RESUMO A doença linfoproliferativa pós-transplante (DLPT) é formada por um grupo heterogêneo de proliferações hematolinfóides resultantes da proliferação mono ou policlonal das células linfoides. O quadro clínico é variado e dependente dos sítios envolvidos, sendo o trato gastrintestinal e o sistema nervoso central os mais comuns, e sintomas constitucionais são frequentes. O envolvimento isolado do enxerto é raro. Relatamos aqui um caso de DLPT policlonal isolada do enxerto em um receptor de transplante renal com doador vivo HLA idêntico, ocorrido sete anos após o transplante. Digno de nota, o paciente não apresentou sintomas constitucionais e sua única manifestação clínica foi disfunção do enxerto, expressa através da elevação da creatinina e discreta proteinuria, sendo o diagnóstico realizado através de biópsia renal, que evidenciou infiltrado intersticial linfoide denso. Tratava-se de DLPT policlonal não relacionada ao vírus Epstein-Bar (EBV) e foi tratado com sucesso com quimioterapia, redução da imunossupressão e sirolimo.

ABSTRACT Post-transplantation lymphoproliferative disease (PTLD) comprises a heterogeneous group of hematolymphoid proliferations resulting from a monoclonal or polyclonal proliferation of lymphoid cells. The clinical presentation varies according to the affected sites. The gastrointestinal tract and the central nervous system are the most common, and constitutional symptoms are frequent. Isolated allograft involvement is rare. We report a case of polyclonal PTLD isolated in the kidney allograft in a patient who received an HLA-identical living donor seven years before. Noteworthy, this patient did not present constitutional symptoms, and his only clinical manifestation was graft dysfunction, expressed by an increase in serum creatinine and mild proteinuria. The diagnosis was performed through renal biopsy, which showed dense lymphoid interstitial infiltrate. The PTLD was polyclonal, unrelated to Epstein-Bar virus (EBV), and it was successfully treated with chemotherapy, reduced immunosuppression, and sirolimus.

ABSTRACT Worldwide, transplant programs have suffered a setback during the coronavirus disease 2019 (COVID-19) pandemic and most have temporarily suspended their transplant activities. . We identified 36 liver transplant patients who tested positive for COVID-19. The cases were confirmed by the nucleic acid test (RT-PCR). Epidemiological, demographic, clinical, laboratory, management and outcome data were obtained from the patients’ medical records. Fourteen patients (38.9%) required admission to the Intensive Care Unit and/or invasive ventilatory support (severe cases). The mean age of these severe cases was 63.8 years. Regarding the time since the transplant, 71.4% (10/14 patients) had undergone the procedure less than one year before. The immunosuppressive therapy was reduced in patients who required Intensive Care Unit. A total of 12 cases (12/14, 85.7%) required invasive ventilatory support. Eight cases (8/14, 57.1%) required renal replacement therapy. In this group of patients, nine died (64.3 %). In turn, 22 patients had mild to moderate symptoms of COVID-19, not requiring invasive ventilatory support or admission to the Intensive Care Unit. The mean age in these patients was 56.5 years and comorbidities were present in 15 (68.2%) of the cases. In this group, only five patients (5/22, 22.7%) required hospitalization due to complications and there were no deaths This report describes the results of COVID-19 infection in a very specific population, suggesting that liver transplant patients have a significant higher risk of progressing to severeCOVID-19 , with a mortality rate among critically-ill patients above that of the general population.

RESUMO A síndrome hemofagocítica (SHF) ou linfo-histiocitose hemofagocítica é uma condição infrequente e subdiagnosticada que tem por base a ativação excessiva da resposta imune, resultando em fagocitose das células do sangue. Após o transplante renal (TxR), a SHF é habitualmente secundária (ou reativa) a processos infecciosos e neoplásicos, culminando em elevadas taxas de mortalidade. Não há evidências quanto ao tratamento ideal dessa condição. Além de investigação e tratamento da patologia desencadeante do processo de desregulação do sistema imune, há descrições do uso de imunoglobulina humana (IVIG), esteroides em altas doses e plasmaférese. Não há evidências quanto à melhor forma de delinear a imunossupressão de manutenção. Este artigo apresenta dois casos de SHF reativa pós-TxR que realizaram tratamento adjuvante com IVIG, obtendo bons resultados clínicos. Apesar da elevada morbimortalidade associada à SHF reativa após o TxR, o diagnóstico ágil e preciso, associado à instituição de terapia com IVIG adjuvante ao tratamento da doença desencadeante, foi uma estratégia eficaz em conter o processo.

