Henry de Holanda Campos

O contexto do transplante renal no Brasil e sua disparidade geográfica

The Brazilian National Transplantation System coordinates and regulates perhaps the largest public transplantation program worldwide. Since its implementation in 1997, the number of kidney transplantations increased from 920 (5.8 pmp) in 1998, to 4,630 (24.1 pmp) in 2010. This growth was primarily due to the increased number of effective donors (from 1.8 pmp in 1998 to 9.3 pmp in 2010), with a corresponding increased number of kidneys transplanted from deceased donors (3.8 pmp in 1999 versus 9.9 pmp in 2010).The number of kidney transplantations from living donors has not increased significantly, from 1,065 (6.7 pmp) in 1998 to 1,641 (8.6 pmp) in 2010, either as a consequence of the observed increase in the deceased donor program or perhaps because of strict government regulations allowing only transplantations from related donors. From 2000 to 2009, the mean age of living donors increased from 40 to 45 years, while it increased from 33 to 41 years for deceased donors, of whom roughly 50% die of stroke. There are clear regional disparities in transplantation performance across the national regions. While the state of Sao Paulo is ranked first in organ donation and recovery (22.5 pmp), some states of the Northern region have much poorer performances. These disparities are directly related to different regional population densities, gross domestic product distribution, and number of trained transplantation physicians. The initial evaluation of the centers with robust outcomes indicates no clear differences in graft survival in comparison with centers in the USA and Europe. Ethnicity and time on dialysis, but not the type of immunosuppressive regimen, decisively influence the measured outcomes. Since the implementation of national clinical research regulations in 1996, Brazilian centers have participated in a number of national and international collaborative trials for the development of immunosuppressive regimens. Besides the challenge of reducing the regional disparities related to access to transplantation, further improvements can be obtained by the creation of a national registry of the outcomes of transplanted patients and living donors, and also by the promotion of clinical and experimental studies to better understand the transplantation-related immune response of the Brazilian population.

Quantitative radioligand assays using de novo-synthesized recombinant autoantigens in connective tissue diseases : new tools to approach the pathogenic significance of anti-RNP antibodies in rheumatic diseases

OBJECTIVE To describe new assays for the detection and quantification of antibodies to RNPs in rheumatic diseases, using soluble nuclear antigens synthesized de novo in reticulocyte lysates. METHODS Sera from 381 patients with various rheumatic diseases, including 212 patients with systemic lupus erythematosus (SLE), were analyzed in order to evaluate the sensitivity and specificity of serum autoantibody reactivities to several recombinant soluble autoantigens: U1-A RNP, Sm-B, SSA/Ro 52 and SSA/Ro 60, SSB/La, and Ku. Radioligand assays (RLAs) were performed following the in vitro transcription and translation of each autoantigen from the corresponding complementary DNA, labeled with 35S-methionine. The radiolabeled protein was then bound by the specific serum autoantibody, forming immune complexes that were captured by protein A-Sepharose beads and quantified by counting the radioactivity. RESULTS Among the SLE patients, 44% were positive for anti-U1-A RNP activity, 34% for anti-Sm-B, 44% for anti-SSA (32% for Ro 52 and 46% for Ro 60), 32% for anti-SSB/La, and 11% for anti-Ku reactivities. SSA antibodies had a high frequency in patients with mixed connective tissue disease (MCTD) (80%); 65% of these patient sera reacted with Ro 52, 45% with Ro 60, and 45% with U1-A RNP. Twenty percent of the MCTD patients also exhibited antibodies to Sm-B and Ku. In patients with Sjögrens syndrome, anti-SSA was the main anti-RNP antibody (63%), together with SSB/La antibodies (44%). Among patients with inflammatory myopathy, only antibodies against Ro 52 (36%) and Ro 60 (36%) were present. These new RLA allowed observation of a strong correlation (P < 0.0001) between Sm-B antibody levels and the severity of SLE (as measured by the SLE Disease Activity Index), and establishment of a correlation between anti-U1-A RNP antibodies and the occurrence of SLE nephritis (P < 0.02). All RLAs were highly specific for the antigen tested and displayed, in the disease groups studied, a higher sensitivity than conventional immunodiffusion assays. CONCLUSION These highly sensitive, specific, and quantitative RLAs represent new tools for the detection of autoantibodies to RNP antigens in rheumatic diseases, and may be useful for (differential) diagnosis in clinical practice.

