TRANSPLANTE DE TRANSPLANTE DE ÓRGÃOS ÓRGÃOS

ABDOMINAISABDOMINAIS

Sumara Barral

TRANSPLANTE TRANSPLANTE RENALRENAL

Sumara Barral

Transplante RenalTransplante Renal

Revolucionou o tratamento da IRC.Revolucionou o tratamento da IRC. Aspecto mais importante: SELEÇÃO dos Aspecto mais importante: SELEÇÃO dos

pacientes.pacientes.

Preparo do ReceptorPreparo do Receptor

AnamneseAnamnese Exames complementares.Exames complementares.

Displasia fibromuscular: 10% das causas de

estenose da artéria renal.

Aterosclerose

Paciente portador de Paciente portador de hepatopatia por vírus? hepatopatia por vírus?

Citomegalovirose? HIV?Citomegalovirose? HIV?

CMV:CMV: profilaxia por 3 meses X profilaxia por 3 meses X seguimento e tratamento com seguimento e tratamento com ganciclovir em dose plena.ganciclovir em dose plena.

HIV:HIV: sem relatos no Brasil. sem relatos no Brasil.

Am J Transplant. 2007 Jun;7(6):1515-25. LinksComment in:

Am J Transplant. 2007 Jun;7(6):1437-8.

Estimated benefits of transplantation of kidneys from donors at increased risk for HIV or hepatitis C infection.Schweitzer EJ, Perencevich EN, Philosophe B, Bartlett ST.Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA. gschweitzer@smail.umaryland.eduKidneys from organ donors who have behaviors that place them at increased risk for infection with human immunodeficiency virus (HIV) or hepatitis C virus (HCV) are often discarded, even if viral screening tests are negative. This study compared policies that would either 'Discard' or 'Transplant' kidneys from Centers for Disease Control classified increased-risk donors (CDC-IRDs) using a decision analytic Markov model of renal failure treatment modalities. Base-case CDC-IRDs were current injection drug users (IDUs) with negative antibody and nucleic acid testing (NAT) for HIV and HCV, comprising 5% of kidney donors. Compared to a CDC-IRD kidney 'Discard' policy, the 'Transplant' policy resulted in higher patient survival, a greater number of quality-adjusted life-years (QALYs) (5.6 vs. 5.1 years per patient), more kidney transplants (990 vs. 740 transplants per 1000 patients) and lower cost of care ($60 000 vs. $71 000 per QALY). The total number of viral infections was lower with the 'Transplant' policy (13.1 vs. 14.8 infections per 1000 patients over 20 years), because the 'Discard' policy led to more time on hemodialysis, with a higher HCV incidence. We recommend that kidneys from NAT-negative CDC-IRDs be considered for transplantation since the practice is estimated to be beneficial from both the societal and individual patient perspective.

ParasitosesParasitoses

Preparo do Receptor Preparo do Receptor Exames complementaresExames complementares

RadiológicoRadiológico CardiológicoCardiológico Exames ImunológicosExames Imunológicos Procedimentos cirúrgicos préviosProcedimentos cirúrgicos prévios EndoscópicoEndoscópico

Nephrol Dial Transplant. 2001 Oct;16(10):2053-7.Nephrol Dial Transplant. 2001 Oct;16(10):2053-7. Links Links

Should Helicobacter pylori infection be treated before kidney transplantation?Should Helicobacter pylori infection be treated before kidney transplantation?SarkioSarkio S S, , RautelinRautelin H H, , KyllönenKyllönen L L, , HonkanenHonkanen E E, , SalmelaSalmela K K, , HalmeHalme L L..Transplantation and Liver Surgery, Helsinki University Hospital, Finland. Transplantation and Liver Surgery, Helsinki University Hospital, Finland.