ABSTRACT Hemophagocytic syndrome or hemophagocytic lymphohistiocytosis (HLH) is an infrequent and underdiagnosed condition caused by an overactive immune response, resulting in blood cells phagocytosis. After kidney transplantation (KTx), HLH is usually secondary (or reactive) to infectious and neoplastic processes and has a high mortality rate. No effective treatment is available for this condition. Usual procedures include detecting and treating the pathology triggering the immune system dysregulation, other than administration of intravenous human immunoglobulin (IVIG) and high doses of steroids, and plasmapheresis. The best protocol for maintenance immunosuppressive therapy is also unknown. This article presents two cases of post-KTx reactive HLH that underwent adjuvant IVIG treatment and obtained good clinical results. Despite the high morbidity and mortality associated with reactive HLH after KTx, the early and precise diagnosis and the administration of IVIG therapy along with the treatment of the triggering disease, was an effective strategy to control HLH.

Resumo Objetivo: Relatar as principais variações anatômicas do tronco celíaco e da artéria hepática em sua origem. Materiais e Métodos: Foram analisadas, de forma prospectiva, 100 angiotomografias abdominais consecutivas realizadas em serviço público no período de um ano. Os achados foram categorizados segundo a classificação de Sureka et al. e de Michels. Resultados: De um total de 100 pacientes, 43 tiveram tronco celíaco normal, ou seja, tronco hepatogastroesplênico e artéria mesentérica superior originando-se separadamente da aorta abdominal. Quatro tipos de variação do tronco celíaco foram encontrados em nosso trabalho. Oitenta e dois pacientes apresentaram o padrão de anatomia normal, ou seja, a artéria hepática originando-se da artéria hepática comum e bifurcando-se em artéria hepática direita e artéria hepática esquerda. Seis tipos de variação da artéria hepática foram encontrados em nosso estudo. Conclusão: O nosso trabalho apresenta índices de variações que diferem dos artigos encontrados na literatura. Esses achados chamam a atenção para a necessidade do conhecimento das variações anatômicas no nosso meio, colaborando e facilitando o seu reconhecimento, sua utilização no planejamento técnico operatório e evitando lesões inadvertidas que poderiam comprometer o resultado dos procedimentos médicos, levando a complicações.

Abstract Objective: To describe the main anatomical variations of the celiac trunk and the hepatic artery at their origins. Materials and Methods: This was a prospective analysis of 100 consecutive computed tomography angiography studies of the abdomen performed during a one-year period. The findings were stratified according to classification systems devised by Sureka et al. and Michels. Results: The celiac trunk was "normal" (i.e., the hepatogastrosplenic trunk and superior mesenteric artery originating separately from the abdominal aorta) in 43 patients. In our sample, we identified four types of variations of the celiac trunk. Regarding the hepatic artery, a normal anatomical pattern (i.e., the proper hepatic artery being a continuation of the common hepatic artery and bifurcating into the right and left hepatic arteries) was seen in 82 patients. We observed six types of variations of the hepatic artery. Conclusion: We found rates of variations of the hepatic artery that are different from those reported in the literature. Our findings underscore the need for proper knowledge and awareness of these anatomical variations, which can facilitate their recognition and inform decisions regarding the planning of surgical procedures, in order to avoid iatrogenic intraoperative injuries, which could lead to complications.

