The main aim of renal transplantation is to achieve the longest patient and graft survival, in part by optimising immunological tolerance of the graft. Acute rejection decreases graft survival in the long term. The aim of this review is to describe the diagnosis criteria for acute rejection, the new classification tools, and its therapeutic alternatives.
The diagnosis of acute kidney injury (AKI) in renal transplantation is a challenge, given the variability of serum creatinine results related to the titration of immunosuppressive drugs and the volume status. Serum creatinine as a biomarker of acute rejection has a low sensitivity and specificity.
The diagnosis of rejection is made using the Banff criteria. The criteria for T-cell mediated rejection have not changed significantly in the past 10 years. However, the category of antibody-mediated rejection was modified in 2013 by adding rejection mediated by C4d-negative antibodies. For the diagnosis of antibody-mediated rejection, 3 main factors are required concomitantly: histological lesions, evidence of antibody-endothelium interaction, and specific donor antibodies.
The quality of the evidence for the different options available for rejection treatment is low. The treatment of cellular rejection has not changed in the last decades and is based on corticosteroids and / or thymoglobulin. Treatment of antibody-mediated rejection is based on the removal of antibodies by immunoadsorption or plasmapheresis, with great variability between transplant centres in terms of complementary treatments (steroids, polyvalent human gammaglobulin, bortezomib, rituximab and/or eculizumab) in order to prevent their production.
Fabry disease (FD) is an X-linked lysosomal storage disorder resulting from the deficiency or absence of the alpha galactosidase A (α-galA) enzyme. Organ involvement in men is well known, but in women it is controversial, partly due to random X-chromosome inactivation (Lyon hypothesis). The aim of this study was to describe renal involvement in a population of 35 women at the time of FD diagnosis.
Thirty-five females were evaluated in three reference centres in Argentina. The activity of the α-galA enzyme was determined on filter paper by a fluorometric method, and the mutational study by MLPA and sequencing. Glomerular filtration rate was calculated usinjg the CKD-EPI formula in adult patients and Schwartz formula in paediatric patients. Albuminuria and proteinuria were observed in at least two different urine samples in all cases, as well as the glomerular filtration rates categories according to KDIGO 2012 guidelines.
Mean age of the complete group (n = 35) was 26.6 ± 16.9 years, of whom 22 were adult women (over 18) and 13 were paediatric patients. Enzymatic activity of α-galA was performed in 29/35 patients, which was normal in 24/29 (82.8%). Seven different mutations of the GLA gene were found. The results showed glomerular hyperfiltration (42.9%), urinary protein loss (45.7%), and decreased glomerular filtration rate (31.4%).
Renal involvement in females with FD may be as severe as in men. The analysis of this group of patients showed a significant proportion of females with early kidney damage demonstrated by renal hyperfiltration, albuminuria, proteinuria and glomerular filtration rate decreased, at the time of diagnosis of FD.
Interstitial nephropathies include a wide spectrum of acute and chronic renal diseases. The aims of this study were to evaluate frequency, clinical onset, histological damage, treatment and outcomes of patients with non-obstructive tubulointerstitial nephropathies (TIN) in Uruguay (defined by clinical diagnosis and/or renal biopsy).
A retrospective analysis was performed on the complete clinical records of 124 patients. They were classified into two groups: Group 1: 66 patients with a clinical diagnosis of TIN and chronic kidney disease from the Uruguayan Renal Healthcare Program (PSR), and Group 2: 58 patients from the national Registry of Kidney biopsies (RUG/RUB).
In both cohorts, being female doubled the risk of TIN vs men (OR 2.3 in the PSR and 1.9 in the RUB, P<.05), mainly due to by drugs. The most frequent clinical presentation in the biopsied group was as acute renal failure/rapidly progressive renal failure (Table 1). A higher degree of interstitial infiltration of inflammatory cells was associated with more frequent steroid treatment (OR 6.3, 95% CI; 1.6–24.3, P<.05). In the steroid-treated group, a lower level of interstitial fibrosis was associated with glomerular filtration rate improvement (OR 0.143, 95% CI; 0.028-0.720, P<.05)
The results were similar to those found in international reports on the clinical presentation of TIN, and highlight the importance of renal histology in treatment decisions and to predict outcomes.
Prevalence of depression in chronic kidney disease (CKD) is higher than in the general population and predicts a higher mortality risk. The aim of this study is to investigate the occurrence of depressive symptoms among individuals with CKD in conservative treatment and renal replacement therapy (hemodialysis).
This is a cross-sectional study conducted at three health centers specialized in CKD care, in Fortaleza-Ceara-Brazil, between June and October 2015. Patients with confirmed diagnosis of CKD were included, in hemodialysis and conservative treatment, older than 18 years. We have applied forms about socio-demographic questionnaire, including questions regarding mental health and the Beck depression inventory.
A total of 147 patients were interviewed, with mean age of 54 ± 16 years, and 61% were males. Regarding treatment, 65.3% were in hemodialysis and 34.6% in conservative treatment. Previous diagnosis of mental disturbance was reported by 12.9% of patients; 29 (19.7%) had follow-up with Psychologist or Psychiatrist; 61 (41.4%) demonstrated interest in having specialized treatment. According to Beck inventory score, 47 (31.9%) patients presented depressive symptoms, being 22 (14.9%) mild, 14 (9.5%) moderate and 7 (4.7%) severe symptoms. Among patients in hemodialysis, 30 (31.2%) had depressive symptoms, while among patients in conservative treatment, the frequency of depressive symptoms was 25.5% (p = 0.2).
There were a significant number of patients with CKD with depressive symptoms, both in conservative treatment and hemodialysis, with no significant difference between these two groups. Further studies are necessary to evaluate the repercussion of depression in clinical outcome, as well as the impact of preventive and treatment measures.
Most research in El Salvador focuses on chronic kidney disease (CKD) in rural coastal populations. Our aim was to determine the prevalence of CKD, diabetes, hypertension and hyperuricemia and associations to CKD in an urban adult population.
Population-based, cross-sectional. A representative sample of adults from an urban community in San Salvador was randomly selected (80.6% participation, N = 121, 65% female, mean age 52 yo). A questionnaire with socio-demographic information was applied; blood and urine samples were collected. Subjects with low estimated glomerular filtration rate (eGFR, MDRD equation) or spot proteinuria were reexamined 3 months later to confirm CKD. Gender, age, educational level, income, tobacco smoking, alcohol consumption, analgesics use, hypertension, diabetes, and hyperuricemia were evaluated as predictors for CKD, diagnosed and staged by KDIGO guidelines.
Prevalence of CKD: 12.6% (N = 15, CI 95%, 7.23–19.94), 14.2% in males and 11.4% in females, all in stages G2-4. Prevalence of eGFR < 60 mL/min/1.73 m2: 9%. Most, 73%, were previously undiagnosed. Prevalence of diabetes: 11.6%; hypertension: 34.7%; hyperuricemia: 24.8%. CKD was present in 42.9%, 21% and 23.3% of diabetic, hypertensive and hyperuricemic patients, respectively. From all predictors, only diabetes (OR 8.1, p = 0.0002), hypertension (OR 3.17, p = 0.03) and hyperuricemia (OR 3.1, p = 0.02) showed increased risk for CKD.
General prevalence of CKD is not increased in this population, but prevalence in stages G3-4 is slightly increased. Most cases were previously undiagnosed. Diabetes, hypertension, and hyperuricemia increase the risk for CKD. Preventive measures and early screening is recommended, especially for those with risk factors.
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