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Previous issue date: 2015-03-18 / This is a retrospective study reporting 35 years of kidney transplantation at Hospital S?o Lucas da Pontif?cia Universidade Cat?lica do Rio Grande do Sul. An historical approach of the origins and development of the Nephrology Unit over the years was performed. Data were separated into different eras, based on the type of immunosuppression, and the patient?s characteristics before, during and after transplantation were assessed. There were significant differences between each era, mainly on the characteristics of the recipients and donors, but also in the rates of complications and technical aspects of surgery. A total of 1231 transplants were performed until 2013, April 30. Of these, 55.8% were male, white (86.9%) and 76.6% from deceased donors. Most recipients aged between 19 and 59 years (77.5%), and 1.9% over 70 years. Significant differences were observed between the characteristics of each era, especially in relation to recipients and donors. Through the eras, an increased number of patients are being transplanted, with grafts from older donors (p<0.001) subjected to longer cold ischemia times (p<0.001) transplanted in an increasing proportion of elderly recipients (p<0.001), maintained in a longer period on the waiting list (p<0.001). Fewer episodes of rejection were observed (p<0.001), lower incidence of some clinical complications such as myocardial infarction (p<0.001), strokes (p=0.02) and post-??transplant diabetes (p<0.001), along of the time. In the present era, survival of patients at 1, 3 and 5 years were 98.3%, 94.6% and 90.5% for living donors and 92.4%, 87.2% and 80.7% for deceased donors, respectively. Survival of grafts were, for living donors, 92.2%, 88.7% and 82.4% and deceased donors 80.4%, 71.1% and 63.7%. Transplants with acute pyelonephritis in the first 30 days after transplantation, had significantly worse graft and patients survivals, compared to patients without pyelonephritis in the first 30 days. In addition, age, use of ureteral stents, thymoglobulin induction and longer hospital stays increased the risk of this infection. Recipients of expanded criteria donors transplants induced with thymoglobulin may be at a 25.75 fold increase in risk for death 24 hours after diagnosis of CRAB septicemia, a severe complication occurring in 10 recipients between January 2000 and April 2013, of 807 transplants patients. In recent years, our study showed a low incidence of cytomegalovirus (CMV) infection, despite the increased use of Thymoglobulin. We found that the use of low thymoglobulin doses reduces the risk of cytomegalovirus and, the use of oral ganciclovir had a protective effect on CMV, in the first year of transplantation. Finally, patients with a positive polyomavirus urinary cytology had worse renal function and graft survival in a seven years follow-??up period, compared with the patients without the presence of decoy cells in urine. The analysis of the 35 years of transplantation at the Renal Unit of Hospital S?o Lucas da PUCRS depicts the evolution and development of a program that is a reference in South Brazil, and the different management and results through the different eras. There were changes in donor and recipient?s characteristics, inclusion selection, compatibility assessment and immunosuppression protocols, among others. / Este trabalho consiste em um estudo retrospectivo que abordou a hist?ria dos 35 anos de transplantes renais no Hospital S?o Lucas da Pontif?cia Universidade Cat?lica do Rio Grande do Sul. Foi realizado um levantamento da hist?ria das origens do servi?o de nefrologia e sua evolu??o ao longo dos anos. Os dados foram separados em diferentes eras, com base no tipo de imunossupress?o, sendo avaliadas as caracter?sticas dos pacientes antes, durante e ap?s o transplante. Encontramos diferen?as