Resumo Introdução: A proteinúria pós-transplante renal tem incidência variável, sendo um fator de risco cardiovascular e para a sobrevida do enxerto. Objetivo: Avaliar a prevalência de PTN pós-Tx em receptores de um único centro e fatores associados. Métodos: A prevalência de PTN foi avaliada segundo a definição ≥ 500 mg/24 hs. Os pacientes foram divididos em 3 grupos: grupo A, < 500 mg, B, 500-1000 mg e C, > 1000 mg. Foi testada a associação entre PTN pós-Tx e: idade/gênero do doador e receptor, tipo de doador, função retardada do enxerto, rejeição aguda, HAS e creatinina. As variáveis com valor de p < 0,20 na analise bivariada foram incluídas em modelo de regressão logística multivariado. Resultados: Foram avaliados 173 receptores, idade média 39 anos, 57,2% sexo masculino e 60,7% doador falecido. A prevalência de PTN pós-Tx foi de 24,3%. A distribuição dos pacientes foi de 75,7% para o grupo A, 15,6% para o grupo B e 8,7% para o grupo C. Foram associados a uma maior chance de PTN ≥ 500 mg/24hs: o sexo masculino do receptor, o doador falecido e a HAS pós-Tx. A creatinina aos 12 meses foi significativamente maior nos pacientes com PTN. 62% dos pacientes com PTN ≥ 500 mg/24 hs receberam tratamento com IECA/BRA. Conclusão: A prevalência de PTN pós-Tx renal foi 24,3% segundo a definição utilizada. O sexo masculino do receptor, o doador vivo e a HAS estiveram associadas à maior chance de PTN pós-Tx. O bloqueio do sistema renina-angiotensina deve ser intensificado.

Abstract Introduction: Proteinuria after kidney transplantation (Tx) has variable incidence and is associated with cardiovascular risk and graft survival. Objective: To evaluate the prevalence of proteinuria after kidney Tx and its associated factors. Methods: The prevalence of PTN was evaluated according to definition ≥ 500 mg/24 hours. Patients were divided into 3 groups: group A, < 500 mg, B, 500-1000 mg and C, > 1000 mg. We tested the association between PTN and: age/gender of the donor and recipient, type of donor, delayed graft function, acute rejection, hypertension and creatinine. The variables with a p value < 0.20 in the bivariate analysis were included in a multivariate logistic regression analysis. Results: 173 recipients were evaluated, mean age 39 years, 57.2% male and 60.7% deceased donor. The prevalence of PTN after kidney Tx was 24.3%. The distribution of patients according to PTN was 75.7% for group A, 15.6% for group B and 8.7% for group C. The following factors were associated with higher risk of PTN: male recipients, living donor and hypertension. Creatinine at month 12 moths post-Tx was higher among patients with proteinuria. 60% of patients with PTN ≥ 500 mg/24 hours were treated with ACEI/ARB. Conclusion: The prevalence of PTN after kidney Tx varied between 24.3%, according to the definition used. The male gender of the recipient, living donor and hypertension were associated with the occurrence of PTN after kidney Tx. Blockade of the renin-angiotensin system must be prescribed to more patients.

Abstract: Dengue is an arbovirosis that ranges from an asymptomatic presentation to a more severe disease, which is characterized by a vascular leakage syndrome where abdominal pain is a major symptom. Transplant recipients are immunosuppressed and are less likely to develop a severe form of the disease because of a reduction in immune-mediated responses that trigger plasma extravasation events. Herein, we report two cases of severe dengue in the early postoperative period of two kidney transplant recipients. Considering the severity of the cases, we emphasize the importance of dengue screening immediately before transplantation in areas endemic for the disease.

Resumo A combinação de imunossupressores faz parte do protocolo de tratamento de pacientes submetidos a um transplante renal (TR). A Thymoglobuline®, imunoglobulina policlonal de coelho dirigida contra timócitos humanos, é o agente mais usado como terapia de indução no TR nos Estados Unidos. No Brasil, a Thymoglobuline® está aprovada para uso em pacientes que foram submetidos a transplante e, apesar de ser amplamente utilizada, ainda existem controvérsias em relação ao seu modo de uso. Realizamos uma revisão sistemática da literatura avaliando os estudos que utilizaram a Thymoglobuline® na indução e no tratamento de rejeição em pacientes submetidos ao TR. A revisão utilizou os bancos de dados computadorizados da EMBASE, LILACS e MedLine e dos trabalhos selecionados foram extraídas informações sobre os dados gerais dos pacientes, as características metodológicas e as variáveis analisadas em cada estudo. Dos resultados obtidos, desenvolvemos um guia prático sobre o uso de Thymoglobuline® em pacientes transplantados renais.

