Orientador: Salomón Soriano Ordinola Rojas / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-24T03:31:12Z (GMT). No. of bitstreams: 1 Miguel_GabrielAntonioStanisci_D.pdf: 3265608 bytes, checksum: 8e5fab35107186e1c25936f84d45682f (MD5) Previous issue date: 2013 / Resumo: Introdução: O transplante (TC) cardíaco é uma alternativa para os indivíduos com doença cardíaca terminal. Na evolução pós-TC, a ocorrência de episódios de rejeição é um evento frequente, sendo responsável pelo aumento da morbi-mortalidade. Uma alternativa relevante seria o emprego de um exame não invasivo que tivesse uma boa acurácia na detecção das alterações da função sisto-diastólica do coração transplantado, pois a biópsia endomiocárdica (BEM) não é um procedimento isento de complicações. Objetivo: Analisar o Índice de Performance Miocárdica como ferramenta para o diagnóstico de rejeição cardíaca e demonstrar sua possibilidade de triagem na seleção de pacientes para BEM. Método: Foram realizados ecocardiogramas transtorácicos no período de janeiro de 2006 a janeiro de 2008, para a avaliação prospectiva de 58 pacientes; sendo 17 pacientes (29,3 %) pertencentes ao grupo controle (grupo GC), 22 (37,9%) pertencentes ao grupo de pacientes transplantados sem rejeição (TX0) e 19 (32,9%) pertencentes ao grupo de pacientes transplantados com rejeição (TX1). Comparou-se a função sisto-diastólica entre os três grupos (GC, TX0, TX1). O teste de Qui-quadrado foi utilizado para verificar se as proporções de gênero e raça eram homogêneas. Para a comparação entre os três grupos, foi utilizado a ANOVA, em caso de normalidade (verificada por meio do teste de Kolmogorov-Smirnov) e homocedasticidade (verificada por meio do teste de Levene) entre as variáveis; caso contrário, optou-se por utilizar o teste não-paramétrico de Kruskal-Wallis. O nível de significância utilizado para os testes foi de 5%. Resultados: Os grupos não diferiram em relação à idade [38,47 (±11,17) X 41,18 (±13,83) X 45,95 (±12,87) p = 0,212], ao peso [71,95 (±15,90) X 68,68 (±13,14) X 66,09 (±11,91) p = 0,442], altura [1,66 (±0,11) X 1,67 (±0,05) X 1,68 (±0,06) p = 0,894] e superfície corpórea [1,82 (±0,25) X 1,78 (±0,18) X 1,75 (±0,17) p = 0,603]. O grupo GC quando comparado com o grupo TX0, apresentou alteração da função sisto-diastólica do ventrículo esquerdo, expressa através do aumento do IPM, sendo esta mais intensa nos pacientes do grupo TX1 [0,38 (0,29 - 0,39) X 0,47 (0,42 - 0,49) X 0,60 (0,52 - 0,71) p <0,001]. Conclusão: Foi evidenciado que o ÍPM encontra-se bastante aumentado nos pacientes transplantados com rejeição em relação aos pacientes transplantados sem rejeição e também em relação ao controle; portanto, este índice mostrou-se como informação não invasiva e de boa acurácia na detecção das alterações da função sisto-diastólica do coração transplantado, podendo auxiliar na triagem de pacientes transplantados, clinicamente descompensados e que anteriormente seriam submetidos à biópsia de rotina / Abstract: Introduction: The transplant (TC) cardiac is an alternative for the individuals with terminal cardiac illness. In the evolution after TC, the occurrence of rejection episodes is a frequent event, being responsible for the increase of morbi-mortality. An excellent alternative would be the job of a not invasive examination that had a good acurácia in the detention of the alterations of the diastolic function of the transplantated heart, therefore the endomyocardial biopsy (EMB) is not an exempt procedure of complications. Objective: Analyze the Myocardial Performance Index (MPI) as a tool for the diagnosis of cardiac rejection and demonstrate their ability to triage in the selection of patients for EMB. Methods: Transthoracic echocardiograms in the period of January of 2006 had been carried through the January of 2008, for the prospective evaluation of 58 patients; being 17 patients (29,3%) pertaining to the group it has controlled (group GC), 22 (37,9%) pertaining to the group of patients transplantated without rejection (TX0) and 19 (32,9%) pertaining ones to the group of patients transplantated with rejection (TX1). It was compared sisto-diastolic function between the three groups (GC, TX0, TX1). The Qui-quadrado test was used to verify that the proportions of gender and race were homogeneous. For comparison between groups, ANOVA was used, in case of normality (verified by the Kolmogorov-Smirnov test) and homoscedasticity (verified by Levene's test) between the variables; otherwise opted to using the nonparametric Kruskal-Wallis test. The significance level used for the tests was 5% Results: The groups did not differ in age [38,47 (±11,17) X 41,18 (±13,83) X 45,95 (±12,87) p = 0,212], weight [71,95 (±15,90) X 68,68 (±13,14) X 66,09 (±11,91) p = 0,442], height [1,66 (±0,11) X 1,67 (±0,05) X 1,68 (±0,06) p = 0,894] and body surface area [1,82 (±0,25) X 1,78 (±0,18) X 1,75 (±0,17) p = 0,603]. The GC group compared with the group TX0, had an alteration of the systolic-diastolic function of left ventricle, expressed by increasing the Miocardic Performance Index (IPM), which is more significant for patients in group TX1 [0,38 (0,29 - 0,39) X 0,47 (0,42 - 0,49) X 0,60 (0,52 - 0,71) p <0,001]. Conclusion: It was shown that the PMI is greatly increased in patients with transplant rejection compared to patients transplanted without rejection and also in relation to the control, so this index proved to be as non-invasive and accurate method for the detection of changes in systolic and diastolic function of the transplanted heart to assist in screening transplant patients clinically decompensated and who previously underwent biopsy would be routine / Doutorado / Fisiopatologia Cirúrgica / Doutor em Ciências

