Acp Martins

Why not to use kidney grafts from elderly donors.

BACKGROUND Kidney transplantation is widely recognized as the best treatment in patients who require renal replacement therapy. Although considered a clinical and surgical triumph, it is also a source of frustration because of lack of donor organs and the growth of waiting lists. Strategies need to be developed to increase the supply of organs. One measure is use of expanded criteria for donation. OBJECTIVE To evaluate the effect of donor age on cadaver graft survival. MATERIALS AND METHODS We reviewed the medical records for 454 patients who underwent kidney transplantation with cadaver donors from April 1987 to December 2003. RESULTS Donor age had a significant effect on kidney transplant survival. Survival of grafts from donors aged 16 to 40 years (mean, 143.30 months) was significantly greater compared with that of grafts from donors older than 40 years (66.46 months) (P = .005). The HLA matching and cold ischemia time did not significantly affect transplant survival (P = .98 and P = .16, respectively). CONCLUSIONS Kidneys from cadaver donors older than 40 years significantly compromised graft survival, generating a negative effect via early return of recipients to waiting lists and increasing the rate of repeat transplantation, risk of death, and unnecessary costs.

CLORORPROMAZINA E FUNÇÃO MITOCONDRIAL NA ISQUEMIA-REPERFUSÃO RENAL

The purpose of this study was to evaluate the function of mitochondria obtained from kidneys submmited to 48 hours of cold ischemia followed by 1 hour of reperfusion, with and without the use of chlorpromazine. Sixteen adult mongrel dogs were submitted to unilateral nephrectomy. In 13 animals the kidney was then perfused with Euro-Collins solution and preserved during 48-hours in cold solution. After that time auto-transplantation was performed. Reperfusion time was 1 hour. After that, the transplanted kidney was taken out and samples were obtained for mitochondrial evaluation. The animals were divided into 3 groups: group N - control without ischemia (3 animals); group I - hypothermia (6 animals); group II - hypothermia + IV injection of 2 mg/Kg of chlorpromazine 15 minutes before nephrectomy. The results of mitochondrial phosphorilation and swelling showed no statistical differences. However, group II animals showed higher values during the reversion phase of the swelling. Chlorpromazine action on mitochondrial function has been previously described, providing better mitochondria recovering from ischemic lesion. The results obtained in this study may be related to the short reperfusion time, or we can argue that chlorpromazine has no protection after prolonged ischemic time, or chlorpromazine action may be masqueraded by hypothermia.

Therapeutic option for infected urinary tract fistulas in renal transplantation.

BACKGROUND Approximately 20% of urinary tract fistulas after renal allografting are complicated by urinary tract infection, which presents a therapeutic challenge. OBJECTIVE To evaluate an option for treatment of urinary tract fistulas associated with urinary tract infection and unsuitable for minimally invasive or primary surgical urinary tract repair. PATIENTS AND METHODS The study included 650 recipients who underwent transplantation over 17 years. Urinary leakage was initially treated with indwelling bladder catheterization. Patients with fistulas refractory to treatment underwent surgical intervention to repair the urinary tract. In patients who were not candidates for primary repair of the urinary tract, temporary urinary diversion was performed, rather than classic percutaneous or open nephrostomy, using a ureteral stent (ie, a 6F or 8F Foley catheter with the balloon placed inside the renal pelvis). RESULTS Overall, urinary leakage occurred in 36 patients (5.5%). Conservative management was successful in 14 vesical fistulas (42.4%) and no ureteral fistulas (0%). Three patients died of sepsis during conservative treatment, before the new surgical approach. Five of 36 urinary leaks (13.9%) were managed using ureteral intubation with an 8F Foley catheter, with a success rate of 80%. CONCLUSION Ureteral catheterization with an 8F Foley catheter is a feasible therapeutic option to treat complicated urinary tract fistulas unsuitable for primary surgical repair of the urinary tract.

EXPRESSÃO IMUNOHISTOQUÍMICA DO MIB-1 EM CARCINOMA DE CÉLULAS TRANSICIONAIS DE BEXIGA

We investigate the immunoexpression of MIB-1 antigen on the outcome of the transitional carcinoma of the bladder. We revised 90 patients with a mean follow-up of 55 (2-231) months. Forty five (50%) tumors were grade I, 29 (32.2%), grade II and 16 (17.8%) grade III. The tumors were staged in pTa-1: 62 (68.9%) and pT2-4: 28 (31.1%). We considered positive the tumors with more than 10% imunostained cells. Sixty three patients (70%) expressed MIB-1, with significant difference (P <0,05) between invasive tumors (pT2-4) and non-invasive (pTA-1) and between pTA and pT1 tumors (P=0,01). There was also a significant association of MIB-1 immunostaining with tumor grade: G1 versus G2 (p < 0,001) and G1 versus G3 (p < 0,001). But such difference did not occur with G2 and G3 tumors ( p = 0,2). The relationship of MIB-1 expression with the size of the lesion was significant (p <0,02). The recurrence was not predicted by the MIB-1 labeling pattern (p=0,86), though, the MIB-1-positive patients had significant smaller metastasis free intervals (p = 0.04), and lower survival rates, both among superficial tumors (p=0.009) and in total sample (p = 0.0002).

