Postoperatorio del paciente pediátrico trasplantado renal

El trasplante renal es la modalidad de tratamiento sustitutivo que mejores resultados proporciona a niños afectos de insuficiencia renal crónica terminal, aunque no está exenta de una importante morbilidad y mortalidad. Se describen el protocolo para el postoperatorio adoptado en nuestro centro: monitorazación y soporte, variantes inmunopresoras, exploraciones complementarias, y las diversas complicaciones que pueden aparecer después del trasplante

Trasplantament renal pediàtric: experiència a l'Hospital Clínic de Barcelona

Resum Introducció. Amb la introducció de la ciclosporina A, el pronòstic dels trasplantaments d'òrgans ha variat radicalment. En aquest estudi es revisa el trasplantament renal pediàtrica des del punt de vista d'una UCIP centrada en la problemática postoperatória i en els resultats finals. Material i mètodes. Es revisen 27 trasplantaments renals que es van fer entre el 1986 i el 1994, la gran majoria entre els 10 i els 14 anys, amb un rang de 4 a 20 anys. Resultats. Quant a l'etiologia de la IRC: 8 casos de malformació quística, 6 de quadres amb patologia intersticial, 4 heredofamiliars i glomerulars i els 5 restants sistèmics o congènits. Tres quartes parts deis pacients (el 78%) ja estaven en diàlisi. Es va detectar risc immunológic elevat (presència l'anticossos limfocitotóxics o retrasplantacions) en el 38%. En l'evolució postoperatória immediata destaquen com a complicacions: un cas de trombosi renal i dos esclats renals; a curt termini es va detectar un rebuig en 16 casos i necrosi tubular aguda en 5, i van necessitar diàlisi el 18% del total. Als 5 anys la supervivència de l'empelt va ser del 78% i la del pacient del 100%. Conclusions. Comparant aquestes darreres dades amb registres similars nacionals, europeus i americans, s'han obtingut uns resultats equiparables

The impact of donor age on the results of renal transplantation

Producción CientíficaBackground. The use of elderly donors is becoming more frequent. An increase in the donor’s age is associated with a greater incidence of delayed graft function (DGF), chronic allograft nephropathy (CAN) and worse graft survival. Poor renal graft function is a risk factor for cardiovascular (CV) complications and, finally, for mortality of the patients. Methods. A total of 3365 adult patients transplanted in 1990 (n¼824), 1994 (n¼1075) and 1998 (n¼1466) with a functioning graft after the first year were included. The impact of donor age on renal function, DGF, acute rejection and other clinical factors was evaluated according to two donor and recipient age categories: young (60 years old). Additionally, donor age was categorized by decades for the analysis of patient and graft survival, acute rejection and CV mortality. Results. Donor mean age significantly increased during the three transplantation periods. A total of 478 out of 3365 donors were older than 60 years. Elderly donors showed an increased risk of DGF (38.9 vs 28.8%) and CAN (56.8 vs 46.2%). Mean serum creatinine at 3 and 12 months and proteinuria were significantly higher in the old donor group. Incidence and severity of acute rejection were similar in both groups. Graft and patient survival were significantly lower in the old donor group. Also, risk of mortality due to CV events was also significantly higher. A linear increase in risk of graft loss, patient death or CV mortality was observed when donor age was divided into 10 year increase subsets. Conclusions. Donor age is a strong predictor of CAN and graft loss. Patient survival is also affected by donor age, particularly by a higher risk of CV mortality

Estimation of renal function by CKD-EPI versus MDRD in a cohort of HIV-infected patients: a cross-sectional analysis.

Background Accurately determining renal function is essential for clinical management of HIV patients. Classically, it has been evaluated by estimating glomerular filtration rate (eGFR) with the MDRD-equation, but today there is evidence that the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation has greater diagnostic accuracy. To date, however, little information exists on patients with HIV-infection. This study aimed to evaluate eGFR by CKD-EPI vs. MDRD equations and to stratify renal function according to KDIGO guidelines. Methods Cross-sectional, single center study including adult patients with HIV-infection. Results Four thousand five hundred three patients with HIV-infection (864 women; 19%) were examined. Median age was 45 years (IQR 37-52), and median baseline creatinine was 0.93 mg/dL (IQR 0.82-1.05). A similar distribution of absolute measures of eGFR was found using both formulas (p = 0.548). Baseline median eGFR was 95.2 and 90.4 mL/min/1.73 m2 for CKD-EPI and MDRD equations (p 90 mL/min/1.73 m2) in 73% patients and "mild reduced GFR" (60-89 mL/min/1.73 m2) in 24.3% of the patients, formerly classified as >60 mL/min/1.73 m2 with MDRD. Conclusions There was good correlation between CKD-EPI and MDRD. Estimating renal function using CKD-EPI equation allowed better staging of renal function and should be considered the method of choice. CKD-EPI identified a significant proportion of patients (24%) with mild reduced GFR (60-89 mL/min/1.73 m2)

Renal Transplantation in Systemic Lupus Erythematosus: Outcome and Prognostic Factors in 50 cases from a Single Centre.

