All patients had immediate diuresis and no delayed post-transplant graft dysfunction was observed. One patient died of an unrelated cause and 3 had post-transplant graft function loss due to acute vasculopathy in 1, post-diarrhea with acute arterial thrombosis in 1 and recurrence of the hemolytic-uremic syndrome in 1. All remaining patients are well with median serum creatinine of 1.4 mg./dl. (normal 0.4 to 1.4). All donors are well and normotensive with normal renal function. CONCLUSIONS The use of kidneys with arterial disease from living donors with unilateral disease is safe. Complete informed consent regarding the risks and benefits by donor and recipient is mandatory.
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Affiliation(s)
- W C Nahas
- Unidade de Transplantes Renais do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
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Teixeira MC, Nahas WC, Mazucchi E, Ianhez LE, David-Neto E. Role of the peripheral renin profile in predicting blood pressure control after bilateral nephrectomy in renal-transplanted patients. Nephrol Dial Transplant 1998; 13:2092-7. [PMID: 9719172 DOI: 10.1093/ndt/13.8.2092] [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: 11/13/2022] Open
Abstract
BACKGROUND The unregulated renin release by native kidneys is one of the factors responsible for the high incidence of hypertension after renal transplantation but, even after three decades of transplantation, there is still a lack of a method to identify it as the major cause of hypertension. METHODS We investigated whether or not peripheral renin activity, before and 90 min after 25 mg of captopril, can play this role. One hundred and five consecutive patients with SCr less than 2 mg/dl were studied 18 +/- 8 months after renal transplantation. Forty-seven of them were considered hypertensive and 58 normotensive. All hypertensive patients were submitted to the captopril test to analyse the peripheral renin activity profile. RESULTS In the hypertensive group, 17 patients (36%) were considered Renin-pos and 30 (64%) Renin-neg. All Renin-pos (stimulated renin = 19.1 +/- 6.4 ng/ml/h) patients were submitted to bilateral nephrectomy (bNx) and re-evaluated 6 months later. All of them normalized renin activity (4.4 +/- 3.0 ng/ml/h, P = 0.0001) and 10 of 17 (60%) became normotensive and off drugs. The remaining seven (40%) decreased the number of hypotensive drugs from 2.2 +/- 0.5 to 0.5 +/- 0.7/pt/day. There was a correlation between b-Renin and dBP (r = 0.47, P < 0.05) which was lost after bNx. An 'in situ' renal-cell carcinoma was found in two cases. Serum creatinine did not change. CONCLUSIONS This study shows that the unregulated renin-angiotensin system from the native kidneys plays a major role in the maintenance of hypertension in some patients with normal graft function and that peripheral renin activity can identify those who will benefit from bilateral nephrectomy.
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Affiliation(s)
- M C Teixeira
- Division of Urology of the Hospital das Clínicas of the University of São Paulo School of Medicine, Brazil
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29
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Ribeiro-David DS, David-Neto E, Castro MC, Souza NA, Reis MM, Saldanha LB, Sabbaga E, Nahas WC, Ianhez IE. Contribution of the expression of ICAM-1, HLA-DR and IL-2R to the diagnosis of acute rejection in renal allograft aspirative cytology. Transpl Int 1998; 11 Suppl 1:S19-25. [PMID: 9664936 DOI: 10.1007/s001470050418] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute rejection is associated with a poor long-term prognosis for renal allografts. Sequential fine-needle aspiration cytology (FNAC) has been used to monitor rejection. However, FNAC diagnoses rejection only when the infiltrating cells are already damaging the graft and, in some borderline cases with a low increment of inflammatory cells in the graft, FNAC lacks the specificity to diagnose rejection. In these cases, the number of inflammatory cells within the graft can decline, stabilize or increase with time. In this study, we sought to determine whether the analysis of the expression of ICAM-I, HLA-DR and IL-2R along with borderline FNAC results increases the specificity to diagnose rejection. Of 117 FNAC samples taken from 24 patients after renal transplantation, 85 (72%) were considered suitable for cytological analysis. Of these patients, 9 (37%) did not suffer an acute cellular rejection (ACR) episode and 15 (63%) had at least one ACR episode. ICAM-1 and IL-2R were studied using an immune-peroxidase technique. The ICAM-1 results are expressed as the percentage of tubular cells in the aspirate stained with this marker and the IL-2R results are expressed as the absolute number of positively stained lymphocytes in the whole cytopreparation. With a total corrected increment (TCI) of > 3 there was a sharp increase in the specificity index for rejection that reached almost 100% at a TCI of > or = 4. Sensitivity for rejection at this level was only 20%. Between a TCI of 2.5 and 2.9 the sensitivity increased to 75%, with specificity for rejection around 75%. There was an upregulation of ICAM-1 and IL-2R when FNAC diagnosed rejection but with a large overlap of the results when compared either to normal graft or acute tubular neurosis. The mean TCI during the week preceding the rejection episode was 2.5 and the TCI reached a mean value of > or = 3 only during rejection. The peak ICAM-1 and IL-2R expression occurred during the week preceding the clinically evident rejection episode. The expression of ICAM-1 by > or = 70% of the tubular cells increased the specificity for rejection of a TCI of > or = 2.5 to 100%. In the same way, the specificity for rejection increased up to 90% when eight to ten IL-2R-positive lymphocytes were seen along with a TCI of > or = 2.5. There was no further increase in specificity after that. A specificity index of 100% for rejection could be obtained for moderate levels of both ICAM-1 (70% or more tubular cells) and IL-2R (eight or more lymphocytes). ICAM-1 expression in 70% or more tubular cells and/or IL-2R expression in eight or more lymphocytes was found in 58% of the FNAC aspirates with a TCI between 2.5 and 2.9. In conclusion, the expression of IL-2R in lymphoid cells and ICAM-1 in tubular cells was upregulated during rejection episodes and the upregulation preceded both the clinical and the routine FNAC diagnosis of rejection by 1 week. The ddition of these markers to the FNAC increased substantially the specificity of the FNAC to diagnose rejection.
