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

Nefrectomia bilateral para doença renal policística gigante associada à diástase do reto abdominal e hérnia umbilical

BACKGROUND: Patients with end-stage renal failure due to huge autosomal dominant polycystic kidney disease usually have an umbilical hernia and rectus abdominis diastasis, which are very troublesome. Pretransplant bilateral nephrectomy techniques does not manage the umbilical hernia and rectus abdominis diastasis. We report our experience in performing bilateral nephrectomy and repairing the rectus abdominis diastasis and umbilical hernia through the one, small incision. METHODS: Four patients aged 37 to 43 years with huge polycystic kidneys, an umbilical hernia, and a rectus abdominis diastasis underwent bilateral pretransplant nephrectomy through a midline supraumbilical incision including the umbilical hernia defect. The kidneys were removed through this incision. The incision was closed with the transposition of rectus abdominis muscle, pants-over-vest-style, to correct the diastasis and the umbilical hernia. RESULTS: The average operative time was 160 minutes (range, 130-180); the average larger kidney size was 33 cm (range, 32-34 cm); no major complications occurred; one patient who had preoperative low hemoglobin required blood transfusion. Patients were discharged from the hospital on postoperative day 7 with an esthetically pleasing belly, no rectus abdominis diastasis, and no umbilical hernia. One to two months after bilateral nephrectomy, the patients received a live donor kidney with an uneventful outcome. CONCLUSION: A midline supraumbilical incision is an excellent approach for bilateral nephrectomy of huge polycystic kidneys. In addition, an umbilical hernia and rectus abdominis diastasis may be successfully repaired through same incision with good cosmetic results.INTRODUÇÃO: Pacientes com insuficiência renal terminal por Doença Renal Policística Autossômica Dominante geralmente apresentam hérnia umbilical e diástase de músculo reto abdominal, que são muito problemáticas. Técnicas de nefrectomia bilateral pré-transplante não dão atenção à hérnia umbilical e à diástase do músculo reto abdominal. Relatamos nossa experiência com nefrectomia bilateral e correção da diastase de músculo reto abdominal e hérnia umbilical através de uma única pequena incisão. MÉTODOS: Quatro pacientes com idade entre 37 a 43 anos com Doença Renal Policística Autossômica Dominante gigante, hérnia umbilical e diástase do múculo reto abdominal foram submetidos à nefrectomia bilateral pré-transplante através de incisão mediana supra-umbilical incluindo o defeito herniário umbilical. Os rins foram removidos através da pequena incisão mediana. A incisão foi fechada com transposição do músculo reto abdominal tipo jaquetão para corrigir a diastase e a hernia umbilical. RESULTADOS: O tempo operatório médio foi 160 minutos (130-180); o tamanho médio do maior rim foi 33cm (32-34); não ocorreram grandes complicações; um paciente, que tinha baixo nível de hemoglobina pré-operatório e precisou de transfusão sangüínea. Pacientes receberam alta hospitalar no 7º pós-operatório com abdome de boa aparência, sem diástase de músculo reto abdominal e sem hérnia umbilical. Os pacientes receberam enxerto renal de doador vivo um ou dois meses após a nefrectomia bilateral, sem intercorrências. CONCLUSÃO: A incisão mediana supra-umbilical é uma abordagem excelente para nefrectomia bilateral de rins policísticos gigantes. Além disso, a hernia umbilical e a diastase de músculo reto abdominal podem ser corrigidas com sucesso pela mesma incisão, com bons resultados cosméticos

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

Tuberculose em pacientes transplantados renais

Tuberculosis (TB) was diagnosed in 25 of 466 patients who underwent renal transplant over a period of 15 years. TB developed from 1 month to 9 years post-transplant. In 56% of the cases the onset was within the first post-transplant year. TB affected several isolated or combined organs. Pulmonary involvement was present in 76% of cases, either as isolated pleuro-pulmonary (56%) or associated with other sites (20%). The non-pulmonary sites were: skin, joints, tests, urinary tract, central nervous system and lymphonodules. The diagnosis was confirmed by biopsy in 64% of the cases, by identification of tubercle bacilli in 24% and only at necropsy in 12% Biopsy specimens could be classified in three histological forms: exudative, that occurred in early onset and more severe cases granulomatous in late onset and benign cases; and mixed in intermediate cases. Azathioprine dosages were similar along post-transplant time periods in TB patients and in the control groups; and in TB patients who were cured and who died. The number of steroid treated rejection crises was greater in TB than in the control group. Prednisone doses were higher and the number of rejection crises was greater in TB patients who died than in those who were cured. Fifteen patients were cured and ten died, two of them of causes unrelated to TB. Six of the eight TB-related deaths occurred in the first 6 post-transplant months. The outcome was poor in patients in whom TB arose early in post-transplant period and where the exudative or mixed forms were present; whereas the prognosis was good in patients with late onset and granulomatous form of TB. In one patient TB was transmitted by the allograft.Tuberculose (TB) foi diagnosticada em 25 de 466 pacientes submetidos a transplante renal. A TB surgiu entre 1 mês e 9 anos pós-transplante. O pulmão foi acometido em 76% dos casos, isoladamente (56%), ou associado a outras localizações (20%). Os outros órgãos envolvidos foram: pele, articulações, testículos, trato urinário, sistema nervoso central e linfonodos. O diagnóstico foi confirmado por biópsia em 64% dos casos, pela identificação do bacilo em 24% e apenas à necrópsia em 12%. Três formas histológicas foram identificadas: exudativa (nos casos de aparecimento precoce e de maior gravidade) granulomatosa (naqueles benignos e de aparecimento tardio) e mista (naqueles intermediários). As doses de azatioprina foram constantes ao longo do período pós-transplante, tanto no grupo tuberculoso como no controle, bem como nos pacientes tuberculosos que faleceram e que se curaram. O número de crises de rejeição tratadas foi maior no grupo TB do que no grupo controle. As doses de prednisona e o número de crises de rejeição foram maiores nos pacientes tuberculosos que faleceram do que naqueles que sobreviveram. Quinze pacientes se curaram e 10 faleceram, oito de causas relacionadas à TB, Seis destes óbitos ocorreram nos 6 primeiros meses pós-transplante. Em um paciente a TB foi transmitida pelo enxerto

Catheter-associated urinary infection in kidney post-transplant patients

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