susanna.sarkio@fimnet.fisusanna.sarkio@fimnet.fiBACKGROUND: Before the introduction of modern medication for ulcer disease, BACKGROUND: Before the introduction of modern medication for ulcer disease,

gastroduodenal complications were often fatal in recipients of kidney transplants. gastroduodenal complications were often fatal in recipients of kidney transplants. Helicobacter pylori causes gastritis and is an important risk factor for peptic ulcer disease Helicobacter pylori causes gastritis and is an important risk factor for peptic ulcer disease and gastric malignancies. The aim of this study was to evaluate whether H. pylori infection and gastric malignancies. The aim of this study was to evaluate whether H. pylori infection influences the outcomes of kidney transplantation. METHODS: Between 1991 and 1994, influences the outcomes of kidney transplantation. METHODS: Between 1991 and 1994, serum H. pylori antibodies were determined in samples taken just before transplantation serum H. pylori antibodies were determined in samples taken just before transplantation from 500 consecutive recipients of kidney transplants. Clinical data were collected from 500 consecutive recipients of kidney transplants. Clinical data were collected retrospectively by means of questionnaires sent to the patients and from the national retrospectively by means of questionnaires sent to the patients and from the national kidney transplantation registry. RESULTS: The prevalence of seropositivity of H. pylori was kidney transplantation registry. RESULTS: The prevalence of seropositivity of H. pylori was 31% in the 500 renal transplant subjects, and the seropositivity increased with age. There 31% in the 500 renal transplant subjects, and the seropositivity increased with age. There were no differences in patient or graft survival between the seronegative and seropositive were no differences in patient or graft survival between the seronegative and seropositive patients. During the first 3 months after transplantation, five seronegative and one patients. During the first 3 months after transplantation, five seronegative and one seropositive patient had gastroduodenal ulcers, with bleeding complications in three of the seropositive patient had gastroduodenal ulcers, with bleeding complications in three of the seronegative ones. After 3 months, there were more ulcers in the seropositive group (6 vs seronegative ones. After 3 months, there were more ulcers in the seropositive group (6 vs 3%) and more oesophagitis in the seronegative group (9 vs 7%). During the 6-year follow-3%) and more oesophagitis in the seronegative group (9 vs 7%). During the 6-year follow-up, two cases of gastroduodenal malignancies were found in the helicobacter-positive up, two cases of gastroduodenal malignancies were found in the helicobacter-positive group and none in the seronegative group. CONCLUSIONS: group and none in the seronegative group. CONCLUSIONS: Helicobacter pylori infections Helicobacter pylori infections did not result in significant postoperative gastric complications. Two of the 155 seropositive did not result in significant postoperative gastric complications. Two of the 155 seropositive patients developed gastroduodenal malignancies.patients developed gastroduodenal malignancies.

Scand J Gastroenterol. 2003 Jan;38(1):20-6. LinksThe course of Helicobacter pylori infection in kidney transplantation patients.Sarkio S, Rautelin H, Halme L.Transplantation and Liver Surgery, Helsinki University Hospital, Helsinki, Finland.BACKGROUND: Helicobacter pylori has been found to be only a minor risk factor for gastroduodenal complications in kidney transplantation patients. The aim of the study was to follow up the course of H. pylori infection in a group of immunosuppressed kidney transplantation patients. METHODS: After a median follow-up of 6.8 years, control serum samples were taken from 93 originally seropositive and 88 originally seronegative kidney transplant recipients. H. pylori antibodies of the IgG and IgA classes and serum pepsinogen I levels were measured from pretransplant and follow-up samples in parallel. In addition, CagA antibodies were measured from the baseline samples of the seropositive patients. RESULTS: 83 of the 93 seropositive patients were also cagA-positive. In addition to the 10 patients who received H. pylori eradication therapy, 27 (29%) of the 92 patients with originally elevated H. pylori IgG antibody titres showed IgG titres at normal level or levels decreased by more than 70% and below 2000 (regarded as seroreverters) after the follow-up. One of the originally seronegative patients seroconverted during the study period. After transplantation, the decrease of serum pepsinogen I values was in accordance with improved kidney function. Patients with lower serum pepsinogen I levels before the transplantation seroreverted more easily. CONCLUSIONS: A spontaneous H. pylori seroreversion occurred in 29% of the immunosuppressed kidney transplantation patients. After a successful kidney transplantation, serum pepsinogen I values declined significantly.

Pai e mãe Avós

Tios

PrimoSobrinha

Irmãos

1º grau

2º grau

3º grau

4º grau

2º grau

Preparo do Doador VivoPreparo do Doador Vivo

Exame clínico.Exame clínico. US renal, urografia excretora, US renal, urografia excretora,

uretrocistografia miccional conforme uretrocistografia miccional conforme protocolo.protocolo.