Orientador: Orlando Fontes Lima Júnior / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Engenharia Civil, Arquitetura e Urbanismo / Made available in DSpace on 2018-08-19T15:05:07Z (GMT). No. of bitstreams: 1 Monteiro_VeraLucia_M.pdf: 6503368 bytes, checksum: 6c3cbfa37d4c6be4c55790c4d7e3a025 (MD5) Previous issue date: 2011 / Resumo: As técnicas do pensamento enxuto ou Lean Thinking têm sido amplamente aplicadas na indústria. Entretanto, elas também têm se mostrado eficazes nas atividades da área da saúde. Sendo assim, este estudo objetivou investigar sua aplicação nas atividades de logística dos transplantes de órgãos sólidos, tentando reduzir seu tempo de ciclo, porque o tempo é a principal e mais importante restrição nos processos de transplante. A pesquisa foi realizada em parceria com a Organização de Procura de Órgãos do Hospital das Clínicas da Universidade Estadual de Campinas. Os procedimentos envolveram o acompanhamento in loco dos processos de transplante escolhidos, desde a retirada do órgão do doador até o seu implante no receptor, tendo sempre por foco as atividades logísticas. Após o mapeamento dos processos, foram feitas análises críticas, buscando detectar os desperdícios em cada etapa e então, um redesenho de processo foi proposto, com vistas a reduzir o seu lead time, através da eliminação dos desperdícios encontrados. Na seqüência, um mapa de valor futuro projetado foi desenhado, representando os processos mais enxutos. Algumas implementações de melhorias sugeridas foram feitas, através da aplicação de ferramentas lean apropriadas a cada situação e, finalmente, um novo processo foi mapeado para comparação dos lead times antes e depois das implementações. Esperou-se com este estudo averiguar a aplicabilidade das técnicas do pensamento enxuto, como capazes de produzir importantes melhorias nos processos da logística de transplantes de órgãos sólidos, assim como vem acontecendo em outras atividades da área da saúde / Abstract: The Lean Thinking Techniques have been widely applied in industries; however they have also been effective in healthcare activities. Thus this study aimed to investigate the use of these techniques in the logistics activities of solid organs transplantation, trying to reduce its cycle time because time is the main and the most important constraint for transplantation operations. The research was developed in partnership with Organ Procurement Organization at the Clinic Hospital in State University of Campinas. The procedures involved the mapping of all logistics activities, into the transplantation processes, from the removal of the organ donor until its transplantation into the recipient. After process mapping, critical analyses were made to look for waste in each stage. Then a process redesign was proposed, trying to reduce the total lead time by reducing waste observed. So a hypothetical future state value stream mapping was drawn representing the processes with less waste. Some improvements were implemented, by applying the appropriate lean tool to the situation observed and finally, a new process was mapped in order to allow the comparison between lead times after and before the implementations. It is hoped this study verify the applicability of the lean thinking techniques as capable of adding important improvements to the logistics processes of solid organs transplantation, following the tendency of other healthcare-related activities / Mestrado / Transportes / Mestre em Engenharia Civil

Orientadores: Ilka de Fátima Ferreira Santana Boin, Raquel Silveira Bello Stucchi / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-20T01:05:47Z (GMT). No. of bitstreams: 1 Sampaio_AnaMaria_D.pdf: 2807263 bytes, checksum: d6e4e66e4a1625c1079f11fd900f0137 (MD5) Previous issue date: 2012 / Resumo: O herpes vírus humano HHV-6 e HHV-7 pertencem à subfamília herpes virinae, família herpes viridae, são vírus universais e após infecção primária permanecem latentes no organismo, podendo ser reativados por período de imunossupressão. O objetivo da pesquisa visou a padronização e implantação da antigenemia para diagnóstico precoce de HHV-6 e HHV-7 e a realização da sorologia para HHV-6 em pacientes submetidos ao transplante de fígado do Hospital das Clínicas da Unicamp. A partir dos dados obtidos da antigenemia para HHV-6 e HHV-7, avaliou com os achados de antigenemia do HCMV, N-PCR para HCMV, HHV-6, HHV-7 e outros aspectos clinico-laboratoriais. O protocolo foi seguido de acordo com os requerimentos para pesquisas e foi aprovado pelo Comitê de Ética Institucional da Faculdade de Ciências Médicas (FCM) da Universidade Estadual de Campinas (Unicamp). Conseguiu-se para o estudo amostras de 32 pacientes, com idade mediana de 47 (18-66) anos, sendo 20 (62,5%) do sexo masculino e 12 (37,5%) do sexo feminino. A monitorização dos pacientes foi realizada prospectivamente desde o pré-transplante e no