Evolução clínica, laboratorial e imunológica da infecção pelo vírus da dengue em pacientes submetidos ao transplante renal
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Data
2018-07-23
Autores
Sawazaki, Jonas Atique
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Universidade Estadual Paulista (Unesp)
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Introdução: Grande número de transplantados renais encontram-se expostos a regiões endêmicas e epidêmicas da dengue, porém, dados sobre o comportamento desta infecção nesta população específica ainda são escassos na literatura. Métodos: Estudo de série de casos, no qual foram incluídos todos os transplantados renais diagnosticados com dengue em nosso serviço dentro do período de janeiro de 2013 a julho de 2016. Foram avaliadas características demográficas, clínicas, laboratoriais gerais, sorológicas e antigênicas. Sempre que possível, foi avaliado o comportamento a longo prazo do antígeno NS1 e dos anticorpos das classes IgG e IgM através de teste de imunocromatografia comercial. Resultados: Foram incluídos 16 pacientes. Houve predomínio do sexo masculino (87,5%), da cor branca (81,2%) e a média de idade foi de 42,0 anos. Metade de doadores eram falecidos. O esquema de manutenção da imunossupressão com tacrolimo, micofenolato sódico e prednisona foi o mais utilizado (62,5%). A mediana de tempo entre o transplante renal e o início dos sintomas foi de 1.426 dias. Apenas um paciente (6,3%) com suspeita de transmissão do vírus da dengue através do enxerto foi classificado como grave e necessitou enxertectomia. Nenhum óbito foi identificado. A disfunção renal ocorreu em 66,7% dos pacientes, mostrando-se transitória em 93,8% das vezes. Dentre os 13 (86,7%) pacientes com NS1 reagente, este mostrou-se ainda detectável até 28 dias após o início dos sintomas. Anticorpos IgM foram identificados em 93,3% dos pacientes. Em 85,7% dos pacientes que apresentaram anticorpos IgM, estes mantiveram-se detectáveis até o final do seguimento sorológico, que se estendeu por até 786 dias. A mediana de tempo entre o início dos sintomas e a primeira detecção de anticorpos IgG foi de 24 dias, porém, chegou a 266 dias. Metade dos pacientes deixaram de apresentar anticorpos IgG durante o acompanhamento sorológico. Discussão: A sintomatologia da dengue na casuística estudada mostrou-se leve, exceto quando esta ocorreu dentro do período pós-operatório. O período de antigenemia NS1 apresentou-se bastante prolongado nos transplantados renais. Devido ao extenso período de detecção de anticorpos IgM, deve-se ter cuidado com futuros diagnósticos falso positivos. Sugere-se que testes para detecção de antígenos devam sempre ser realizados e, quando indisponíveis ou negativos, outros diagnósticos diferenciais não devam ser prontamente desconsiderados.
Introduction: A large number of renal transplant recipients are exposed to endemic and epidemic areas for dengue fever, but data on the behavior of this infection in this specific population are still scarce in the literature. Methods: A case series study that included all renal transplant recipients with confirmed diagnosis of dengue fever followed at our institution between January 2013 and July 2016. Demographic, clinical, laboratory, serological and antigenic characteristics were evaluated. Whenever possible, the long-term behavior of NS1 antigen and IgG and IgM class antibodies were evaluated by commercial immunochromatographic test. Results: We included 16 patients. There was a predominance of males (87.5%), caucasians (81.2%) and mean age was 42.0 years. Half of donors were deceased. The most used immunosuppression regimen was tacrolimus, mycophenolate sodium and prednisone (62.5%). The median time between kidney transplantation and the onset of symptoms was 1,426 days. Only one patient (6.3%) with suspected transmission of the dengue virus through the graft was classified as severe and required removal of the graft. No deaths were identified. Graft dysfunction occurred in 66.7% of the patients and was transient in 93.8% of cases. NS1 antigen was detected in 13 patients (86.7%) and it was still detectable up to 28 days after the onset of symptoms. IgM antibodies were identified in 93.3% of the patients. In 85.7% of the patients who had IgM antibodies, they remained detectable until the end of the serological follow-up, which lasted for up to 786 days. Ten (76.9%) patients had IgG antibodies. The median time between the onset of symptoms and the first detection of IgG antibodies was 24 days, but reached 266 days. IgG antibodies were no longer detectable in half of the patients during the serological follow-up. Discussion: The clinical presentation of dengue fever in the study population was mild, except when it occurred within the postoperative period. The period of detection of NS1 antigenemia was quite prolonged in renal transplant recipients. Due to the long period of detection of IgM antibodies, care should be taken with future false positive diagnoses. It is suggested that tests for the detection of antigens should always be performed and, when unavailable or negative, other differential diagnoses should not be promptly disregarded.
Introduction: A large number of renal transplant recipients are exposed to endemic and epidemic areas for dengue fever, but data on the behavior of this infection in this specific population are still scarce in the literature. Methods: A case series study that included all renal transplant recipients with confirmed diagnosis of dengue fever followed at our institution between January 2013 and July 2016. Demographic, clinical, laboratory, serological and antigenic characteristics were evaluated. Whenever possible, the long-term behavior of NS1 antigen and IgG and IgM class antibodies were evaluated by commercial immunochromatographic test. Results: We included 16 patients. There was a predominance of males (87.5%), caucasians (81.2%) and mean age was 42.0 years. Half of donors were deceased. The most used immunosuppression regimen was tacrolimus, mycophenolate sodium and prednisone (62.5%). The median time between kidney transplantation and the onset of symptoms was 1,426 days. Only one patient (6.3%) with suspected transmission of the dengue virus through the graft was classified as severe and required removal of the graft. No deaths were identified. Graft dysfunction occurred in 66.7% of the patients and was transient in 93.8% of cases. NS1 antigen was detected in 13 patients (86.7%) and it was still detectable up to 28 days after the onset of symptoms. IgM antibodies were identified in 93.3% of the patients. In 85.7% of the patients who had IgM antibodies, they remained detectable until the end of the serological follow-up, which lasted for up to 786 days. Ten (76.9%) patients had IgG antibodies. The median time between the onset of symptoms and the first detection of IgG antibodies was 24 days, but reached 266 days. IgG antibodies were no longer detectable in half of the patients during the serological follow-up. Discussion: The clinical presentation of dengue fever in the study population was mild, except when it occurred within the postoperative period. The period of detection of NS1 antigenemia was quite prolonged in renal transplant recipients. Due to the long period of detection of IgM antibodies, care should be taken with future false positive diagnoses. It is suggested that tests for the detection of antigens should always be performed and, when unavailable or negative, other differential diagnoses should not be promptly disregarded.
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Palavras-chave
Dengue, Transplante renal, Imunossupressão