Avaliação do impacto do volume do enxerto na melhora da função renal em pacientes transplantados
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Data
2017-02-23
Autores
Ordones, Flávio Vasconcelos [UNESP]
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Universidade Estadual Paulista (Unesp)
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Introdução e Objetivos: A insuficiência renal crônica (IRC) é considerada um problema de saúde pública, cujas incidências e prevalências estão aumentando. Atualmente,o transplante renal (TR) se constituiu no melhor tratamento para pacientes portadores de IRC estadio terminal. Embora o aperfeiçoamento dos regimes de imunossupressão tenha resultado em melhoras significativas na função renal precoce, a sobrevida do enxerto em longo prazo permanece subótima. Vários fatores podem interferir nesta evolução e a qualidade do órgão doado é um deles. Considerando-se características do rim transplantado, parece intuitivo supor que rins de maior volume apresentarão melhores taxas de filtração glomerular (TFG).De acordo com alguns autores, o volume e/ou a massa do enxerto parecem se correlacionar com uma melhor função renal no transplante com doador vivo, no entanto, pouco se sabe sobre doador falecido. Este estudo tem como objetivo primário correlacionar a estimativa do volume renal do rim do doador, obtida a partir da fórmula da elipsóide, com a função renal ao final de um ano de transplante, tanto em doadores vivos quanto em doadores falecidos. Materiais e Métodos: Trata-se de estudo prospectivo realizado na Faculdade de Medicina de Botucatu, envolvendo 256 transplantes realizados entre 2011 e 2015. Os rins foram medidos durante a cirurgia de banco e seu volume estimado através da formula do elipsóide, corrigida a posterior pela superfície corpórea.Os dados de volume renal e TFG, foram correlacionados, utilizando-se do Teste de Spearman. Uma análise multivariada foi realizada. Resultados: Dos 256 transplantes, 71 foram realizados com doadores vivos e 185 com doadores falecidos. E media de idade dos receptores foi de 37 ± 11 no grupo que recebeu rins oriundos de doadores vivos e 50 ± 13 anos no de doadores falecidos. A taxa de rejeição e infecção por Citomegalovirus(CMV) no primeiro grupo fois de 26,8% e 18,6%, com volume renal medio ajustado de 151,69±41,66 (cm3/1,73m2), tendo ao final de um ano uma media de TGF de 64,8 ± 23,9 ml/min. Houve correlação positive entre volume renal corrigido e TFG ao final de um ano (p=0,008 e r=0,311). Entre o grupo de doadores falecidos, taxas de rejeição e infecção por CMV foram 12,6% e 38,1%, com volume renal médio de 167,7 ± 55,1 cm3 e TGF de 53,97 ± 26,5 ml/min ao final de um ano. Também houve correlação positiva entre as duas variáveis (r=0,08 e p=0,279). Regressão linear mostrou Volume renal como fator independente associado a melhor função renal ao final de um ano. Conclusão: A medida do volume renal elipsoide, realizada durante a cirurgia de banco, tanto para rins oriundos de doadores vivos ou falecidos, correlaciona-se positivamente com a TGF ao final de um ano tanto para doadores vivos e marginalmente para doadores falecidos. No grupo de doadores vivos, rejeição e volume renal impactaram TGF ao final de um ano, enquanto que no grupo de doadores falecidos, a TGF foi influenciada por idade do doador, rejeição e volume renal. Um volume renal corrigido pela superfície corpórea menor que 140cm3 associou-se a pior função renal.