Background. End-stage renal disease (ESRD) is an important cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Objectives. To analyze the outcome and prognostic factors of renal transplantation in patients with ESRD due to SLE from January 1986 to December 2013 in a single center. Results. Fifty renal transplantations were performed in 40 SLE patients (32 female (80%), mean age at transplantation 36 ± 10.4 years). The most frequent lupus nephropathy was type IV (72.2%). Graft failure occurred in a total of 15 (30%) transplantations and the causes of graft failure were chronic allograft nephropathy (), acute rejection (), and chronic humoral rejection (1). The death-censored graft survival rates were 93.9% at 1 year, 81.5% at 5 years, and 67.6% at the end of study. The presence of deceased donor allograft () and positive anti-HCV antibodies () negatively influence the survival of the renal transplant. The patient survival rate was 91.4% at the end of the study. Recurrence of lupus nephritis in renal allograft was observed in one patient. Conclusion. Renal transplantation is a good alternative for renal replacement therapy in patients with SLE. In our cohort, the presence of anti-HCV antibodies and the type of donor source were related to the development of graft failure

Rituximab, plasma exchange and immunoglobulins: an ineffective treatment for chronic active antibody-mediated rejection

BACKGROUND: Chronic active antibody-mediated rejection (c-aABMR) is an important cause of allograft failure and graft loss in long-term kidney transplants. METHODS: To determine the efficacy and safety of combined therapy with rituximab, plasma exchange (PE) and intravenous immunoglobulins (IVIG), a cohort of patients with transplant glomerulopathy (TG) that met criteria of active cABMR, according to BANFF'17 classification, was identified. RESULTS: We identified 62 patients with active c-aABMR and TG (cg ≥ 1). Twenty-three patients were treated with the combination therapy and, 39 patients did not receive treatment and were considered the control group. There were no significant differences in the graft survival between the two groups. The number of graft losses at 12 and 24 months and the decline of eGFR were not different and independent of the treatment. A decrease of eGFR≥13 ml/min between 6 months before and c-aABMR diagnosis, was an independent risk factor for graft loss at 24 months (OR = 5; P = 0.01). Infections that required hospitalization during the first year after c-aABMR diagnosis were significantly more frequent in treated patients (OR = 4.22; P = 0.013), with a ratio infection/patient-year of 0.65 and 0.20 respectively. CONCLUSIONS: Treatment with rituximab, PE, and IVIG in kidney transplants with c-aABMR did not improve graft survival and was associated with a significant increase in severe infectious complications

Renal transplantation in patients with hepatitis C virus antibody. A long national experience

Background. Renal transplantation is the best therapy for patients with hepatitis C virus (HCV) infection with end-stage renal disease. Patient and graft survival are lower in the long term compared with HCV-negative patients. The current study evaluated the results of renal transplantation in Spain in a long period (1990–2002), focusing on graft failure

Perioperative prophylaxis with ertapenem reduced infections caused by extended-spectrum betalactamase-producting Enterobacteriaceae after kidney transplantation

Backgound: In recent years we have witnessed an increase in infections due to multidrug-resistant organisms in kidney transplant recipients (KTR). In our setting, we have observed a dramatic increase in infections caused by extended-spectrum betalactamase-producing (ESBL) Enterobacteriaceae in KTR. In 2014 we changed surgical prophylaxis from Cefazolin 2 g to Ertapenem 1 g. Methods: We compared bacterial infections and their resistance phenotype during the first post-transplant month with an historical cohort collected during 2013 that had received Cefazolin. Results: During the study period 110 patients received prophylaxis with Cefazolin and 113 with Ertapenem. In the Ertapenem cohort we observed a non-statistically significant decrease in the percentage of early bacterial infection from 57 to 47%, with urine being the most frequent source in both. The frequency of infections caused by Enterobacteriaceae spp. decreased from 64% in the Cefazolin cohort to 36% in the Ertapenem cohort (p = 0.005). In addition, percentage of ESBL-producing strains decreased from 21 to 8% of all Enterobacteriaceae isolated (p = 0.015). After adjusted in multivariate Cox regression analysis, male sex (HR 0.16, 95%CI: 0.03–0.75), cefazolin prophylaxis (HR 4.7, 95% CI: 1.1–22.6) and acute rejection (HR 14.5, 95% CI: 1.3–162) were associated to ESBL- producing Enterobacteriaceae infection. Conclusions: Perioperative antimicrobial prophylaxis with a single dose of Ertapenem in kidney transplant recipients reduced the incidence of early infections due to ESBL-producing Enterobacteriaceae without increasing the incidence of other multidrug-resistant microorganisms or C. difficile

Taking care of kidney transplant recipients during the COVID-19 pandemic: experience from a medicalized hotel.

