O uso da imunossupressão e a presença do vírus EBV como fatores estimulantes de PTLD posterior à rejeição de enxerto renal: relato

Introdução: A maioria das etiologias que desencadeiam transplantes renais são explicadas pela GESF.O paciente transplantado, a fim de diminuir riscos de rejeição, é induzido à imunossupressão, o que pode acabar desencadeando intercorrências, como a PTLD. Essa doença tem alta correlação com a presença do vírus EBV. Uma grande terapêutica usada para a PTLD, é o uso do medicamento Rituximab, que também é usado para combater à proteinúria característica da GESF.Objetivos: Apresentar uma pesquisa exploratória sobre a PTLD, EBV e imunossupressão e apresentar um relato de caso sobre esse tema. Métodos: Pesquisa exploratória dos temas discutidos no caso clínico e busca em acervo pessoal a respeito de um caso clínico bem sucedido. Resultados: Paciente de 11 anos, submetido a transplante renal após 8 anos de GESF, que induziu síndrome nefrótica crônica. Paciente recebeu imunossupressor, e apesar disso, cursou com rejeição. Rejeição curada, mas após um tempo houve recidiva da GESF. 8 meses após, paciente iniciou quadro sugestivo de PTLD, confirmado por biópsia. Iniciada quimioterapia, com o uso de Rituximab, que contribuiu para o fim da PTLD e da GESF.Discussão: A GESF é uma doença de origem idiopática autoimune, responsável pela causa de síndrome nefrótica na infância e a longo prazo pode gerar insuficiência renal crônica, sendo necessário a realização de transplante. Para evitar rejeição pós-transplante, o uso de um imunossupressor se faz necessário. Nesse contexto, se destaca a ciclosporina, que gera uma inibição da proliferação das células T, que possuem grande importância para o sistema imune. O EBV, se presente no organismo, invade as células B e começa a se proliferar descontroladamente diante da queda dos mecanismos de defesa do organismo, gerando a PTLD. Conclusão: Portanto, pode-se dizer que há uma relação entre o uso de imunossupressores como a ciclosporina e o surgimento de distúrbios como o PTLD, quando associados ao EBV

Acute Ischemic Strokes in Patients With Developmental Disabilities: A Cross-Sectional Analysis

OBJECTIVE: Patients with developmental disabilities (DD) are frequently excluded from acute ischemic stroke (AIS) randomized control trials. We sought to evaluate the impact of having DD on this patient cohort. METHODS: The National Inpatient Sample was analyzed to explore the impact of AIS and treatment on discharge dispositions in patients with DD. Clinical characteristics, treatments, and outcomes were compared to fully-abled patients with AIS. RESULTS: 1,605,723 patients with AIS were identified from 2010-2019, of whom 4094 (0.30%) had a DD. AIS patients with DD were younger (60.31 vs 70.93 years, p \u3c 0.01), less likely to be Caucasian (66.37%vs 68.09%, p = 0.01), and had higher AIS severity (0.63 vs 0.58, p \u3c 0.01). Tissue plasminogen activator (tPA) was administered in 99,739 (6.2%) fully-abled patients and 196 (4.79%) of patients with DD (p \u3c 0.01). Endovascular thrombectomy (EVT) was performed in 21,066 (1.31%) of fully-abled patients and 35 (0.85%) of patients with DD (p \u3c 0.01). The presence of developmental disabilities were predictive of lower rates of tPA (OR:0.71,CI:0.56-0.87,p \u3c 0.01) and EVT (OR:0.24,CI:0.16-0.36,p \u3c 0.01). In a propensity score-matched cohort of all AIS patients who underwent EVT, there was no difference in functional outcome (p = 0.41), in-hospital mortality (0.10), and LOS (p = 0.79). CONCLUSION: AIS patients with DD were less likely to receive tPA and EVT compared to fully-abled patients. Individuals with DD had higher mortality and worse discharge disposition. There was no significant difference in post-EVT outcomes between fully-abled patients and patients with developmental disabilities. In the absence of prospective clinical trials, population based cross-sectional analyses such as the present study provide valuable clinical insight

Cardiac Arrest in Spontaneous Subarachnoid Hemorrhage and Associated Outcomes

OBJECTIVE: The authors sought to analyze a large, publicly available, nationwide hospital database to further elucidate the impact of cardiopulmonary arrest (CA) in association with subarachnoid hemorrhage (SAH) on short-term outcomes of mortality and discharge disposition. METHODS: This retrospective cohort study was conducted by analyzing de-identified data from the National (Nationwide) Inpatient Sample (NIS). The publicly available NIS database represents a 20% stratified sample of all discharges and is powered to estimate 95% of all inpatient care delivered across hospitals in the US. A total of 170,869 patients were identified as having been hospitalized due to nontraumatic SAH from 2008 to 2014. RESULTS: A total of 5415 patients (3.2%) were hospitalized with an admission diagnosis of CA in association with SAH. Independent risk factors for CA included a higher Charlson Comorbidity Index score, hospitalization in a small or nonteaching hospital, and a Medicaid or self-pay payor status. Compared with patients with SAH and not CA, patients with CA-SAH had a higher mean NIS Subarachnoid Severity Score (SSS) ± SD (1.67 ± 0.03 vs 1.13 ± 0.01, p \u3c 0.0001) and a vastly higher mortality rate (82.1% vs 18.4%, p \u3c 0.0001). In a multivariable model, age, NIS-SSS, and CA all remained significant independent predictors of mortality. Approximately 18% of patients with CA-SAH survived and were discharged to a rehabilitation facility or home with health services, outcomes that were most predicted by chronic disease processes and large teaching hospital status. CONCLUSIONS: In the largest study of its kind, CA at onset was found to complicate roughly 3% of spontaneous SAH cases and was associated with extremely high mortality. Despite this, survival can still be expected in approximately 18% of patients