Prova cruzada.Prova cruzada. Imunossupressão prévia com tacrolimus Imunossupressão prévia com tacrolimus

ou ciclosporina (conforme protocolo).ou ciclosporina (conforme protocolo).

Preparo do Doador Preparo do Doador CadavéricoCadavérico

Lei 10.211 de 20 de março de 2001.Lei 10.211 de 20 de março de 2001. Idade entre 5 a 65 anos, ausência de Idade entre 5 a 65 anos, ausência de

HAS e DM, doença renal que cause HAS e DM, doença renal que cause disfunção, neoplasias, infecções disfunção, neoplasias, infecções sistêmicas e choque por mais de 12h.sistêmicas e choque por mais de 12h.

Cr < 2,5 mg/dl e sem anúria.Cr < 2,5 mg/dl e sem anúria.

Cuidados Pós-Operatórios Cuidados Pós-Operatórios

Controle ClínicoControle Clínico DV 1/1h nas primeiras 24h.DV 1/1h nas primeiras 24h. Reposição volêmica e Analgesia.Reposição volêmica e Analgesia. Proteção à mucosa gástrica.Proteção à mucosa gástrica. Profilaxia: Profilaxia: P. cariniiP. carinii e ITU (SMT-TMP), e ITU (SMT-TMP),

TEP e TVP.TEP e TVP. Avaliar necessidade de diálise.Avaliar necessidade de diálise. Evitar acesso venoso e medida de PA no Evitar acesso venoso e medida de PA no

braço com fístula.braço com fístula.

Cuidados ClínicosCuidados Clínicos

Avaliação laboratorial Avaliação laboratorial (imunossupressores, íons, (imunossupressores, íons, urocultura, hemocultura).urocultura, hemocultura).

Avaliação Avaliação hemodinâmica.hemodinâmica.

ImunossupressãoImunossupressão

ImunossupressãoImunossupressão

Inibidores da calcineurina.Inibidores da calcineurina.

Azatioprina.Azatioprina.

Corticóides.Corticóides.

Micofenolato.Micofenolato.

Anticorpos monoclonais (OKT3, ATG).Anticorpos monoclonais (OKT3, ATG).

ciclosporin

a

tacrolimus

COMPLICAÇÕESCOMPLICAÇÕES

Disfunção precoce do enxerto renal.Disfunção precoce do enxerto renal. Causas Pré-Renais: hipovolemiaCausas Pré-Renais: hipovolemia Causas Renais: (NTA, rejeição, infecção, Causas Renais: (NTA, rejeição, infecção,

nefrotoxicidade por drogas)nefrotoxicidade por drogas) Causas Pós-renais: cateter obstruído, fístula Causas Pós-renais: cateter obstruído, fístula

urinária, linfocele, trombose venosa)urinária, linfocele, trombose venosa)

COMPLICAÇÕESCOMPLICAÇÕES

Disfunção tardia do enxerto renal.Disfunção tardia do enxerto renal. Estenose da artéria renalEstenose da artéria renal Estenose do ureterEstenose do ureter Rejeição aguda ou crônicaRejeição aguda ou crônica Glomerulopatia (recidiva ou incidência).Glomerulopatia (recidiva ou incidência).

Infecções:Infecções:

Intensidade de exposição aos

patógenos potenciais.

SUSCEPTIBILIDADE

Imunossupressores

Viroses (CMV)

Leucopenia

Hiperglicemia

Azotemia

Idade

Infecções:Infecções: Mais de 80% dos pacientes: pelo menos um episódio infeccioso no primeiro ano após o transplante.

Primeiro mês: complicações do ato operatório.

De 1 a 6 meses: oportunistas.

Mais de 6 meses: três grupos de pacientes...

Infecções:Infecções: Mais de 6 meses: três grupos de pacientes...

Evolução semelhante à população geral: 80%.

Infecção crônica: 10%.

Rejeição recorrente: 5 a 10%

ComplicaçõesComplicações

ImunológicasImunológicas CirúrgicasCirúrgicas TGITGI HepatopatiasHepatopatias HematológicasHematológicas Diabete MelitoDiabete Melito