The global overload that health systems are undergoing since the start of the COVID-19 pandemic has forced hospitals to explore sustainable alternatives to treat vulnerable patients that require closer monitoring and higher use of resources, such as Kidney Transplant Recipients (KTRs)1,2 .The use of telemedicine and hospital-like infrastructures represent a valid option for most patients with mild-moderate COVID-19, as well as for patients in the recovery phase who cannot be discharged from hospital

Cistinosis en pacientes adolescentes y adultos: Recomendaciones para la atención integral de la cistinosis

ResumenIntroducciónLa cistinosis es una enfermedad lisosomal minoritaria de expresión sistémica con especial afectación renal y oftalmológica, en la que los pacientes inician terapia renal sustitutiva en la primera década de la vida en ausencia de tratamiento. El pronóstico de la cistinosis depende del diagnóstico precoz, la pronta instauración del tratamiento con cisteamina y el buen cumplimiento terapéutico. La progresión de la enfermedad renal y de las complicaciones extrarrenales y una menor supervivencia, son más acentuadas en pacientes no adherentes.ObjetivoEl objetivo de este trabajo fue la elaboración de unas recomendaciones para la atención integral de la cistinosis y la transición del adolescente a la medicina del adulto, basadas en la experiencia clínica, con el fin de reducir el impacto de la enfermedad y mejorar la calidad de vida y el pronóstico del paciente.MétodoBúsqueda bibliográfica y reuniones de consenso de un equipo multidisciplinar de expertos en la práctica clínica con pacientes afectos de cistinosis (Grupo T-CiS.bcn), procedentes de 5 hospitales localizados en Barcelona.ResultadosEl documento recoge recomendaciones específicas y necesarias para el diagnóstico, tratamiento y seguimiento multidisciplinar de la cistinosis en las siguientes áreas: nefrología, diálisis, trasplante renal, oftalmología, endocrinología, neurología, laboratorio, consejo genético, enfermería y farmacia.ConclusionesDisponer de un documento de referencia para la atención integral de la cistinosis constituye una herramienta de soporte para los profesionales de la salud que asisten a estos pacientes. Los principales pilares en los que se sustenta son: a) el enfoque multidisciplinar, b) la adecuada monitorización de la enfermedad y control de los niveles de cistina intraleucocitarios, c) la importancia de la adherencia al tratamiento con cisteamina y d) la promoción del autocuidado del paciente mediante programas de educación en la enfermedad. Todo ello conducirá, en una segunda fase, a la elaboración de un modelo de transición coordinado entre los servicios de pediatría y de adultos que contemple las necesidades específicas de la cistinosis.AbstractIntroductionCystinosis is a rare lysosomal systemic disease that mainly affects the kidney and the eye. Patients with cystinosis begin renal replacement therapy during the first decade of life in absence of treatment. Prognosis of cystinosis depends on early diagnosis, and prompt starting and good compliance with cysteamine treatment. Kidney disease progression, extra-renal complications and shorter life expectancy are more pronounced in those patients that do not follow treatment.The objective of this work was to elaborate recommendations for the comprehensive care of cystinosis and the facilitation of patient transition from paediatric to adult treatment, based on clinical experience. The goal is to reduce the impact of the disease, and to improve patient quality of life and prognosis.MethodsBibliographic research and consensus meetings among a multidisciplinary professional team of experts in the clinical practice, with cystinotic patients (T-CiS.bcn group) from 5 hospitals located in Barcelona.ResultsThis document gathers specific recommendations for diagnosis, treatment and multidisciplinary follow-up of cystinotic patients in the following areas: nephrology, dialysis, renal transplant, ophthalmology, endocrinology, neurology, laboratory, genetic counselling, nursing and pharmacy.ConclusionsA reference document for the comprehensive care of cystinosis represents a support tool for health professionals who take care of these patients. It is based on the following main pillars: a) a multi-disciplinary approach, b) appropriate disease monitoring and control of intracellular cystine levels in leukocytes, c) the importance of adherence to treatment with cysteamine, and d) the promotion of patient self-care by means of disease education programmes. All these recommendations will lead us, in a second phase, to create a coordinated transition model between paediatric and adult care services which will cover the specific needs of cystinosis