pós-transplante, de modo semanal no 1º e 2º, quinzenal no 3º mês e mensal do 4º mês até o final do 6º mês. A partir de linfócitos extraídos de sangue periférico realizou-se a detecção de antígenos de HHV-6 com anticorpos monoclonais C65206M (marca Biodesign International, France) e MAB8535 (marca Biodesign International - USA) e conjugados de soro de coelho anti-IgG de camundongo Z0412-1 (marca Dako - CA, USA) e soro de cabra anti-IgG de coelho marcado com peroxidase 81-6120 (marca Zymed, CA, USA). Para a detecção de antígenos de HHV-7 foi utilizado o anticorpo monoclonal de rato KR4 (marca Advance Biotechnologies, Canada), conjugado soro de coelho anti-imunoglobulina de camundongo P0260 (marca Dako Cytomation, USA) e conjugado soro de cabra anti-IgG de coelho 81-6120 (marca Zymed, CA, USA) diluídos em PBS/BSA e aplicados sobre a fixação celular. Foi realizado a detecção de anticorpos IgM anti HHV-6 pelo teste de Elisa (marca Panbio, USA). Com essas metodologias a detecção de IgM anti HHV-6 foi positiva em 15,6% dos pacientes no pré transplante, 25% na quarta semana, 40,6% na 12 semana e em 46,9% na 24 semana após o enxerto. A antigenemia para HCMV, HHV-6 e HHV-7 foi positiva em 46,9%, 62,5% e 46,8% respectivamente. A N-PCR para HCMV e HHV-6 ocorreu em 81% dos casos, e para HHV-7 foi de 46,8%. Detectou-se que 50% dos pacientes estudados tiveram doença por HCMV. A doença causada pelo HHV-6 foi em 46,8% dos pacientes e em 15,6% para HHV-7. A concomitância de doenças foi observada nos pacientes com HCMV e HHV-6 em 21,9% e em 15,6% dos pacientes com HHV-6 e HHV-7. A doença causada pelos beta herpes vírus foi detectada com maior frequência ao redor da quinta semana. E os episódios de doença para HHV-6 e HHV-7 surgiram antes do aparecimento da doença por HCMV. Este estudo confirma a relevância da infecção pelo HCMV, HHV-6 e HHV-7 e a importância do monitoramento através de técnicas para a detecção precoce desses agentes, possibilitando a utilização de um tratamento preemptivo, com redução do risco de doença / Abstract: Introduction: The human herpes viruses type 6 (HHV-6) and 7 (HHV-7) belong to the herpes virus subfamily, herpes viridae family, are universal viruses and after primary infection remain latent in the organism and may be reactivated during an immunosuppression period. The aims of the research were to standardize, implement and monitor antigenemia for early diagnosis of HHV-6 and HHV-7 and serology for HHV-6 in patients who underwent liver transplantation in the Hospital of the State University of Campinas. The data obtained for HHV-6 and HHV-7 antigenemia were correlated with results for HCMV, N-PCR for HCMV, HHV-6, HHV-7 and other clinical and laboratorial aspects. The protocol was followed according to the research requirements and was approved by the Institutional Ethics Committee of the State University of Campinas. Thirty-two patients were studied, mean age 47 (18-66) years old, in which 20 (62.5%) were male and 12 (37.5%) were female. The monitoring of the patients was carried out prospectively since pre-transplantation and during post-transplantation period; weekly in the first and second month, fortnightly in the third month and monthly up to the sixth month. Detection of HHV-6 antigens was held from lymphocytes extracted from peripheral blood using monoclonal antibodies C65206M (Biodesign International, France) and MAB8535 (Biodesign International-USA); rabbit anti-mouse IgG Z0412-1 (Dako, USA) conjugate serum and goat anti-rabbit marked with peroxidase IgG 81-6120 (Zymed, USA) conjugate serum. For HHV-7 antigens detection, KR4 (Advance Biotechnologies, Canada) mouse monoclonal antibody, conjugate P0260 (Dako Cytomation, USA) rabbit anti-mouse IgG serum and conjugate goat anti-rabbit IgG serum 81-6120 (Zymed, USA) were used, diluted in PBS/BSA and applied over the cell fixation. IgM anti HHV-6 antibody detection was held by ELISA test (Panbio, USA). Using this methodology IgM anti HHV-6 detection was positive for 15.6% of the patients in pre-transplantation, 25% in the fourth week, 40,6% in the twelfth week and 46,9% in the 24th week after the transplantation. HCMV, HHV-6 and HHV-7 antigenemia was positive in 46.9%, 62.5% and 46.8%, respectively. HCMV and HHV-6 PCR occurred in 81% of the cases and for HHV-7, 46.8% of the cases. It was detected that 50% of the patients manifested HCMV disease. Disease manifested in 46.8% and 15.6% of the patients for HHV-6 and HHV-7, respectively. Concomitance of the diseases was observed in patients with HCMV and HHV-6 in 21.9% and 15.6% of the patients with HHV-6 and HHV-7. The disease caused by beta herpes virus was detected with higher frequency around the fifth week. HHV-6 and HHV-7 disease episodes appeared prior to HCMV disease. This study confirms the relevance of HCMV, HHV-6 and HHV-7 infection and the importance of monitoring through techniques for early detection of these agents, allowing the usage of a preemptive treatment, reducing the risk of disease / Doutorado / Fisiopatologia Cirúrgica / Doutor em Ciências

