Late Cytomegalovirus Infection in Kidney Transplant Recipients after a Six-Month Prevention Protocol

BACKGROUND: Despite a reduction in the incidence of cytomegalovirus (CMV) infections after kidney transplantation, less is known about late CMV infection in kidney transplant recipients. OBJECTIVE: To assess incidence of CMV infection in a cohort of patients under a high surveillance CMV prevention protocol and identify factors associated with late CMV infection. METHODS: Analysis of a consecutive cohort of 181 kidney allograft recipients between January 2012 and Aug 2015. CMV prevention-protocol consisted of 6-month universal prophylaxis and pre-emptive therapy for high-risk group (D+/R- or patients submitted to lymphocyte-depleting agent for induction or rejection treatment) and pre-emptive therapy for standard-risk group (D±/R+). Stopping valganciclovir was followed by CMV screening in the next two appointments. RESULTS: CMV infection was identified in 73 of 181 patients; the rate in high-risk group and standard-risk group was similar (p=0.443). However, in the latter group, the infection occurred mostly in the first 6 months. Late CMV infection occurred in 25 of 181 patients (5 of standard-risk group and 20 of high-risk group), after a median (IQR) of 253 (230.3-312.3) days after transplantation and 55 (41-89.5) days after the protocol period. Screening for CMV after valganciclovir discontinuation revealed 56% of late CMV infections. In high-risk group, D+/R- was associated with late CMV infection (HR 2.7, p=0.039) and in standard-risk group; lower age was associated with late CMV infection (HR 0.89, p=0.02). CONCLUSION: The incidence of CMV infection was similar to that reported in the literature. In high-risk patients, antigenemia surveillance during prophylaxis did not appear to reduce late CMV infections. Antigenemia screening after valganciclovir had limited results in the diagnosis of late CMV infection. D+/R- was associated to late CMV infection in high-risk group. Lower age appeared to influence late CMV infection in standard-risk group.info:eu-repo/semantics/publishedVersio

A Comparative Study of Cardiovascular Tolerability with Slow Extended Dialysis Versus Continuous Haemodiafiltration in the Critical Patient

Background: In the haemodynamically unstable patient the method of treatment of acute renal failure is still largely controversial. The purpose of our study was to compare slow extended dialysis with continuous haemodiafiltration in the critical patient with indication for renal replacement therapy and haemodynamic instability. Patients and Methods: This is a cohort study comparing in 63 ventilated critical patients a 12 month period when only continuous haemodiafiltration was used (n=25) with an equal period of slow extended dialysis (n=38). Our primary objective was to evaluate the impact of the dialytic procedure on cardiovascular stability in those patients. As secondary aims we considered system coagulation/thrombosis and predictors of mortality. In the two groups we analysed the first session performed, the second session performed and the average of all the sessions performed in each patient. Results: In these patients, mortality in the intensive care unit was high (68% in the continuous haemodiafiltration group and 63% in the slow extended dialysis group). We did not find any association between the dialytic technique used and death; only the APACHE score was a predictor of death. Slow extended dialysis was a predictor of haemodynamic stability, a negative predictor of sessions that had to be interrupted for haemodynamic instability, and a predictor of achieving the volume removal initially sought. Slow extended dialysis was also associated with less coagulation of the system. Conclusions: Our data suggested that slow extended dialysis use was not inferior to continuous haemodiafiltration use in terms of cardiovascular tolerability

Doença Mineral e Óssea (DMO) num Transplantado Renal

A 50-year-old post-menopausal recipient of a kidney allograft with bone pain, osteoporosis, persistent hypercalcaemia and elevated parathormone (PTH) levels, despite a satisfactory graft function, was treated with bisphosphonates and cinacalcet starting, respectively, 5 and 6 months after renal transplantation (RT). Sixteen months after treatment, there was improvement of bone mineral density (BMD) measured by dualenergy X-ray absorptiometry (DEXA). A bone biopsy was taken, unveiling a surprising and worrisome result. Post-RT bone disease is different from classic CKD-MBD and should be managed distinctly, including, in some difficult cases, an invasive evaluation through the performance of a bone biopsy, as suggested in the KDIGO guidelines

