Current management issues of immediate postoperative care in pediatric kidney transplantation

The number of pediatric kidney transplants has been increasing in many centers worldwide, as the procedure provides long-lasting and favorable outcomes; however, few papers have addressed the immediate postoperative care of this unique population. Herein, we describe the management of these patients in the early postoperative phase. After the surgical procedure, children should ideally be managed in a pediatric intensive care unit, and special attention should be given to fluid balance, electrolyte disturbances and blood pressure control. Antibiotic and antiviral prophylaxes are usually performed and are based on the recipient and donor characteristics. Thrombotic prophylaxis is recommended for children at high risk for thrombosis, although consensus on the optimum therapy is lacking. Image exams are essential for good graft control, and Doppler ultrasound must be routinely performed on the first operative day and promptly repeated if there is any suspicion of kidney dysfunction. Abdominal drains can be helpful for surveillance in patients with increased risk of surgical complications, such as urinary fistula or bleeding, but are not routinely required. The immunosuppressive regimen starts before or at the time of kidney transplantation and is usually based on induction with monoclonal or polyclonal antibodies, depending on the immunological risk, and maintenance with a calcineurin inhibitor (tacrolimus or ciclosporin), an anti-proliferative agent (mycophenolate or azathioprine) and steroids

A EFICIÊNCIA DO CONSENTIMENTO FRENTE A (HIPER)VULNERABILIDADE INFORMACIONAL DO TITULAR DE DADOS NO CONTEXTO PROTETIVO DA LGPD

The current stage, called informational society, consecrated by technological democratization and the unprecedented use of personal data and for the most diverse purposes, to the point that they become true commodities. This collection and processing of data, along with the numerous advantages it offers, also presents a perverse side that must be contemplated and regulated by the legal system, which, although the LGPD sought to minimize by providing the holders with mechanisms to authorize and control this flow of your personal information, requiring from these, among other bases, free, informed and unequivocal consent, the practice has shown that (hyper)vulnerability, especially of consumers, makes this mechanism for a supposed empowerment have become a true "horse of troy”, in view of the lack of knowledge about its future developments. The purpose of this article is to investigate the extent to which consumers can give conscious and valid consent, given the context of the processing of their personal data. At this juncture, through qualitative bibliographic research, it will be sought to understand to what extent the consumer has knowledge and control of the future treatment of their personal data, freely available for a certain purpose as well as the de facto empowerment regarding its unfolding and the possibilities of revocation.O estágio atual, denominado sociedade informacional, consagrado pela democratização tecnológica e o uso sem precedentes dos dados pessoais e para os mais diversos propósitos, ao ponto destes se tornarem verdadeiras commodities. Essa coleta e tratamento dos dados, ao lado das inúmeras vantagens que oferece, também apresenta um lado perverso que deve ser contemplado e regulado pelo ordenamento jurídico, que, muito embora a LGPD buscasse minimizar ao munir os titulares de mecanismos para autorizar e controlar esse fluxo de suas informações pessoais, exigindo destes dentre outras bases, o consentimento livre, informado e inequívoco, a prática vem demonstrando que a (hiper)vulnerabilidade, sobretudo dos consumidores, faz com que este mecanismo para um suposto empoderamento tenha se tornado um verdadeiro “cavalo de tróia”, tendo em vista a  falta de ciência quanto aos seus desdobramentos futuros. Perquirir até que ponto o consumidor pode dar um consentimento consciente e válido, tendo em vista o contexto do tratamento de seus dados pessoais é a proposta do presente artigo. Nessa conjuntura, por meio de pesquisa bibliográfica de cunho qualitativo buscar-se-á compreender até que ponto o consumidor detém ciência e controle dos tratamentos futuro de seus dados pessoais, livremente disponibilizados para determinada finalidade bem como o empoderamento de fato quanto aos seus desdobramentos e as possibilidades de revogação