Orientador: Afonso Celso Vigorito / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-20T03:28:20Z (GMT). No. of bitstreams: 1 Souza_ClarissaVasconcellosde_M.pdf: 2809498 bytes, checksum: ac6c5e1a4f9ab38a684ec0a6a1a664a6 (MD5) Previous issue date: 2011 / Resumo: O procedimento de transplante de células-tronco hematopoiéticas (TCTH) pode causar perdas funcionais que dificultam atividades diárias que requeiram habilidades físicas. Nosso objetivo foi avaliar a função dos pacientes pré e após o TCTH utilizando uma avaliação em ambiente ambulatorial. De novembro de 2008 a Novembro de 2010, 50 pacientes, 29 (58%) mulheres, mediana de idade de 48 anos (24-67), foram arrolados no estudo. A coleta foi realizada pré e pós TCTH alogênico ou autólogo. Os instrumentos utilizados foram o teste de caminhada de 2 minutos (TC2M), saturação de oxigênio (SatO2), freqüência cardíaca (FC) e escala modificada de Borg (EMB) antes e depois do TC2M para avaliação da performance da marcha, teste de força de preensão (TFP) para avaliação de força muscular, teste de Schober (TS) para avaliação de mobilidade de coluna lombar e escala máxima e adaptada de atividade (EMA e EAA) do questionário Perfil de Atividade Humana (PAH) para avaliação da função física. Cinqüenta pacientes foram avaliados pré TCTH; 6 não foram submetidos ao TCTH; 3 morreram previamente, 1 se recusou e 2 foram excluídos. Quarenta e quatro de 50 (88%) foram submetidos ao TCTH, 21 alogênicos e 23 autólogos. Trinta e três de 44 (75%) pacientes foram submetidos à ambas as avaliações, 11/44 (25%) pacientes não foram submetidos: 9 morreram e 2 foram excluídos. Entre os grupos que foram submetidos às duas avaliações, achamos valores estatisticamente menores na avaliação pós para TC2M (p= 0,004), TFP para mão direita e esquerda (p= 0,004 e < 0,0001), TS, EMA e EAA (p< 0,0001); e valores maiores para FC (p= 0,01) antes do TC2M e SatO2 (p= 0,02) após o TC2M. Também encontramos diferenças estatisticamente significantes entre os grupos de pacientes autólogo e alogênico nas variáveis Hemoglobina (Hb), EMA (p= 0,002) e EAA (p= 0,008) no pós TCTH. Estas diferenças indicam um decréscimo no condicionamento aeróbico antes do stress físico, redução da performance da marcha, da força muscular, da flexibilidade da coluna e na função em atividades de vida diária no pós TCTH, mostrando perdas físicas nesta população. Ademais, o prejuízo funcional e físico foi mais severo nos pacientes submetidos ao procedimento alogênico no pós TCTH. Concluindo, o entendimento da intensidade e a especificidade dessas perdas físicas podem ajudar a conduzir melhor um programa de reabilitação no pós TCTH / Abstract: Hematopoietic stem cell transplant (HSCT) procedure may cause functional losses that impair daily tasks that require physical skills. Our aim was to evaluate function of patients pre and post HSCT using an assessment in outpatient basis. From November 2008 to November 2010, 50 patients, 29 (58%) female, median age 48 years (24-67), were enrolled in the study. Collection was performed pre and post autologous or allogeneic HSCT. Instruments were 2 minutes walking test (2MWT), oxygen saturation (Sa02), heart rate (HR) and Borg Scale (BS) before and after 2MWT for gate performance evaluation; Grip Strength (GS) for strength evaluation, Schober Test (ST) for spine mobility testing and maximum and adapted activity score (MAS and AAS) of Human Activity Profile (HAP) questionnaire for function role evaluation. Fifty patients were evaluated pre HSCT; 6 did not undergo HSCT; 3 died, 1 refused, and two were excluded. Forty four out of 50 (88%) underwent HSCT, 21 allogeneic, 23 autologous. Thirty three out of 44 (75%) patients performed both evaluations, 11/44 (25%) patients did not: 9 died and 2 were excluded. Among groups who performed both evaluations, we found significant lower values in the post evaluation for 2MWT (p= 0.004), GS for right and left hand (p= 0.004 and <0.0001 respectively), ST, MAS and AAS (p< 0.0001); and higher HR (p= 0.01) before 2MWT and Sa02 (p=0.02) after 2MWT. We also found statistically differences between allogeneic and autologous groups of patients for hemoglobin (Hb), MAS (p= 0.002) and AAS (p= 0.008) variables on post HSCT. Those differences indicate decrease on aerobic conditioning before physical stress, decline of gate performance, hand strength, spine flexibility and on function role on daily activities post HSCT, showing physical losses in this population. Moreover, functional and physical prejudice was more severe in patients that underwent allogeneic procedure on post HSCT. In conclusion a better understanding of intensity and specificity of those physical losses may help to conduct a better rehabilitation program on post HSCT period / Mestrado / Ciencias Basicas / Mestre em Clinica Medica