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Affiliation(s)
- D S Ribeiro-David
- Renal Transplantation Unit, University of São Paulo Medical School, Brazil
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30
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Teixeira MC, Mazucchi E, Nahas WC, Ianhez LE, Machado MM, Arap S, Sabbaga E, David-Neto E. Peripheral renin activity predicts blood pressure control after bilateral nephrectomy in renal transplant patients. Transplant Proc 1997; 29:220-1. [PMID: 9122969 DOI: 10.1016/s0041-1345(96)00068-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- M C Teixeira
- Renal Transplantation Unit, Hospital das Clinicas, University of São Paulo, Brazil
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31
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Nahas WC, Mazzucchi E, Antonopoulos I, David-Neto E, Ianhez LE, Sabbaga E, Arap S. Kidney transplantation in patients with bladder augmentation: surgical outcome and urodynamic follow-up. Transplant Proc 1997; 29:157-8. [PMID: 9122941 DOI: 10.1016/s0041-1345(96)00047-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- W C Nahas
- Unidade de Transplante Renal, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, Brazil
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Abdallah KA, David-Neto E, Centeno JR, Nahas WC, Arap S. Reversal of the OKT3-related shivering and chest tightness by intravenous meperidine. Transplantation 1996; 62:145-6. [PMID: 8693536 DOI: 10.1097/00007890-199607150-00033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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David-Neto E, Ianhez LE, Nahas WC, Krasilcic S, Sabbaga E, Arap S. Do steroids matter in one-haplotype pediatric renal allograft recipients on cyclosporine/azathioprine? Transplant Proc 1994; 26:95-6. [PMID: 8109040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- E David-Neto
- Renal Transplantation Unit, Hospital das Clínicas, University of São Paulo, Brazil
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Nahas WC, Mazzucchi E, Henrique A, Ianhez LE, Saldanha LB, Sabbaga E, Arap S. Percutaneous needle biopsy of the renal allograft using the automated needle system: evaluation of 87 procedures. J Urol 1993; 150:313-5. [PMID: 8326550 DOI: 10.1016/s0022-5347(17)35469-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [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: 01/29/2023]
Abstract
Between April 1991 and February 1992 we obtained 87 percutaneous core needle biopsy specimens from 60 patients with the automatic biopsy gun. In 78 cases (89.7%) enough renal tissue was obtained for histological analysis. Acute rejection was present on 35 biopsies (40.3%) indicating antirejection therapy. No pathological signs of rejection were detected on 43 biopsies (49.4%). In 38 instances (43.7%) biopsy diagnosis differed from clinical presumptive diagnosis, affecting patient management, while in the remainder it was helpful to confirm clinical impressions. The only complication of the procedure was gross hematuria (requiring vesical irrigation in 1 patient). Due to its simplicity and low morbidity rate, renal biopsy with the automated needle system is the procedure of choice for evaluation and management of renal allograft dysfunction.