ANTÍGENO NUCLEAR DE PROLIFERAÇÃO CELULAR (PCNA) EM CARCINOMA DE CÉLULAS TRANSICIONAIS DE BEXIGA

O antigeno nuclear de proliferacao celular (PCNA) foi descrito como marcador da atividade proliferativa. Correlacionamos a marcacao do PCNA com a evolucao dos pacientes com carcinoma de celulas transicionais de bexiga. Revisamos 90 pacientes do HC-FMRP-USP de 1980-2000; com idade variando de 29 a 93 anos e media de 71 anos; sendo 77,8% homens e 22,2% mulheres; seguimento medio de 55 meses (2-231 meses). Constatamos 50% de tumores grau I, (32,2%) grau II e 17,8% grau III; estadiados em pTA-60%, pT1-8,9% e >pT1 31,1%. Utilizamos o anticorpo primario Monoclonal Mouse Anti-Proliferating Cell Nuclear Antigen (PCNA) Clone PC10 (DAKO). Foram contadas 500 celulas (X400), e utilizado ponto de corte de 50%. A analise estatistica foi realizada com o teste de Mann-Whitney. Kaplan-Meier e Logrank Oitenta e sete tumores (96,66%) expressaram PCNA (mediana 72.5%, media 60,16%). Observamos diferenca nao significativa (P=0,39) na imunomarcacao do PCNA entre tumores pT2-4 e pTA-1. A comparacao de medias entre G1 e G2 (P=0,087), G1 e G3 (P=0,11) e entre G2 e G3 (P=0,66) nao mostraram significado estatistico,assim como entre tumores com recidiva e sem recidiva (P=0,84). Os individuos PCNA positivos nao tiveram intervalo livre de doenca significativamente diferente (P=0,86); entretanto foi significativa a diferenca nas curvas de sobrevida (P=0,003) e nas curvas de intervalos livres de metastase (P=0,01). A expressao imunohistoquimica do PCNA nao foi efetiva para diferenciar os tumores mais avancados e agressivos, assim como para predizer recidivas. Desta forma, apesar da correlacao com o tempo livre de metastase e a sobrevida, nao mostrou utilidade pratica.

AVALIAÇÃO DOS GÂNGLIOS REGIONAIS NO CARCINOMA EPIDERMÓIDE DO PÊNIS (CEP) ATRAVÉS DE UM ÍNDICE DE RISCO

O objetivo desse estudo foi investigar a validade de um indice de risco (IR) no prognostico de metastases ganglionares no carcinoma epidermoide do penis (CEP). Foram analisados 53 pacientes com CEP atendidos no Hospital das Clinicas da FMRP-USP, de janeiro de 1978 a dezembro de 1995. A idade variou de 32 a 97 anos. Os tumores foram graduados de acordo com a classificacao de Broders e estadiados retrospectivamente (TNM 1999). O IR foi determinado pela soma de TeG (IR = T+G). A linfadenectomia inguinal bilateral (LD) foi indicada naqueles que apresentaram gânglios suspeitos apos a antibioticoterapia ou que vieram apresentar alteracoes durante o periodo de observacao. Faleceram 17 pacientes; A LD foi realizada em 14 pacientes e os 39 restantes permaneceram em observacao clinica, sendo que em 8 deles foi feito LD apos tempo mediano de 9 meses. Dos pacientes com indice de risco 2 e 3 92% e 80% respectivamente nao apresentavam metastase ganglionar, ao passo que a totalidade daqueles com IR=6 tinha gânglios comprometidos. A associacao dos grupos 2 e 3, comparada ao conjunto 4, 5 e 6, mostrou percentual maior de comprometimento nestes ultimos (p = 0,0046). Dos 36 pacientes inicialmente No, 27 apresentavam IR 2 ou 3, dos quais 5 evoluiram para N+ (19%); os 9 restantes eram IR > 4 e 3 tambem evoluiram para N+ (33%). Apesar da diferenca, nao houve significância estatistica entre eles (p = 0,3837). Embora tenha ocorrido maior comprometimento naqueles com IR > 4, o indice de risco nao foi capaz de identificar previamente pacientes que evoluiram para N+.