Os imunossupressores tacrolimo (Tac) e sirolimo (Srl) são amplamente utilizados no transplante renal. Estes medicamentos apresentam estreita faixa terapêutica e estão associados a uma vasta gama de efeitos colaterais. Polimorfismos de nucleotídeo único (SNP) parecem ter um impacto significativo sobre a farmacocinética dos imunossupressores. Com o objetivo de avaliar a associação de SNP nos genes PPP3CA e MTOR com a resposta farmacológica dos imunossupressores tacrolimo e sirolimo foram selecionados 156 indivíduos indicados para transplante renal entre os pacientes atendidos no Hospital do Rim e Hipertensão da UNIFESP. Esses indivíduos foram tratados com esquema imunossupressor baseado em tacrolimo ou convertido para sirolimo. Amostras de sangue foram coletadas antes do transplante para extração de DNA. As determinações das concentrações sanguíneas de Tac foram determinadas por chemiluminescent microparticle immunoassay (CMIA) e as concentrações sanguíneas de Srl foram obtidas pela técnica de HPLC (High- Performance Liquid Chromatography). Os polimorfismos do MTOR (c.1437T>C, T c.2997C>T e c.4731G>A) e PPP3CA (c.249G>A) foram identificados por PCR em tempo real. O polimorfismo PPP3CA c.246G>A não foi associado à dose diária de tacrolimo ou sirolimo. Já a concentração sanguínea de tacrolimo foi menor nos portadores do alelo A no terceiro dia e terceiro mês de estudo. Os polimorfismos do MTOR foram relacionados à concentração sanguínea corrigida pela dose de tacrolimo. Os portadores dos alelos raros G, T e C dos polimorfismos c.4731G>A, c.14337T>C e c.2997C>T, respectivamente, apresentaram valores de Co/Do de tacrolimo menores em relação aos não portadores destes alelos. As diferenças significativas ocorreram principalmente nos primeiros três meses de estudo. A concentração sanguínea de tacrolimo foi no geral menor nos portadores dos alelos raros, sendo significativamente menor no décimo quarto dia. Doses maiores de tacrolimo foram associadas aos alelos T do c.14337T>C e C do c.2997C>T. No sexto mês de estudo, os portadores dos alelos raros receberam doses de sirolimo significativamente maiores do que os não portadores. O alelo T do polimorfismo c.1437T>C foi associado a menores valores de Co/Do de sirolimo. Os SNPs c.2997C>T e c.1437T>C do MTOR encontram-se em desequilíbrio de ligação (D\'=0,981; r2=0,690). Nos três primeiros meses de estudo, os portadores do haplótipo TC receberam doses menores de tacrolimo e apresentaram a melhor relação Co/Do. Foi possível observar que após a randomização, o haplótipo TC continuou associado a menores doses de tacrolimo e de sirolimo e manteve a tendência de melhores índices de Co/Do de ambos os fármacos. Os polimorfismos c.1437T>C e c.4731G>A foram associados a parâmetros de função renal no grupo TAC. O alelo G do SNP c.4731G>A relacionou-se a valores menores de ureia no pré-Tx, menor redução de ureia e creatinina entre o pré-Tx e o sexto mês de estudo. O alelo T do SNP c.1437T>C também foi relacionado a menores valores de ureia no pré-Tx e menor redução de creatinina. No grupo TAC, o alelo raro do SNP PPP3CA c.249G>A foi relacionado a menores valores de triglicérides no pré-Tx e no grupo SRL uma menor variação de LDL-colesterol. Os portadores do alelo C do SNP c.2997C>T apresentaram menor aumento de colesterol total e LDL colesterol entre o pré-Tx e o sexto mês de estudo, maiores valores de HDL colesterol no pré-Tx e menores valores de triglicérides no sexto mês de estudo. Os portadores do alelo T do SNP c.1437T>C apresentaram menor aumento de colesterol total, LDL colesterol, VLDL colesterol e triglicérides. No sexto mês de estudo apresentaram menores valores de triglicérides em relação aos não portadores deste alelo. Os portadores do alelo G do SNP c.4731G>A tiveram variação menor de colesterol total, VLDL colesterol e triglicérides. Não foi encontrada relação dos polimorfimos estudados e a rejeição aguda comprovada por biópsia ou com a nefropatia crônica do enxerto. Esses resultados são sugestivos de que os polimorfismos do MTOR e PPP3CA estão associados com a dose e concentração sanguínea dos imunossupressores tacrolimo e sirolimo, assim como um perfil lipídico menos aterogênico. / The immunosuppressant tacrolimus (Tac) and Sirolimus (Srl) are widely used in renal transplantation. These drugs have a narrow therapeutic range and are associated with a wide range of side effects. Single nucleotide polymorphisms (SNPs) have a significant impact on the pharmacokinetics of immunosuppressants. In order to evaluate the association of SNPs in genes MTOR and PPP3CA with the pharmacological response of immunosuppressive drugs tacrolimus and sirolimus were selected 156 individuals referred for kidney transplantation among patients treated in the Hospital do Rim e Hipertensão, UNIFESP. These individuals were treated with tacrolimus-based immunosuppressive regimen or converted to sirolimus. Blood samples were collected before transplantation for DNA extraction. Determinations of blood concentrations of Tac were determined by Chemiluminescent microparticle immunoassay (CMIA) and blood concentrations Srl were obtained by the technique of HPLC (High-Performance Liquid Chromatography). Polymorphisms of MTOR (c.1437T>C, T c.2997C>T and c.4731G>A) and PPP3CA (c.249G>A) were identified by real-time PCR. The Polymorphism PPP3CA c.246G>A was not associated with the daily dose of tacrolimus or sirolimus. The blood concentration of tacrolimus was lower in carriers of the allele on the third day and third month of study. The Polymorphisms of MTOR were related to blood concentration corrected by the dose of tacrolimus. The carriers of rare alleles G, T and C polymorphisms c.4731G> A, c.14337T> C and c.2997C> T, respectively, had values of Co/Do tacrolimus lower than the non-carriers of these alleles. Significant differences occurred mainly during the first three months of study. The blood concentration of tacrolimus was generally lower in carriers of the rare alleles being significantly lower on the fourteenth day. Higher doses of tacrolimus were associated with alleles