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Affiliation(s)
- W C Nahas
- Renal Transplantation Service, Hospital das Clinicas, Faculdade de Medicine, Universidade de São Paulo, Brazil
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Ianhez LE, de Paula FJ, Campagnari JC, Nahas WC, Saldanha LB, Arap S, Sabbaga E. [Survival analysis of 487 patients with kidney transplantation]. Rev Hosp Clin Fac Med Sao Paulo 1992; 47:180-4. [PMID: 1340599] [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] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The causes of graft loss were analysed in a group of 487 kidney transplants, of which 252 (51.46%) concerned related donors, 139 (28.5%) cadaver donors and 96 (19.7%) non-related donors. A total of 74 kidneys were lost in the first 3 months after transplantation (15.19%). In 34 cases the loss was due to immunological factors (45.9%) in 21 cases (28.3%) to the death of the patients and in 19 cases (25.7%) to the technical causes. From 34 losses by immunological problems, 32 were rejections with humoral character (acute vascular rejection in 11 cases, late humoral rejection in 11 cases, immediate humoral rejection in 9 cases, ABO incompatibility in one case) and recurrence of original disease in one case. Acute cellular rejection was observed in only one patient. None of the patients died from immunological loss of the graft. The most frequent cause of death were sepsis (13 out of 21 patients) and the most common focus of infection was pulmonary (5 patients). It occurred most frequently with cadaveric donor, (10.07%). Death related to cardiovascular causes occurred in four patients, digestive in two and in consequence of arterial bleeding in two. Among the 23 losses by technical factors renal artery thrombosis was the most frequent (11 cases); renal rupture occurred in three cases, renal vein thrombosis in two rupture of arterial anastomosis in one and inviable kidney in another one. The technical loss was most frequent with cadaver donors (8.63%), followed by non-related donors (4.16%) and related donors (2.77%). Four patients died from causes directly related to technical factors.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- L E Ianhez
- Unidade de Transplante Renal-Divisão de Clínica Urológica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo
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Affiliation(s)
- J A Fares
- Renal Transplantation Unit, Hospital Das Clinicas, University of Sao Paulo, Brazil
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Abstract
We review 38 cases of surgically corrected incontinent epispadias with a followup of 5 months to 18 years. In 20 cases the Leadbetter, in 8 the Tanagho and in 8 the Young-Dees techniques of bladder neck reconstruction were used. Of 3 patients with minimal (15 to 25 ml.) bladder capacity the Arap procedure was performed in 1, while small constriction of the bladder neck to improve the bladder capacity and compliance was done in 2. In 1 of the latter patients a 60 ml. capacity was achieved and a secondary Leadbetter operation provided an excellent result. Continence was attained after the initial operation in 18 patients, followup is too short to determine the result in 3 and 15 did not acquire urinary control. Revision of the bladder neck plasty was performed in 11 patients, which resulted in continence in 4 and partial continence in 2. Among 34 patients with an adequate followup 22 (73.3 per cent) are continent and 8 (26.4 per cent) are incontinent. The results were similar with the 3 techniques.
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Affiliation(s)
- S Arap
- Clinica Urologica do Hospital das Clinicas da Faculdade de Medicina, da Universidade de Sao Paulo, Brazil
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Abstract
The authors report 4 cases of urinary tract malakoplakia. This rare disease of unknown etiopathogenesis can present with a benign character in the bladder, but when the upper urinary tract is affected, loss of renal function can occur. Treatment aims to control the primary infection, as well as enhance intracellular bactericidal activity, which seems to be compromised in these cases. Cytoreductive surgery may be indicated when this treatment fails.
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Borrelli M, Bruschini H, Nahas WC, Figueiredo JA, Prado MJ, Spinola R, Walligora M, Freire GC, de Góes GM. Sacral agenesis: why is it so frequently misdiagnosed? Urology 1985; 26:351-5. [PMID: 4049612 DOI: 10.1016/0090-4295(85)90182-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Thirty-four patients with sacral agenesis were seen from 1954 to 1983, cases of meningomyelocele excluded. Five recognizable and consistent patterns of bone malformation were identified. Urodynamic examinations were done in 10 of the 34 patients. Their evaluation and response to treatment are analyzed; we tried to determine and establish the possible causes for its late diagnosis and consequences regarding the upper urinary tract.
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Arap S, Mitre AI, Giron AM, Nahas WC. [Surgical repair of mid-penis, proximal penis and penile-scrotal hypospadias using a double island flap of the prepuce]. Rev Hosp Clin Fac Med Sao Paulo 1985; 40:223-6. [PMID: 3836476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Arap S, Nahas WC, Alonso G, Denes FT, Martins LR, Menezes de Góes G. Assessment of hydroureteronephrosis by renographic evaluation under diuretic stimulus. Urol Int 1984; 39:170-4. [PMID: 6740807 DOI: 10.1159/000280968] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
42 dilated renal units, from 32 patients, were evaluated renographically with 131I, under diuretic stimulus, with the aim of differentiating between obstructed and atonic ureters. The results of this study are similar to the clinical follow-up and surgical findings in 88% of cases.
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Abstract
A case of congenital cyst of the seminal vesicle in association with an ectopic ureter is presented. The clinical, diagnostic and therapeutic aspects are discussed with special emphasis on the role played by ultrasound and computerized tomography in the evaluation of pelvic pain and painful ejaculation.
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Mitre AI, Alfer Júnior WU, Nahas WC, Lopes RN, Arap S. [Vesical schistosomiasis mansoni simulating a tumor. Report of a case (author's transl)]. AMB Rev Assoc Med Bras 1980; 26:74-6. [PMID: 6968941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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