significativas entre cada era, principalmente nas caracter?sticas dos receptores e doadores, mas tamb?m na ocorr?ncia de complica??es e nos aspectos cir?rgicos. Foram realizados 1231 transplantes at? 30 de abril de 2013, sendo 55,8% do sexo masculino, ra?a branca (86,9%) e com 76,6% de doadores falecidos. A maioria dos receptores com idade entre 19 e 59 anos (77,5%), sendo 1,9% acima de 70 anos. Diferen?as significativas entre as caracter?sticas de cada era, principalmente em rela??o aos receptores e doadores. Estamos transplantando um n?mero progressivamente maior de pacientes, significativamente mais idosos (p<0,001), com maior tempo em lista de espera (p<0,001), com doadores mais idosos (p<0,001) e tempos mais longos de isquemia (p<0,001). Foram verificados menos epis?dios de rejei??o (p<0,001), menor ocorr?ncia de algumas complica??es cl?nicas, tais como infarto de mioc?rdio (p<0,001), AVE (p=0,02) e diabete p?s transplante (p<0,001), ao longo do tempo. Na era atual, sobrevida de pacientes foram em 1, 3 e 5 anos de 98,3%, 94,6% e 90,5% para doadores vivos e de 92,4%, 87,2% e 80,7% para doadores falecidos, respectivamente. Sobrevida de enxertos foram para doadores vivos de 92,2%, 88,7% e 82,4% e doadores falecidos de 80,4%, 71,1% e 63,7%. Foi encontrado que transplantados que apresentaram pielonefrite aguda nos primeiros 30 dias ap?s o transplante, apresentavam significativamente pior sobrevida de enxertos e pacientes, comparado com os que n?o apresentavam pielonefrite nos primeiros 30 dias. Al?m disto, idade, uso de cateteres de duplo J, indu??o com timoglobulina e tempo maior de hospitaliza??o aumentam o risco desta infec??o. Pacientes que receberam rins com doadores com crit?rios expandidos e induzidos com timoglobulina podem apresentar risco maior para morte ap?s 24 horas do diagn?stico de septicemia por Acinetobacter baumannii resistentes a carbapen?micos, complica??o grave que ocorreu em 10 pacientes transplantados, dentre os 807 transplantados entre janeiro de 2000 e abril de 2013. Ocorreu baixa incid?ncia de citomegalov?rus nos ?ltimos anos, apesar do aumento do uso de timoglobulina. Verificamos que o uso de timoglobulina em doses menores diminui o risco de citomegalov?rus e que o uso de ganciclovir oral tem efeito protetor para o desenvolvimento de citomegalov?rus no primeiro ano do transplante. E por fim, verificamos que pacientes que apresentavam presen?a de citologia urin?ria positiva para poliomav?rus apresentaram pior fun??o renal e pior sobrevida de enxerto, em acompanhamento de 7 anos, comparado com grupo de pacientes que n?o tinha presen?a de c?lulas decoy na urina. A an?lise de 35 anos de transplante do Servi?o de Nefrologia da PUCRS, mostra a evolu??o de um programa de refer?ncia no nosso meio e as diferentes condutas e resultados nas diversas ?pocas. Ocorreram mudan?as nas caracter?sticas dos doadores e receptores, crit?rios de sele??o, avalia??o de compatibilidade e protocolos de imunossupress?o, entre outros.
| Identifer | oai:union.ndltd.org:IBICT/oai:tede2.pucrs.br:tede/6070 |
| Date | 18 March 2015 |
| Creators | Kroth, Leonardo Viliano |
| Contributors | Figueiredo, Carlos Eduardo Poli de |
| Publisher | Pontif?cia Universidade Cat?lica do Rio Grande do Sul, Programa de P?s-Gradua??o em Medicina e Ci?ncias da Sa?de, PUCRS, Brasil, Faculdade de Medicina |
| Source Sets | IBICT Brazilian ETDs |
| Language | Portuguese |
| Detected Language | English |
| Type | info:eu-repo/semantics/publishedVersion, info:eu-repo/semantics/doctoralThesis |
| Format | application/pdf |
| Source | reponame:Biblioteca Digital de Teses e Dissertações da PUC_RS, instname:Pontifícia Universidade Católica do Rio Grande do Sul, instacron:PUC_RS |
| Rights | info:eu-repo/semantics/openAccess |
| Relation | 7620745074616285884, 600, 600, 600, -8624664729441623247, -969369452308786627 |
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