c.14337T T>C and C c.2997C>T. In the sixth month of study, the carriers of rare alleles received doses of sirolimus significantly higher than non-carriers. SNPs c.2997C>T and c.1437T>C MTOR are in linkage disequilibrium (D \'= 0.981; r2 = 0.690). In the first three months of study, carriers of the TC haplotype received lower doses of tacrolimus and presented the best value for Co/Do. It was observed that after randomization, the TC haplotype remained associated with lower doses of tacrolimus and sirolimus and continued the trend of higher rates of Co/Do of both drugs. Polymorphisms c.1437T>C and c.4731G>A were associated with renal function parameters in the TAC group. The G allele of SNP c.4731G> A was related to lower levels of urea in the pre-Tx, a smaller reduction of urea and creatinine between the pre-Tx and sixth months of study. The T allele of SNP c.1437T>C was also related to lower levels of urea in the pre-Tx and a smaller reduction of creatinine. In the TAC group, the rare allele of SNP PPP3CA c.249G>A was related to lower levels of triglycerides in the pre-Tx and the SRL group a smaller variation of LDL-cholesterol. The C allele of the SNP c.2997C>T showed a lower increase in total cholesterol and LDL cholesterol between pre-Tx and sixth months of study, higher HDL cholesterol in pre-Tx and lower levels of triglycerides in the sixth month of study. The T allele of SNP c.1437T>C showed a lower increase in total cholesterol, LDL cholesterol, VLDL cholesterol and triglycerides. In the sixth month of the study, they had lower triglyceride levels compared to non-carriers of this allele. The G allele of SNP c.4731G>A change had lower total cholesterol, VLDL cholesterol and triglycerides. There was no relationship between the studied polymorphisms and biopsy-proven acute rejection or chronic allograft nephropathy. These results suggest that MTOR and PPP3CA polymorphisms are associated with dose and blood concentration of immunosuppressants tacrolimus and sirolimus, as well as a less atherogenic lipid profile.

M.A. (Psychology) / The purpose of this study was to determine whether psychological factors contribute to the rejection of a transplanted kidney. After a review of existing literature on the relationship between various psychological factors and immunological system of the body, it was hypothesized that psychological factors such as state- and trait anxiety, stress, locus of control as well as hopelessness would affect immune responses, and therefore contribute to the acceptance or rejection of a transplanted kidney. In order to test the hypothesis, patients of the Johannesburg Hospital undergoing haemodialysis and on the waiting list for kidney transplant were tested. Out of the initial sample, 12 of these patients, who had undergone a renal transplant, were used in the study. Out of the 12 patients, 6 patients had accepted the graft, while 6 patients had rejected the graft. The tests used in the study were the Spielberger State-Trait Anxiety Scale, Hopelessness Scale, Health Locus of Control and the Rotter Internal-External Locus of Control Scale. The analysis of the data indicated a significant difference in the mean score for the two groups with relation to state anxiety, trait anxiety and health locus of control. The results indicated that the higher the state and trait anxiety, and the more internal the health locus of control of the patient, the greater the chances that the graft would be accepted. The results of this study indicated that psychological factors do contribute to the immune response of the body to a transplanted kidney. This would imply that more research is necessary to establish influence of various psychological as well as social variables in transplants and medical immunology.

Många människor idag drabbas av sjukdom som kan leda till organsvikt. Flertalet drabbade kan där av behöva genomgå en transplantation, för att personen i fråga ska ha en chans att överleva. Transplantation är en resultatrik metod som ger människor en andra chans till liv. De senaste åren har transplantationer ökat drastiskt i västvärlden, därför har den medicinska forskningen med åren varit tvungen att utvecklas. Listan över de patienter som väntar på en transplantation blir allt längre. Många tidigare studier talar om upplevelsen efter en transplantation, dock belyser få studier patientens upplevelser i väntan på en transplantation. Detta är något som den här studien kommer gå djupare in på. Studiens syfte är att ur ett patientperspektiv beskriva upplevelsen av att vänta på ett nytt organ. Den här studien är en litteraturstudie, där totalt åtta artiklar har analyserats och använts till resultatet. Där ur skapades fem kategorier; att stå i standby – när livet begränsas av sjukdom, att lägga sitt liv i någon annans händer, att bekanta sig med döden, att uppleva hopp – det som håller patienten vid liv och att inte vara ensam – stöd från olika håll. Ur dessa kategorier har författarna sammanfattat hur patientens upplevelser och känslor i väntan på en transplantation kan yttra sig. Känslor så som ångest och oro, samt svårigheter med att inte kunna kontrollera sitt liv. Diskussionen talar om de huvudfynd författarna funnit i resultatet samt belyser vikten av vårdpersonalens roll relaterat till patientens upplevelser och känslor.