Empagliflozin and the New Age in the Treatment of Type 2 Diabetes: Beyond Glycemic Control

A diabetes mellitus tipo 2 (DMT2) tem associado um risco aumentado de mortalidade, principalmente, por doença cardiovascular (DCV). Interessa ter disponíveis opções terapêuticas que permitam o controlo glicémico mas que considerem, igualmente, a atuação sobre fatores de risco cardiovascular e a redução de eventos micro e macrovasculares. Nos últimos anos foram desenvolvidos vários inibidores do transporte renal de glicose via cotransporte de sódio/glicose (iSGLT), nomeadamente a empagliflozina, para promover a excreção urinária de glicose filtrada pelo rim. A empagliflozina é um inibidor competitivo, reversível, altamente potente e seletivo dos SGLT2, indicada no tratamento da hiperglicemia da DMT2. O EMPA-REG OUTCOME®, um ensaio clínico de resultados cardiovasculares aleatorizado, em dupla ocultação, controlado com placebo, que incluiu 7020 indivíduos com DMT2 e DCV estabelecida, avaliou o efeito da empagliflozina versus placebo, associado ao tratamento standard, na ocorrência de um compósito de 3 pontos MACE (Major Adverse Cardiovascular Events) - morte por causa cardiovascular, acidente vascular cerebral não fatal ou enfarte agudo de miocárdio não fatal. Com os resultados do EMPA-REG OUTCOME®, a empagliflozina foi o primeiro iSGLT2 a demonstrar uma redução de morbilidade cardiovascular em indivíduos com DMT2 com elevado risco cardiovascular, adicionando a proteção cardiovascular ao efeito anti-hiperglicémico do fármaco e abrindo uma nova era no tratamento e gestão da DMT2.Type 2 diabetes mellitus (T2DM) has an increased risk of mortality, mainly due to cardiovascular disease (CVD). There should be available therapeutic options that allow glycemic control but also consider the action on cardiovascular risk factors and the reduction of micro and macrovascular events. Several inhibitors of renal glucose transport via sodium/glucose cotransport (iSGLT), namely empagliflozin, have been developed in recent years, to promote kidney urinary excretion of glucose. Empagliflozin is a highly potent and selective, competitive, reversible inhibitor of SGLT2, indicated for hyperglycemia treatment in T2DM. EMPA-REG OUTCOME®, a randomized, double-blind, placebo-controlled clinical trial of 7020 subjects with established T2DM and CVD, evaluated the effect of empagliflozin versus placebo, associated with standard treatment, on the occurrence of a 3-point composite MACE (Major Adverse Cardiovascular Events) - cardiovascular death, nonfatal stroke or nonfatal myocardial infarction. With the results of EMPA-REG OUTCOME®, empagliflozin was the first iSGLT2 to demonstrate a reduction in cardiovascular morbidity in subjects with T2DM at high cardiovascular risk, adding cardiovascular protection to the antihyperglycaemic effect of the drug and, opening a new era in the management of T2DM.info:eu-repo/semantics/publishedVersio

Achieving K/DOQI Targets with Cinacalcet in Dialysis Patients with Secondary Hyperparathyroidism. A Portuguese Observational Study

