Utilidade das biópsias de vigilância em transplantados renais na vigência de disfunção inicial do enxerto

Base teórica. As diretrizes assistenciais recomendam biópsias de vigilância na DGF, no entanto, tais diretrizes são de uma época em que a efetividade dos regimes imunossupressores, em prevenir rejeição aguda, era consideravelmente menor. A elevada incidência de disfunção inicial do enxerto (DGF) observada no Brasil determina que biópsias de vigilância sejam realizadas com considerável frequência em pacientes transplantados renais. Objetivo. O objetivo do estudo é avaliar a utilidade presente dessas biópsias e as características clínico-laboratoriais associadas aos desfechos do enxerto renal. Métodos. Coorte retrospectiva de pacientes transplantados renais com órgãos de doadores falecidos no Hospital de Clínicas de Porto Alegre entre Janeiro de 2006 e Julho de 2019 com DGF submetidos à biópsia de vigilância. Resultados. Realizadas 356 biópsias, maioria dos pacientes masculinos (61,2%), caucasóides (74,9%), sendo 51,7% sem sensibilização HLA. O tempo de isquemia fria foi 25,6±5,6 horas. Em 89,1% dos casos houve indução da imunossupressão com anticorpos. Em média as biópsias foram realizadas no dia 14,7±8,2 de pós-operatório. Na análise histológica foram identificadas 6 (1,7%) biópsias normais, 142 (39,9%) biópsias com necrose tubular aguda isolada, 90 (25,3%) alterações borderline, 87 (24,4%) casos de rejeição aguda celular, 5 (1,4%) rejeiões agudas mediadas por anticorpos, 23 (6,5%) necroses de coagulação, 1 (0,3%) microangiopatia trombótica e 2 (0,6%) pielonefrites. Não houve correlação entre idade do doador, raça, sensibilização e doador limítrofe com rejeição aguda. Em análise multivariada foram significativas as correlações da rejeição aguda com o tempo de DGF, idade do receptor e tipo da terapia de indução. Conclusão. A elevada incidência de rejeição aguda nesse grupo de pacientes, mesmo sob terapia imunossupressora contemporânea, faz com que as biópsias de vigilância permaneçam um recurso diagnóstico essencial em pacientes transplantados renais com órgãos de doador falecido que apresentem DGF.Background. The high incidence of delayed graft dysfunction (DGF) observed in Brazil determines that surveillance biopsies are performed with considerable frequency in kidney transplant recipients. The still current guidelines were written in an era in which the effectiveness of immunosuppressive therapy was substantially lower in preventing acute rejection. Objective. To evaluate the usefulness of surveillance biopsies and the clinical-laboratory characteristics associated with renal graft outcomes in particular acute graft rejection. Methods. Retrospective cohort of kidney transplant patients at the Hospital de Clínicas of Porto Alegre between January 2006 and July 2017 who underwent a surveillance graft biopsy during the DGF period. Results. Three hundred and fifty-six biopsies were performed in 335 patients who were predominantly males (61.2%), Caucasoid (74.9%), and without HLA sensitization (51.7%). Mean cold ischemia time was 25.6±5.6 hours. Antibody induction therapy occurred in 89.1% of patients. On average, biopsies were performed at 14.7±8.2 days after transplantation. Histological analysis identified 6 (1.7%) normal biopsies, 142 (39.9%) biopsies with isolated acute tubular necrosis, 90 (25.3%) borderline alterations, 87 (24.4%) cases of acute cellular rejection, 5 (1.4%) acute antibody-mediated rejections, 23 (6.5%) coagulation necrosis, 1 (0.3%) thrombotic microangiopathy and 2 (0.6%) pyelonephritis. There was no correlation between donor age, race, sensitization and borderline donor with acute rejection. In the multivariate analysis, the correlations between DGF length, recipient age and type of induction therapy were significant. Conclusion. The high incidence of acute rejection in the subset of kidney transplant recipients with DGF, even under contemporary immunosuppressive therapy, sustains surveillance biopsies as an essential diagnostic resource in deceased donor kidney transplant recipients with DGF

Delayed graft function under the microscope : surveillance biopsies in kidney transplantation

Delayed graft function (DGF) is a common complication of kidney transplantation and frequently leads to the necessity of surveillance biopsies. The purpose of this study is to describe the histological findings in surveillance biopsies of deceased donor kidney transplant recipients and evaluate the risk factors for graft outcomes. This is a monocentric, retrospective study including kidney transplant recipients that underwent a graft biopsy during the DGF period between January 2006 and July 2019. 356 biopsies were performed in 335 deceased donor transplant recipients. Biopsies were analyzed according to the Banff classification. The main histological findings were: acute tubular necrosis in 150 biopsies (42.1%), acute rejection in 96 biopsies (26.9%), and borderline findings in 91 biopsies (25.5%). In the multivariate analysis, recipient age (p = 0.028) and DGF duration (p = 0.005) were associated with rejection, antibody-induction with anti-thymocyte globulin (ATG) was protective (p = 0.001). The occurrence of rejection was associated with lower death-censored graft survival (log-rank; p = 0.009). Surveillance biopsies of kidney grafts experiencing DGF remain an essential tool for the care of kidney transplant recipients. The recipient’s age and duration of DGF are independent risk factors for acute rejection, while antibody-induction therapy with ATG is associated with protection from its occurrence