Prevalence and associated factors to hepatitis C in hemodialysis patients in Brazil

OBJECTIVE The prevalence of hepatitis C virus (HCV) is higher in patients on hemodialysis than in the general population, probably due to greater exposure to risk situations. The purposes of the study were to determine anti-HCV antibodies prevalence among hemodialysis patients and dialysis clinics and patients factors associated with HCV transmission. METHODS A cross-sectional study was conducted in 752 hemodialysis patients in all 12 dialysis clinics of Fortaleza, Brazil, and were screened using third generation ELISA. Sociodemographic, clinical, and epidemiological data of 663 patients were collected through interviews. Nosocomial factors were assessed using a specific questionnaire tool. Statistical analysis was conducted using Students t test, odds ratio and multivariate analysis. RESULTS The prevalence of anti-HCV was 52% (390/746; ranged from 6% to 72%). The anti-HCV positivity was higher in patients who had previous peritoneal dialysis (OR=1.76; 95% CI 1.12-2.76) and blood transfusion (OR=2.75; 95% CI 1.25-6.03). Dialysis age has been associated with anti-HCV positivity (OR=1.47; 95% CI 1.35-1.61). Clinics practices associated with anti-HCV positivity were: previous preparing of heparin (OR=2.92; 95% CI 1.23-6.92), failure in gloves use or change (OR=5.73; 95% CI 1.75-18.72), unsatisfactory dialysis machine disinfection (OR=2.79; 95% CI 1.57-4.96), and patient isolation in dialysis room (OR=0.18; 95% CI 0.05-0.61). CONCLUSIONS The results show high anti-HCV prevalence among hemodialysis patients and the association of nosocomial factors with new HCV infection cases.

Visceral Leishmaniasis in Renal Transplant Recipients: Clinical Aspects, Diagnostic Problems, and Response to Treatment

Visceral leishmaniasis (VL) is a parasitic infection that uncommonly affects renal transplantation recipients, even in endemic areas. It may be associated with other infections, or masked by these, and may present subclinically and/or atypically for extended periods. The evolution may be particularly severe and diagnosis is often delayed. If not adequately diagnosed and treated, VL can be fatal and so should be suspected in renal transplantation recipients presenting unexplained fever, splenomegaly, and pancytopenia. The authors report 8 cases of VL out of a total of 800 renal transplant recipients from two transplant hospitals centers in Brazil. The clinical, diagnostic, and therapeutic features are reviewed.

A model for linkage between health professions education and health: FAIMER international faculty development initiatives

Linking faculty development to improvement of community health is of particular interest to health professions educators and researchers. While individuals and institutions engaged in health professions education have the potential to improve health, limited literature connects capacity building in education with improvements in health. Understanding the mechanism by which faculty development may promote development of socially accountable institutions and improve health can be useful for improving this connection and evaluating program effectiveness.

Chemical and morphological analysis of kidney stones: a double-blind comparative study

PURPOSE To compare chemical to morphological kidney stone composition analysis based on a sample of 50 stones retrieved from patients at a nephrology service. METHODS The chemical analysis was performed with a Bioclin® kit, while a 10-mm magnifying glass (10x; Prolabo, Paris, France) was employed in the morphological analysis. Findings obtained with the two methods were compared and classified as concordant (100% agreement), partly concordant (concordant for major components, discordant for minor components) or discordant (discordant for major components). RESULTS In the chemical analysis, the most commonly observed major component was calcium (70%), followed by oxalate (66%), ammonium (56%), urate (28%) and carbonate (24%). In the morphological analysis, the most commonly observed major components were calcium phosphate and magnesium (32% each), followed by calcium oxalate monohydrate (24%), uric acid and urates (20% each), calcium oxalate dihydrate (18%) and cystine (6%). Infectious kidney stones were identified in 34% and 24% of cases by morphological and chemical analysis, respectively. Thirty-eight percent of the samples were classified as concordant, 52% were partly concordant and 10% were discordant. CONCLUSION We suggest kidney stones be routinely submitted to both types of analysis for a better understanding of the mechanisms involved in lithogenesis.

Prevalence and staging of chronic kidney disease in renal transplant recipients

Abstract:  Introduction:  Diagnosis and staging of chronic kidney disease (CKD) is important for management and prevention of renal disease progression. It is unclear whether K/DOQI guidelines of the National Kidney Foundation are applicable to diagnosis of CKD in renal transplant recipients (RTRs) and which method is most appropriate for estimating glomerular filtration.