Abstract The combination of immunosuppressive drugs is part of the treatment regimen of patients undergoing kidney transplantation (RT). Thymoglobulin®, a rabbit immunoglobulin directed against human thymocytes, is the most commonly agent used for induction therapy in RT in the US. In Brazil, Thymoglobulin® is approved by ANVISA for the use in patients who underwent kidney transplantation and despite being widely used, there are controversies regarding the drug administration. We prepared a systematic review of the literature, evaluating studies that used Thymoglobulin® for induction and for acute rejection treatment in patients undergoing RT. The review used the computadorized databases of EMBASE, LILACS and MedLine. Data were extracted from the studies concerning general features, methodological characteristics and variables analyzed in each study. From the results, a practical guide was prepared analyzing various aspects on the use of Thymoglobulin® in patients submitted to RT.

CONTEXTO E OBJETIVO: A prevalência de anemia pós-transplante renal (APR) relatada na literatura é variável e vários fatores contribuem para sua fisiopatologia. Este estudo objetivou investigar a prevalência de APR, os fatores de risco associados e o impacto da terapia sem esteroides. TIPO DE ESTUDO E LOCAL: Estudo de coorte retrospectivo em unidade de transplante renal em hospital terciário. MÉTODOS: Anemia foi definida como hemoglobina (Hb) < 12 g/dl em receptores adultos do sexo feminino e < 13 g/dl no masculino. Idade e gênero do doador e do receptor, tipo de doador, creatinina, função retardada do enxerto (FRE), rejeição aguda, uso de inibidores da enzima conversora da angiotensina (IECA)/bloqueadores dos receptores da angiotensina (BRA) e terapia sem esteroides foram investigados como fatores de risco para APR em análise de regressão logística multivariada. RESULTADOS: Duzentos e cinquenta e oito receptores foram avaliados (idade média: 38,8 anos; 60,5% homens; 35,7% em terapia sem esteroides). Anemia foi diagnosticada em 38% no sexto mês (M6), 28% (M12), 32% (M24) e em 45% dos pacientes na última data de acompanhamento. Idade do doador > 50 anos associou-se a maior risco de APR aos 6 (odds ratio, OR = 4,68) e 24 meses (OR = 6,57), bem como terapia sem esteroides aos 6 meses (OR = 2,96). FRE associou-se independentemente com APR aos 6 (OR = 3,66) e 12 meses (OR = 2,85). CONCLUSÃO: A menor prevalência de APR foi observada entre 9 e 24 meses pós-transplante renal. FRE, idade do doador e terapia sem esteroides foram os principais fatores associados à APR.

CONTEXT AND OBJECTIVE: The prevalence of post-renal transplant anemia (PTA) reported in the literature is variable and several factors contribute towards its pathophysiology. This study aimed to investigate the prevalence of PTA, its associated risk factors and the impact of therapy without steroids. DESIGN AND SETTING: Retrospective cohort study in a renal transplantation unit at a tertiary hospital. METHODS: Anemia was defined as hemoglobin (Hb) < 12 g/dl in female adult recipients and < 13 g/dl in males. Donor and recipient age and gender, type of donor, creatinine, delayed graft function, acute rejection, use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) and therapy without steroids were investigated as risk factors for PTA through multivariate logistical regression analysis. RESULTS: Evaluations were performed on 258 recipients (mean age: 38.8 years; 60.5% males; 35.7% did not receive steroids). Anemia was diagnosed in 38% of the patients (at the sixth month, M6), 28% (M12), 32% (M24) and 45% (at last follow up). Donor age > 50 years was associated with greater risks of PTA at M6 (odds ratio (OR) = 4.68) and M24 (OR = 6.57), as well as with therapy without steroids at M6 (OR = 2.96). Delayed graft function was independently associated with PTA at M6 (OR = 3.66) and M12 (OR = 2.85). CONCLUSION: The lowest prevalence of PTA was observed between M9 and M24 after renal transplantation. Delayed graft function, donor age and therapy without steroids were the most important factors associated with PTA.