Les alloanticorps anti-HLA sont dirigés vis-à-vis de différents épitopes des molécules du système HLA. Cette immunisation survient lors d'une transplantation d'organe, de transfusions sanguines ou d'une grossesse. On retrouve aussi ces anticorps, lorsque les techniques de détection sont sensibles, en l'absence de tout évènement immunisant. En transplantation d'organe, rénale en particulier, la présence d’anticorps anti-HLA, du fait des lésions de rejet humoral qu'ils induisent, constitue une des premières causes de perte de fonction des greffons à moyen et long terme. Néanmoins, les cellules lymphocytaires qui sont la source de ces anticorps anti-HLA demeurent mal identifiées.Dans la première partie de ce travail, nous avons étudié, dans une cohorte de patients en attente de transplantation rénale, la distribution des différentes sous-populations lymphocytaires B circulantes par cytométrie de flux en relation avec la nature des évènements immunisants vis-à-vis du système HLA, la présence et la diversité des anticorps anti-HLA. Nous avons étudié en parallèle les concentrations sériques de BAFF ("B cell activating factor belonging to the TNF family"), principal facteur impliqué dans la survie et la différenciation des lymphocytes B matures. Nous avons retrouvé une association entre la présence et la diversité des anticorps anti-HLA, et l'augmentation de la proportion de lymphocytes B naïfs activés Bm2, par rapport aux autres sous-populations lymphocytaires B, et indépendamment de l'existence d'évènements immunisants. Les concentrations sériques de BAFF étaient également associées positivement à la présence et à la diversité des anticorps anti-HLA. Ces données suggèrent que l'augmentation des lymphocytes B naïfs activés et des concentrations sériques de BAFF favorise le développement des anticorps anti-HLA à la suite d'un événement immunisant. A l'instar du mécanisme évoqué en auto-immunité, BAFF pourrait intervenir en présence de l'alloantigène en favorisant la survie de clones B alloréactifs.Dans la deuxième partie de notre travail, nous nous sommes intéressés plus particulièrement à l'implication des lymphocytes B mémoire alloréactifs dans la réponse humorale anti-HLA. Pour détecter les lymphocytes B mémoire circulants, nous avons utilisé un test de stimulation polyclonale permettant leur différenciation en plasmablastes puis nous avons recherché et étudié la spécificité des anticorps anti-HLA produits dans les surnageants de culture. Un premier résultat important a été la possibilité de détecter, chez les patients présentant des anticorps anti-HLA, des lymphocytes B mémoire alloréactifs circulants plusieurs années après un événement immunisant. En deuxième lieu, la présence de ces lymphocytes B mémoire était associée au nombre d'évènements immunisants. En effet, les patients ayant développé, en l'absence d'événement immunisant des anticorps anti-HLA - dont nous montrons par ailleurs le caractère potentiellement pathogène - n'ont pas présenté de lymphocytes B mémoire alloréactifs circulants. Enfin, à l'aide du logiciel HLAMatchmaker, nous avons montré que les anticorps produits par les lymphocytes B mémoire étaient dirigés contre un nombre restreint d'épitopes partagés par plusieurs antigènes HLA, ce qui suggère une oligoclonalité du contingent B mémoire alloréactif. Chez les mêmes patients, les anticorps anti-HLA circulants présentaient une diversité de spécificité plus large, étant dirigés contre de multiples épitopes HLA. Ces résultats suggèrent l'existence d'au moins deux types de réponse humorale vis-à-vis des alloantigènes HLA : l'une aboutissant à la production de lymphocytes B mémoire et de plasmocytes à la suite d'une réaction de centre germinatif T-dépendante, l'autre impliquant seulement des plasmocytes, possiblement issus de réponses extra-folliculaires. Les facteurs orientant vers l’un ou l’autre type de réponse sont encore mal définis mais pourraient impliquer la dose et la voie d'exposition aux alloantigènes. / Anti-HLA antibodies are directed against various epitopes of HLA molecules. They develop during organ transplantations, red cell transfusions or pregnancies. But anti-HLA antibodies are also detected with sensitive assays in the absence of any sensitizing event. In renal transplantation, anti-HLA antibodies, through the development of antibody-mediated rejection, represent the first cause of late allograft loss. Nevertheless, the mechanisms and the exact nature of B cells involved in anti-HLA antibodies synthesis are poorly understood.In a first part, we studied by flow cytometry in patients awaiting kidney transplantation the distribution of the different peripheral B cell subsets in relation with immunizing events, titer and diversity of anti-HLA antibodies. We also studied the serum levels of BAFF ("B cell activating factor belonging to the TNF family"), the main factor involved in survival and differentiation of mature B cells. We found an association between the presence and the diversity of anti-HLA antibodies, and the proportion of activated naive Bm2 B cells, at the expense of other subsets, independently of immunizing events. BAFF serum levels were also positively associated with the presence and the diversity of anti-HLA antibodies. These data suggest that the increase in activated naive B cells and in BAFF levels facilitate the development of anti-HLA antibodies, following an immunizing event. Similarly to what is observed in autoimmunity, BAFF could help to the positive selection of alloreactive B cell clones, in the presence of alloantigen.In a second part, we focused on the role of circulating alloreactive memory B cells in anti-HLA humoral response. To detect those alloreactive memory B cells, we used a polyclonal stimulation assay allowing the differentiation of memory B cells into plasmablasts and we studied the specificity of anti-HLA antibodies recovered from culture supernatant. A first important result was the detection, decades after an imunizing event, of specific alloreactive memory B cells, even in the absence of the antigen. The detection of those circulating alloreactive memory B cells was related to the strength of immunizing events, i.e. the number of different immunizing events in the history of patients. Indeed, patients with anti-HLA antibodies with no history of immunizing event had no circulating alloreactive memory B cells. Eventually, with HLAMatchmaker software, we showed that antibodies produced by memory B cells were directed against a limited number of epitopes shared by HLA antigens, which suggests an oligoclonality of the alloreactive memory B cell population. By comparison, serum antibodies displayed a greater diversity, with multiple epitopic specificities. These results suggest two distinct cellular arms of humoral response towards HLA epitopes: medullar plasma cells, involved in long term HLA antibodies synthesis, and memory B cells waiting for a recall response in the presence of the antigen. The factors involved in the choice of those two cellular fates are poorly understood but may involve dose and route of exposition to the alloantigen.