Fatores preditivos de hipertensão gestacional em adolescentes primíparas: análise do pré-natal, da MAPA e da microalbuminúria

OBJECTIVE: To quantify PH prevalence in primiparous adolescents; define predictive factors for the occurrence of PH and its impact on newborns. METHODS: We followed 29 primiparous adolescents from the prenatal period through the 12th week of the puerperium, with a mean of sixteen years of age, served at the Outpatient Facility for Adolescents of Maternidade Escola Assis Chateaubriand (MEAC) of Universidade Federal do Ceara (Fortaleza, Brazil). The pregnant adolescents were divided into two groups, that is, those who remained normotensive (Group I) and those who developed PH (Group II). The variables investigated in the assessment of the value of predictability for the development of PH were anthropometric measures, socioeconomic aspects, smoking habit, inheritance for SAH (father/mother), prenatal tests requested in the first prenatal care visit in addition to microalbuminuria and ambulatory blood pressure monitoring (ABPM) in the 28th week of gestation. The pregnant adolescents were followed up at delivery and late puerperium (12th week after the puerperium). The newborns to the mothers included in our study were assessed at birth according to the Apgar score and the Capurro method, for weight, height and perinatal hypoxia. RESULTS: The prevalence of PH was 51.7%. Inheritance for SAH presented the highest predictive value for PH with an odds ratio of 10.99. Diastolic arterial pressure equal to or above 70 mmHg at the gestational age of 35 weeks was statistically significant as a predictive value for PH. At ABPM we found a predictive value for PH: diastolic pressure load during alertness, diastolic and systolic pressure load during night sleep, pressure variability and maximum diastolic pressure during sleep. Specifically a maximum diastolic arterial pressure (DAP) at ABPM during the period of night sleep ³64 mmHg presented an odds ratio of 6 for PH with a sensitivity of 80% and a specificity of 60% for the development of PH. CONCLUSION: The research for PH predictive factors in primiparous adolescents showed to be easy to apply and useful to stratify high-risk pregnant women as regards the development of PH.

Aloimunidade contra antígenos HLA de classe I em pacientes com síndromes mielodisplásicas e anemia aplástica

As sindromes mielodisplasicas (SMD) e a anemia aplastica (AA) apresentam citopenias perifericas necessitando, com frequencia, de reposicoes transfusionais continuas de concentrados de hemacias e/ou de concentrados de plaquetas. O objetivo do presente estudo foi verificar a ocorrencia de anticorpos anti-HLA de classe I em pacientes portadores das SMD e AA atendidos no ambulatorio de Hematologia do Hemoce/UFC. Foram analisados 110 pacientes, sendo 70 com SMD e 40 com AA. A pesquisa de anticorpos anti-HLA de classe I foi realizada frente a um painel (PRA), utilizando-se a tecnica de microlinfocitotoxicidade dependente do complemento. Vinte (28,6%) dos 70 pacientes com as SMD e 18 (45%) dos 40 pacientes com AA desenvolveram anticorpos anti-HLA contra o PRA. Esses pacientes que receberam uma carga de antigenos estranhos advindos de multiplas transfusoes de varios doadores de CH e/ou CP, geralmente desenvolvem aloanticorpos contra os antigenos HLA presentes na superficie das plaquetas e dos leucocitos que contaminam esses concentrados. A producao desses anticorpos pode trazer serias complicacoes para o tratamento dos pacientes com SMD e AA. As avaliacoes sistematicas para deteccao de anticorpos anti-HLA apos a reposicao transfusional podem ser valiosas para adocao de estrategias transfusionais mais adequadas para esta populacao de pacientes.

Randomized trial of early corticosteroid reduction vs. regular‐dose corticosteroid maintenance in combination with tacrolimus and mycophenolate mofetil in living donor kidney transplant recipients: the Brazilian CORRETA trial

Garcia VD, Carvalho DBM, Gonçalves RT, Cavalcanti RL, Campos HH, Abbud‐Filho M, Lobao‐Neto AA. Randomized trial of early corticosteroid reduction vs. regular‐dose corticosteroid maintenance in combination with tacrolimus and mycophenolate mofetil in living donor kidney transplant recipients: the Brazilian CORRETA trial.
Clin Transplant 2010: 24: E109–E115.
© 2009 John Wiley & Sons A/S.