Introduction and objectives: Chronic renal failure is a public health problem with high incidence and prevalence worldwide. Currently, renal transplantation is regarded as the best therapeutic indication for patients with chronic kidney disease, offering greater survival and better quality of life than dialysis. Although the improvement of immunosuppressive regimens has resulted in significant improvements in early renal function, long-term graft survival remains suboptimal. Graft volume and/or mass are apparently correlated with improved renal function in living donor transplantations. In contrast, according to some authors, the results from deceased donor transplantations are controversial. The primary objective of this study is to correlate renal volume estimation, assessed using the ellipsoid formula, with renal function one year after transplantation from both living and deceased donors. Methods: This is a single-centre, prospective cohort study conducted at the School of Medicine of São Paulo State University with 256 patients who underwent living or deceased donor renal transplantation from 2011- 2015. During the back-table surgery, kidneys from living or deceased donors were perfused, dissected and prepared. The excess fat was removed and length, width and thickness measurements, expressed in centimetres, were made. The final graft volume was calculated using ellipsoid formula, corrected by bodys surface area. The correlation between adjusted kidney volume and one-year eGFR was obtained. Multivariate analysis was performed. Results: Among the 185 deceased donor transplantations, the mean recipient age was 50 ± 13 years; 71 transplantations were living donor transplantations and the mean age was 37 ± 11 years, one-year rejection rate was 26.8%, and cytomegalovirus infection rate 18.6% with a mean adjusted kidney volume of 151.69±41.66 (cm3/1.73 m2) and eGFR at the one-year was 64.8 ± 23.9 ml/min. Between deceased donors, rejection rate and CMV infection were 12.6% and 38.1% respectively and mean adjusted Kidney Volume was 167.7 ± 55.1 cm3, with a mean GFR of 53.97 ± 26.5 ml/min after one year. Table 1-living donors (r=0.311 and p=0.008) and 2 – deceased donors(r=0.08 and p=0.279) show positive correlation between kidney volume and eGFR after one year in both groups. Linear regression showed kidney volume as associated factor for improved kidney function after one year in both groups. Multivaryate analysis showed adjusted kidney volume as independent factor for improved one-year kidney function in the living donor group and a clear trend was observed towards adjusted kidney volume being an independent predictive factor for that endpoint. Conclusion: Kidney volume calculated using the ellipsoid formula was positively correlated with an improvement in eGFR one year after living donor transplantations and marginally correlated in deceased donor transplantations. Rejection and kidney volume independently affected the eGFR in living donor transplantations, while donor age, rejection and (marginally) volume affected the eGFR in deceased donor transplantations. Following adjustment for body surface area, a volume lower than 140 cm3 was associated with worsened renal function. Some authors evaluated relation between CT kidney volume and long term kidney function, but only for living donors. In our study we also analised deceased donors and considered several possible confounders.
Introduction and objectives: Chronic renal failure is a public health problem with high incidence and prevalence worldwide. Currently, renal transplantation is regarded as the best therapeutic indication for patients with chronic kidney disease, offering greater survival and better quality of life than dialysis. Although the improvement of immunosuppressive regimens has resulted in significant improvements in early renal function, long-term graft survival remains suboptimal. Graft volume and/or mass are apparently correlated with improved renal function in living donor transplantations. In contrast, according to some authors, the results from deceased donor transplantations are controversial. The primary objective of this study is to correlate renal volume estimation, assessed using the ellipsoid formula, with renal function one year after transplantation from both living and deceased donors. Methods: This is a single-centre, prospective cohort study conducted at the School of Medicine of São Paulo State University with 256 patients who underwent living or deceased donor renal transplantation from 2011- 2015. During the back-table surgery, kidneys from living or deceased donors were perfused, dissected and prepared. The excess fat was removed and length, width and thickness measurements, expressed in centimetres, were made. The final graft volume was calculated using ellipsoid formula, corrected by bodys surface area. The correlation between adjusted kidney volume and one-year eGFR was obtained. Multivariate analysis was performed. Results: Among the 185 deceased donor transplantations, the mean recipient age was 50 ± 13 years; 71 transplantations were living donor transplantations and the mean age was 37 ± 11 years, one-year rejection rate was 26.8%, and cytomegalovirus infection rate 18.6% with a mean adjusted kidney volume of 151.69±41.66 (cm3/1.73 m2) and eGFR at the one-year was 64.8 ± 23.9 ml/min. Between deceased donors, rejection rate and CMV infection were 12.6% and 38.1% respectively and mean adjusted Kidney Volume was 167.7 ± 55.1 cm3, with a mean GFR of 53.97 ± 26.5 ml/min after one year. Table 1-living donors (r=0.311 and p=0.008) and 2 – deceased donors(r=0.08 and p=0.279) show positive correlation between kidney volume and eGFR after one year in both groups. Linear regression showed kidney volume as associated factor for improved kidney function after one year in both groups. Multivaryate analysis showed adjusted kidney volume as independent factor for improved one-year kidney function in the living donor group and a clear trend was observed towards adjusted kidney volume being an independent predictive factor for that endpoint. Conclusion: Kidney volume calculated using the ellipsoid formula was positively correlated with an improvement in eGFR one year after living donor transplantations and marginally correlated in deceased donor transplantations. Rejection and kidney volume independently affected the eGFR in living donor transplantations, while donor age, rejection and (marginally) volume affected the eGFR in deceased donor transplantations. Following adjustment for body surface area, a volume lower than 140 cm3 was associated with worsened renal function. Some authors evaluated relation between CT kidney volume and long term kidney function, but only for living donors. In our study we also analised deceased donors and considered several possible confounders.
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Palavras-chave
Transplante de rins, Urologia, Insuficiência renal crônica, Taxa de filtração glomerular, Volume renal