Class of 2014 Abstract / Specific Aims: Busulfan is a chemotherapy used in conditioning regimens for hematopoeitic stem cell transplant (HSCT) that requires therapeutic drug monitoring (TDM) to reduce ther risk of adverse effects. Variable oral absorption and several studies demonstrating decreased toxicity with the intravenous formulation have led to IV preference despite the lower acquisition cost of oral busulfan. However, these studies failed to consider therapeutic drug monitoring and their results may therefore be flawed. The objective of this retrospective chart review was to determine the adverse effect, outcome profile, and cost-effectiveness of IV versus PO busulfan at a single medical center under TDM. Methods: This quality improvement project was a retrospective cohort analysis using patient data from a single large academic medical center from January 2007 to April 2013. Patients were included if they were 18 years or older and had undergone HSCT using either IV or PO busulfan using standard dosing regimens. This data was then used to design a cost-effectiveness model in order to determine if IV or PO busulfan is cost effective. Main Results: There were 68 subjects receiving autologous transplants and 37 subjects receiving allogeneic transplants that received busulfan as part of their pretreatment therapy and were included in this study. Allogeneic and autologous transplant populations were analyzed separately. In both populations there was no difference in occurrence of pulmonary toxicity, HVOD, or mucositis between the IV or PO groups. IV busulfan was significantly associated with an increased need for patient controlled analgesia in both autologous and allogeneic populations (p=0.038 and 0.028 respectively). Total cost of PO therapy was $30,081 and $30,047 less than IV for autologous and allogeneic transplants, respectively. PO therapy also represented a cost savings of $41 and $57 dollars for autologous and allogeneic transplants, respectively. This was confirmed through bootstrapping technique, which found PO to be dominant to IV busulfan. Conclusion: In conclusion, this study finds PO busulfan to be a therapeutically equivalent and cost saving option as part of a pretreatment regimen for both autologous and allogeneic hematopoietic stem cell transplants when therapeutic drug monitoring is performed.

Doctor of Philosophy / Department of Anatomy and Physiology / Mark L. Weiss / Umbilical cord matrix or Wharton’s Jelly is a mucous connective tissue ensheathing the cord blood vessels and contains mesenchymal-like stem cells. Previously, we have shown that pig umbilical cord matrix stem (pUCMS) cells transplanted into normal rat brain were recovered up to 6 weeks post-transplantation, where a sub-population of pUCMS cells exhibited neuronal morphology and expressed a variety of neuronal markers. Here, approximately 150 pUCMS cells were transplanted into non-immunesuppressed rats that previously received a brain lesion by neurotoxin, 6-hydroxydopamine (6-OHDA), which specifically affects midbrain dopaminergic neurons, leading to pathologic findings similar to that of Parkinson’s disease (PD). The pUCMS cells proliferated up to 8 weeks post-transplantation and there was a significant increase in the percentage and number of pUCMS cells expressing tyrosine hydroxylase (TH), which is a marker for dopaminergic cells. We conclude that 1. Xenotransplants of pig UCMS cells are not rejected by rats at least up to 8 weeks after transplantation and 2. The pig UCMS cells proliferate and differentiate after transplantation into PD model rats. The surface antigen and gene expression profile of human umbilical cord matrix stem (hUCMS) cells resemble that of mesenchymal stem cells. Apomorphine-induced rotatory behavior was used to analyze the motor deficits of the PD model rats. In different experiments 1000, 2500 and 25000 hUCMS cells were transplanted into the brain of non-immunesuppressed PD model rats. There was a dose-dependent decrease in apomorphine-induced rotations; the maximum benefit was found in the rats that received 1000 hUCMS cells. The graft cells were recovered at 2 days and 1 week, but not at 6, 10 or 12 weeks post-transplantation. Quantitative assessment of host TH-positive midbrain dopaminergic neurons revealed a positive correlation between the behavioral improvement and TH-positive cell number in the low-density (1000 cells) transplant group, showing that the hUCMS cells may play a role in rescuing damaged host dopaminergic neurons and promote improvement of motor deficits in PD-model rats. In summary, hUCMS cells appear to be mesenchymal stem cells that can be harvested in great numbers from a non-controversial, inexhaustible source. Human UCMS cells show therapeutic benefit in PD model rats, but the mechanism by which they promote improvement is presently unknown.