Cystatin C measurement as renal function marker

INTRODUÇÃO: A cistatina C sérica tem sido apontada como um marcador de filtração glomerular. OBJETIVO: Realizar a validação de um método específico e automatizado, a imunonefelometria, mensurando os níveis séricos de cistatina C por meio do nefelômetro da empresa Behring (BN II) e correlacionar resultados obtidos entre pacientes transplantados. O ensaio perfaz o intervalo de referência de 0,23-7,25 mg/l. A imprecisão intra e interensaio foi de 8,73% e 5,38%, respectivamente. A recuperação analítica da cistatina C após adição de controle foi entre 86,7 % e 98% (média 92,3%). A estabilidade da cistatina C à temperatura ambiente, sob refrigeração e sob congelamento foi testada. A perda mais significativa foi encontrada nas amostras armazenadas à temperatura ambiente, em que foram perdidos até 10% da concentração inicial. Foi encontrado coeficiente de variação de 14,79% para sensibilidade analítica. Durante todo o processo foram comparados os resultados com o controle de qualidade e obtivemos bons resultados. Depois desses testes, nós comparamos as correlações em três grupos de pacientes transplantados renais sob diferentes esquemas de imunossupressão (n = 197) - azatioprina (n = 36), micofenolato mofetil (n = 131) e sirolimus (n = 30) - entre as equações de estimativa de filtração glomerular (Cockroft Gault, Nankivell e Modification of Diet in Renal Disease) e cistatina C sérica ou creatinina sérica. CONCLUSÃO: O ensaio nefelométrico cistatina C pode perfeitamente ser adequado à nossa rotina laboratorial e as correlações entre creatinina sérica e as diferentes equações de estimativa de filtração glomerular são melhores do que quando comparamos as mesmas à cistatina C nos três grupos, independentemente da terapia imunossupressora utilizada.INTRODUCTION: Serum cystatin C has been identified as a glomerular filtration marker. OBJECTIVE: To validate immunonephelometry, a specific and automated method, by measuring levels of serum cystatin C through Behring nephelometer (BN II) and correlate results among transplant patients. The assay comprises the reference range of 0:23 to 7:25 mg/l. The intra-assay and inter- assay imprecision rates were 8.73% and 5.38%, respectively. The analytical recovery of cystatin C after addition of control was between 86.7% and 98% (average 92.3%). The stability of cystatin C to room temperature, refrigerated or frozen was tested. The most significant loss was found in samples stored at room temperature, in which up to 10% of the initial concentration was lost. The coefficient of variation was 14.79% for analytical sensitivity. Throughout the process the results were compared with quality control and good results were achieved. After these tests, we compared the correlations between equations for estimating glomerular filtration rate (Cockroft Gault, Nankivell and MDRD) and serum cystatin C or serum creatinine in three groups of kidney transplant patients under different immunosuppressive regimens (n = 197) [azathioprine (n = 36), mycophenolate mofetil (n = 131) or sirolimus (n = 30)]. CONCLUSION: The nephelometric cystatin C assay may be perfectly suitable for our routine laboratory. The correlations between serum creatinine and the various equations for estimating glomerular filtration are better than those between cystatin C and equations for estimating glomerular filtration in the three groups irrespective of the immunosuppressive therapy used

Micofenolato mofetil pode proteger contra a pneumonia por Pneumocystis carinii em transplantados renais

Pneumocystis carinii pneumonia (PCP) is usually prevented in transplanted patients by prophylactic trimethoprim-sulfamethoxazol (TMS). Mycophenolate mofetil (MMF) has been shown to have a strong protective effect against PCP in rats. This effect is also suggested in humans by the absence of PCP in patients receiving MMF. After January 1998 MMF has been used with no TMS prophylaxis in renal transplanted patients. In azathioprine (AZA) treated patients TMS prophylaxis was maintained. The incidence of PCP was analyzed in both groups. Data were collected in order to have a minimum 6-month follow-up. Two hundred and seventy-two patients were eligible for analysis. No PCP occurred either in patients under MMF without TMS prophylaxis nor in patients under AZA. MMF may have an effective protective role against PCP as no patient under MMF, despite not receiving TMS coverage, developed PCP. A larger, controlled, trial is warranted to consolidate this information.A pneumonia por Pneumocystis carinii (PPC) em transplantados renais é, habitualmente, prevenida pelo uso profilático de trimetoprim-sulfametoxazol (TMS). Foi demonstrado que o micofenolato mofetil (MMF) exerce um poderoso efeito protetor sobre a PPC experimental em ratos. Este efeito também foi sugerido em humanos pela ausência de PPC em pacientes recebendo MMF. A partir de janeiro de 1998 passamos a usar o MMF em transplantados renais sem profilaxia por TMS. Nos pacientes recebendo azatioprina (AZA) a profilaxia com TMS continuou a ser empregada. A incidência de PPC foi analisada em ambos os grupos. Os dados foram coletados após um mínimo de seis meses de seguimento. Foram analisados 272 pacientes. Não ocorreu nenhum caso de PPC tanto nos pacientes recebendo MMF como naqueles recebendo AZA. O MMF pode ter exercido um efeito protetor contra a PPC, já que nenhum paciente sob MMF e sem receber profilaxia por TMS desenvolveu PPC. Estudos maiores e controlados se fazem necessários para confirmar estas informações