Secondary hyperparathyroidism is a common complication of chronic kidney disease. The elevated serum intact parathyroid hormone, phosphorus, calcium and calcium x phosphorus product have been independently associated with an increased relative risk of mortality. The standard therapy for secondary hyperparathyroidism, including active vitamin D analogues and phosphate binders, is often insufficient to allow patients to achieve the recommended Kidney Disease Outcomes Quality Initiative targets for bone and mineral metabolism. Randomised controlled phase III clinical studies in chronic kidney disease patients with secondary hyperparathyroidism have shown that cinacalcet treatment increases the proportion of patients achieving the recommended Kidney Disease Outcomes Quality Initiative targets for intact parathyroid hormone, phosphorus, calcium and calcium x phosphorus product. Aims: This observational multicentre study aims to evaluate cinacalcet’s ability to achieve and maintain Kidney Disease Outcomes Quality Initiative targets in a population with secondary hyperparathyroidism on chronic haemodialysis in Portugal. Patients and Methods: Patients on chronic dialysis that received cinacalcet during a free sampling programme were enrolled. Retrospective and prospective monthly data were collected from 3 months before until 6 months after the beginning of cinacalcet treatment. Additional assessment included a 12 month evaluation of all parameters. Results: 140 dialysis patients with secondary hyperparathyroidism were enrolled, 60% male, mean age 57.4±14.1 years. The mean intact parathyroid hormone, calcium, phosphorus, and calcium x phosphorus product values at baseline were 751.7±498.8 pg/ml, 9.7±3.8 mg/dl, 5.5±1.5 mg/dl, and 52.7±25.3 mg2/dl2, respectively. After 6 months’ cinacalcet treatment, 26.2%, 53.6%, 59.3%, and 81.0% of the patients achieved the Kidney Disease Outcomes Quality Initiative recommended levels for intact parathyroid hormone, calcium, phosphorus, and calcium x phosphorus product, respectively. The mean dose of cinacalcet at 6 months was 57.1±29.7 mg/day. Conclusions: The use of cinacalcet in clinical practice is an effective option for the treatment of secondary hyperparathyroidism in chronic dialysis patients, allowing more patients to reach and maintain the Kidney Disease Outcomes Quality Initiative targets

Attention deficit hyperactivity disorder (ADHD) in adults: social-demographic profile from a university hospital ADHD outpatient unit in São Paulo, Brazil Transtorno de déficit de atenção e hiperatividade (TDAH) no adulto: perfil sócio-demográfico de pacientes com TDAH atendidos em ambulatório de um hospital universitário de São Paulo, Brasil

PURPOSE: To describe the social-demographic variables, including interpersonal, academic, and professional performance in adult individuals with the diagnoses of attention deficit hyperactivity disorder (ADHD). There are no reports of this kind in the Brazilian population with ADHD. The ADHD is a common disorder, which can reach up to 3% of the general population. METHOD: Descriptive study of adults with ADHD, according to the DSM-IV criteria (American Psychiatric Association). The sample was selected from a specialized outpatient service in São Paulo city. The social-demographic data was obtained by personal interviews. RESULTS: There was a predominance of males in the sample (61.2%) and a high education level (90.2% had at least a high school degree) and 52% of the 102 patients had repeated their class at a least once during their school lives. In addition, 22.5% of the population sample were unemployed at the time of the interview. CONCLUSION: The distribution of the socio-demographic variables in adult ADHD is similar to other ADHD samples reported in other countries, despite the high education level met in our sample. Similarities between child and adult ADHD could also be traced.<br>OBJETIVO: Descrever as variáveis sócio-demográficas incluindo desempenho acadêmico, profissional e interpessoal em uma população adulta com diagnóstico de transtorno de déficit de atenção e hiperatividade (TDAH). Até o momento não há relato na literatura do perfil desses pacientes na população brasileira. O TDAH é comum na população geral, podendo chegar a 3% das pessoas. MÉTODO: Foram avaliados adultos que tomaram conhecimento do serviço de atendimento especializado em TDAH através da mídia. O diagnóstico de TDAH foi realizado utilizando-se os critérios da Associação Psiquiátrica Americana (DSM-IV). Os dados sócio-demográficos foram obtidos através de entrevista pessoal com cada paciente. RESULTADOS: 102 indivíduos preencheram critérios para TDAH. Houve predomínio do sexo masculino (61,2%) com alto nível de escolaridade (90,2% tinham no mínimo 2º grau completo). Cinquenta e três pacientes (52%) foram reprovados pelo menos uma vez durante vida estudantil. No momento da entrevista, 22,5% encontravam-se desempregados. CONCLUSÃO: Observou-se uma semelhança da distribuição das variáveis sócio-demográficas com os indivíduos adultos com TDAH de outros países, apesar da escolaridade ser acima da média nacional. Além disso, pode-se também observar semelhanças entre as populações infantil e adulta com TDAH