Polyclonal anti T-lymphocyte antibody therapy monitoring in kidney transplant recipients : comparison of CD3+ T cell and total lymphocyte counts

Objetivo: Investigar a correlação entre a contagem de linfócitos totais e células T CD3+ no sangue periférico em receptores de transplante renal submetidos a tratamento com globulina antitimocitária, e discutir resultados relacionados. Métodos: Estudo retrospectivo de centro único envolvendo 226 pacientes submetidos a transplante renal entre 2008 e 2013 e tratados com globulina antitimocitária, para fins de indução ou tratamento de rejeição celular. As doses foram ajustadas de acordo com a contagem de células T CD3+ ou linfócitos totais no sangue periférico. Resultados: No total, 664 amostras pareadas foram analisadas. O coeficiente de correlação de Spearman para as amostras em geral foi de 0,416 (p20 células/mm³. Conclusão: A contagem de linfócitos totais no sangue periférico não substitui a contagem de células T CD3+ enquanto estratégia de monitorização da terapia à base de globulina antitimocitária.Objective: To investigate the correlation between total lymphocyte and CD3+ T cell counts in peripheral blood in renal transplant patients treated with anti-thymocyte globulin, and discuss related outcomes. Methods: A single-center, retrospective study involving 226 patients submitted to kidney transplant between 2008 and 2013, and treated with anti-thymocyte globulin for induction or treatment of cellular rejection. Doses were adjusted according to CD3+ T cell or total lymphocyte counts in peripheral blood. Results: A total of 664 paired samples were analyzed. The Spearman’s correlation coefficient was 0.416 (p20 cells/mm³. Conclusion: Total lymphocyte and CD3+ T cell counts in peripheral blood are not equivalent monitoring strategies in anti-thymocyte globulin therap

Posterior reversible leukoencephalopathy syndrome (PRES) after kidney transplantation: a case report

<div><p>ABSTRACT Introduction: Posterior reversible leukoencephalopathy syndrome (PRES) was first described by Hinchey in 1996. The syndrome is characterized by altered level of consciousness, headache, visual changes, and seizures associated with a vasogenic edema of the white matter that occurs predominantly in the occipital and parietal lobes. Imaging tests such as computed tomography (CT) and especially magnetic resonance imaging (MRI) support the diagnosis. Case Report: We report a case of a 48-year-old female patient who underwent a deceased donor kidney transplant and received tacrolimus as a part of the immunosuppressive regimen. Five weeks after transplantation she was admitted to the emergency due to sudden onset of confusion, disorientation, visual disturbances, and major headache. PRES was suspected and the diagnosis confirmed by brain MRI. Tacrolimus was withdrawn and rapid improvement of the neurological signs occurred leading to the conclusion that this drug triggered the syndrome. Conclusion: PRES is an unusual complication after organ transplantation and should be considered in the appropriate clinical setting. Physicians must be aware of this condition in order to provide early detection and appropriate treatment since delay in removing the cause may lead to permanent sequelae.</p></div

Posterior reversible leukoencephalopathy syndrome (PRES) after kidney transplantation: a case report

<div><p>ABSTRACT Introduction: Posterior reversible leukoencephalopathy syndrome (PRES) was first described by Hinchey in 1996. The syndrome is characterized by altered level of consciousness, headache, visual changes, and seizures associated with a vasogenic edema of the white matter that occurs predominantly in the occipital and parietal lobes. Imaging tests such as computed tomography (CT) and especially magnetic resonance imaging (MRI) support the diagnosis. Case Report: We report a case of a 48-year-old female patient who underwent a deceased donor kidney transplant and received tacrolimus as a part of the immunosuppressive regimen. Five weeks after transplantation she was admitted to the emergency due to sudden onset of confusion, disorientation, visual disturbances, and major headache. PRES was suspected and the diagnosis confirmed by brain MRI. Tacrolimus was withdrawn and rapid improvement of the neurological signs occurred leading to the conclusion that this drug triggered the syndrome. Conclusion: PRES is an unusual complication after organ transplantation and should be considered in the appropriate clinical setting. Physicians must be aware of this condition in order to provide early detection and appropriate treatment since delay in removing the cause may lead to permanent sequelae.</p></div