Parathyroidectomy after kidney transplantation: short- and long-term impact on renal function

INTRODUCTION: Kidney transplantation corrects endocrine imbalances. Nevertheless, these early favorable events are not always followed by rapid normalization of parathyroid hormone secretion. A possible deleterious effect of parathyroidectomy on kidney transplant function has been reported. This study aimed to compare acute and longterm renal changes after total parathyroidectomy with those occurring after general surgery. MATERIALS AND METHODS: This was a retrospective case-controlled study. Nineteen patients with persistent hyperparathyroidism underwent parathyroidectomy due to hypercalcemia. The control group included 19 patients undergoing various general and urological operations. RESULTS: In the parathyroidectomy group, a significant increase in serum creatinine from 1.58 to 2.29 mg/dl (P < 0.05) was noted within the first 5 days after parathyroidectomy. In the control group, a statistically insignificant increase in serum creatinine from 1.49 to 1.65 mg/dl occurred over the same time period. The long-term mean serum creatinine level was not statistically different from baseline either in the parathyroidectomy group (final follow-up creatinine = 1.91 mg/dL) or in the non-parathyroidectomy group (final follow-up creatinine = 1.72 mg/dL). CONCLUSION: Although renal function deteriorates in the acute period following parathyroidectomy, long-term stabilization occurs, with renal function similar to both preoperative function and to a control group of kidney-transplanted patients who underwent other general surgical operations by the final follow up

The perception of sleep quality in kidney transplant patients during the first year of transplantation

OBJECTIVE: Poor sleep quality is one of the factors that adversely affects patient quality of life after kidney transplantation, and sleep disorders represent a significant cardiovascular risk factor. The objective of this study was to investigate the prevalence of changes in sleep quality and their outcomes in kidney transplant recipients and analyze the variables affecting sleep quality in the first years after renal transplantation. METHODS: Kidney transplant recipients were evaluated at two time points after a successful transplantation: between three and six months (Phase 1) and between 12 and 15 months (Phase 2). The following tools were used for assessment: the Pittsburgh Sleep Quality Index; the quality of life questionnaire Short-Form-36; the Hospital Anxiety and Depression scale; the Karnofsky scale; and assessments of social and demographic data. The prevalence of poor sleep was 36.7% in Phase 1 and 38.3% in Phase 2 of the study. RESULTS: There were no significant differences between patients with and without changes in sleep quality between the two phases. We found no changes in sleep patterns throughout the study. Both the physical and mental health scores worsened from Phase 1 to Phase 2. CONCLUSION: Sleep quality in kidney transplant recipients did not change during the first year after a successful renal transplantation

Comparação dos imuno-ensaios de fluorescência polarizada (TDx) e enzimático competitivo (EMIT 2000 ) na dosagem da concentração de ciclosporina A no sangue total

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, pA avaliação da concentração sanguínea de ciclosporina A (CyA) é necessária em transplantes de órgãos sólidos para obter-se máxima imunosupressão e mínimos efeitos colaterais. Nós comparamos os resultados da concentração de CyA em 50 amostras sanguíneas analisadas pelos métodos dos imuno-ensaios de fluorescência polarizada (TDx) e enzimático competitivo (EMIT 2000). Houve uma forte correlação entre ambos métodos para qualquer faixa de concentração de CyA (R=0.99,

Hypovitaminosis D in patients undergoing kidney transplant: the importance of sunlight exposure

OBJECTIVES: Recent studies have shown a high prevalence of hypovitaminosis D, defined as a serum 25-hydroxyvitamin D level less than 30 ng/ml, in both healthy populations and patients with chronic kidney disease. Patients undergoing kidney transplant are at an increased risk of skin cancer and are advised to avoid sunlight exposure. Therefore, these patients might share two major risk factors for hypovitaminosis D: chronic kidney disease and low sunlight exposure. This paper describes the prevalence and clinical characteristics of hypovitaminosis D among patients undergoing kidney transplant. METHODS: We evaluated 25-hydroxyvitamin D serum levels in a representative sample of patients undergoing kidney transplant. We sought to determine the prevalence of hypovitaminosis D, compare these patients with a control group, and identify factors associated with hypovitaminosis D (e.g., sunlight exposure and dietary habits). RESULTS: Hypovitaminosis D was found in 79% of patients undergoing kidney transplant, and the major associated factor was low sunlight exposure. These patients had higher creatinine and intact parathyroid hormone serum levels, with 25-hydroxyvitamin D being inversely correlated with intact parathyroid hormone serum levels. Compared with the control group, patients undergoing kidney transplant presented a higher prevalence of 25-hydroxyvitamin D deficiency and lower serum calcium, phosphate and albumin but higher creatinine and intact parathyroid hormone levels. CONCLUSIONS: Our results confirmed the high prevalence of hypovitaminosis D in patients undergoing kidney transplant. Therapeutic strategies such as moderate sunlight exposure and vitamin D supplementation should be seriously considered for this population

The perception of sleep quality in kidney transplant patients during the first year of transplantation

OBJECTIVE: Poor sleep quality is one of the factors that adversely affects patient quality of life after kidney transplantation, and sleep disorders represent a significant cardiovascular risk factor. The objective of this study was to investigate the prevalence of changes in sleep quality and their outcomes in kidney transplant recipients and analyze the variables affecting sleep quality in the first years after renal transplantation. METHODS: Kidney transplant recipients were evaluated at two time points after a successful transplantation: between three and six months (Phase 1) and between 12 and 15 months (Phase 2). The following tools were used for assessment: the Pittsburgh Sleep Quality Index; the quality of life questionnaire Short-Form-36; the Hospital Anxiety and Depression scale; the Karnofsky scale; and assessments of social and demographic data. The prevalence of poor sleep was 36.7% in Phase 1 and 38.3% in Phase 2 of the study. RESULTS: There were no significant differences between patients with and without changes in sleep quality between the two phases. We found no changes in sleep patterns throughout the study. Both the physical and mental health scores worsened from Phase 1 to Phase 2. CONCLUSION: Sleep quality in kidney transplant recipients did not change during the first year after a successful renal transplantation.CAPESCAPE

BK virus salivary shedding and viremia in renal transplant recipients

Objectives: This study aimed to verify the presence of polyomavirus BK (BKPyV) in the saliva of kidney transplant recipients and to correlate it with blood viremia. Material and Methods: We have conducted a crosssectional study with a sample involving 126 renal transplant recipients. 126 samples of saliva and 52 samples of blood were collected from these patients. Detection and quantification of BKPyV were performed using a real-time PCR. To compare the presence of BKPyV in blood and saliva, the binomial proportion test was used. To verify associations between salivary shedding BKPyV and post-transplant periods (in months), the Mann-Whitney test was used. Spearman’s correlation was used to correlate the viral load in the saliva with blood of kidney transplant recipients. Results: The mean age of the study group was 51.11±12.45 years old, and 69 participants (54.8%) were female, with a mean post-transplantation time of 4.80±6.04 months. BKPyV was quantified in several samples of saliva and blood, with medians of 1,108 cp/mL and 1,255 cp/mL, respectively. Only 16/52 (30.8%) participants presented BKPyV in blood, and 59/126 (46.8%) excreted the virus in saliva (p=0.004). BKPyV shedding was found in patients at a shorter post-transplantation period (3.86±5.25, p=0.100). A weak correlation was observed between viral quantification in saliva and blood (Spearman’s correlation coefficient=0.193). Conclusion: The results of this study suggested that, although saliva excretes more BKPyV than blood, there is no reliable correlation between salivary shedding and blood viremia, showing two independent compartments of viral replication