FLAVIO JOTA DE PAULA
Índice h a partir de 2011
13
Projetos de Pesquisa
Unidades Organizacionais
Instituto Central, Hospital das Clínicas, Faculdade de Medicina - Médico
9 resultados
Resultados de Busca
Agora exibindo 1 - 9 de 9
conferenceObject Cardiac scintigraphy fails to identify patients with single-vessel coronary artery disease and end-stage renal disease: potential impact on cardiovascular morbidity(2012) GOWDAK, Luis Henrique W.; PAULA, Flavio J. de; CESAR, Luiz Antonio M.; LIMA, Jose Jayme G. deIntroduction: Patients (pt) with end-stage renal disease (ESRD) are at increased risk for CAD and major adverse cardiovascular events. Cardiac scintigraphy is regarded as a non-invasive, useful screening tool for risk stratification and to exclude significant CAD in the general population; invasive coronary angiography is usually performed following a positive result in the non-invasive assessment. Objectives: To determine the accuracy of such approach in pt with ESRD being considered as renal transplant candidates. Methods: 482 pt with ESRD (56 ±9 years; 69% men) underwent cardiac scintigraphy (99mTc MIBI-SPECT with dipyridamole) and coronary angiography, regardless of symptoms. Myocardial perfusion scans were categorized as normal or abnormal (fixed and/or transient perfusion defects); significant CAD was defined by luminal stenosis ≥70%. The sensitivity (Sen), specificity (Spe), positive (PPV) and negative (NPV) predictive values were calculated for pt with 1-, 2- or 3-vessel CAD. Kaplan-Meier curves were constructed for the probability of survival free of fatal/non-fatal MACE during a 5-year follow-up based on the results of angiography. Results: 240 pt (50%) had perfusion defects; 237 pt (49%) had significant CAD, of which 89 (38%), 70 (29%), and 78 (33%) had 1-, 2-, and 3-vessel disease, respectively. Figure 1 shows that pt with any degree of significant CAD had a worse-long term prognosis than pt with no CAD. Figure 2 shows that abnormal myocardial scans were more likely to be found in pt with 2- (69%) or 3-vessel CAD (76%), whereas in pt with no CAD, 64% of them had a normal perfusion scan (P<0.0001). However, in pt with 1-vessel CAD, the occurrence of normal and abnormal scans was almost identical (48 vs. 52%). A myocardial perfusion defect yielded a Sen=52%, 69% and 76%, a Spe=28%, 37% and 41%, a PPV=30%, 31% and 39%, and a NPV = 49%, 74% and 77% for the diagnosis of 1-, 2- and 3-vessel CAD, respectively. Conclusion: In pt with ESRD: 1) the prevalence of significant CAD is high, and this imposes a worse long-term prognosis independently of the number of affected vessels; 2) myocardial perfusion assessment by SPECT has a low sensitivity to detect 1-vessel CAD; 3) as a consequence, many pt with 1-vessel CAD could be mistakenly deemed to be free of CAD and, therefore, not treated accordingly, although their long-term prognosis seemed to be no different of that from pt with 2- or 3-vessel disease.- Pamidronate for the treatment of osteoporosis secondary to chronic cholestatic liver disease in Wistar rats(2012) PEREIRA, F. A.; MATTAR, R.; FACINCANI, I.; DEFINO, H. L. A.; RAMALHO, L. N. Z.; JORGETTI, V.; VOLPON, J. B.; PAULA, F. J. A. deOsteoporosis is a major complication of chronic cholestatic liver disease (CCLD). We evaluated the efficacy of using disodium pamidronate (1.0 mg/kg body weight) for the prevention (Pr) or treatment (Tr) of cholestasis-induced osteoporosis in male Wistar rats: sham-operated (Sham = 12); bile duct-ligated (Bi = 15); bile duct-ligated animals previously treated with pamidronate before and 1 month after surgery (Pr = 9); bile duct-ligated animals treated with pamidronate 1 month after surgery (Tr = 9). Rats were sacrificed 8 weeks after surgery. Immunohistochemical expression of IGF-I and GH receptor was determined in the proximal growth plate cartilage of the left tibia. Histomorphometric analysis was performed in the right tibia and the right femur was used for biomechanical analysis. Bone material volume over tissue volume (BV/TV) was significantly affected by CCLD (Sham = 18.1 +/- 3.2 vs Bi = 10.6 +/- 2.2%) and pamidronate successfully increased bone volume. However, pamidronate administered in a preventive regimen presented no additional benefit on bone volume compared to secondary treatment (BV/TV: Pr = 39.4 +/- 12.0; Tr = 41.2 +/- 12.7%). Moreover, the force on the momentum of fracture was significantly reduced in Pr rats (Sham = 116.6 +/- 23.0; Bi = 94.6 +/- 33.8; Pr = 82.9 +/- 22.8; Tr = 92.5 +/- 29.5 N; P < 0.05, Sham vs Pr). Thus, CCLD had a significant impact on bone histomorphometric parameters and pamidronate was highly effective in increasing bone mass in CCLD; however, preventive therapy with pamidronate has no advantage regarding bone fragility.
- The role of myocardial scintigraphy in the assessment of cardiovascular risk in patients with end-stage chronic kidney disease on the waiting list for renal transplantation(2012) LIMA, Jose Jayme Galvao De; GOWDAK, Luis Henrique Wolff; PAULA, Flavio Jota de; RAMIRES, Jose Antonio Franchini; BORTOLOTTO, Luiz A.The usefulness of stress myocardial perfusion scintigraphy for cardiovascular (CV) risk stratification in chronic kidney disease remains controversial. We tested the hypothesis that different clinical risk profiles influence the test. We assessed the prognostic value of myocardial scintigraphy in 892 consecutive renal transplant candidates classified into four risk groups: very high (aged epsilon 50 years, diabetes and CV disease), high (two factors), intermediate (one factor) and low (no factor). The incidence of CV events and death was 20 and 18, respectively (median follow-up 22 months). Altered stress testing was associated with an increased probability of cardiovascular events only in intermediate-risk (one risk factor) patients [30.3 versus 10, hazard ratio (HR) 2.37, confidence interval (CI) 1.693.33, P 0.0001]. Low-risk patients did well regardless of scan results. In patients with two or three risk factors, an altered stress test did not add to the already increased CV risk. Myocardial scintigraphy was related to overall mortality only in intermediate-risk patients (HR 2.8, CI 1.55.1, P 0.007). CV risk stratification based on myocardial stress testing is useful only in patients with just one risk factor. Screening may avoid unnecessary testing in 60 of patients, help stratifying for risk of events and provide an explanation for the inconsistent performance of myocardial scintigraphy.
- De Novo Thrombotic Microangiopathy After Kidney Transplantation: Clinical Features, Treatment, and Long-Term Patient and Graft Survival(2012) CAIRES, R. A.; MARQUES, I. D. B.; REPIZO, L. P.; SATO, V. A. H.; CARMO, L. P. F.; MACHADO, D. J. B.; PAULA, F. J. de; NAHAS, W. C.; DAVID-NETO, E.Introduction. Posttransplant thrombotic microangiopathy (TMA)/hemolytic uremic syndrome (HUS) can occur as a recurrent or de novo disease. Methods. A retrospective single-center observational study was applied in order to examine the incidence and outcomes of de novo TMA/HUS among transplantations performed between 2000 and 2010. Recurrent HUS or antibody-mediated rejections were excluded. Results. Seventeen (1.1%) among 1549 kidney transplant recipients fulfilled criteria for de novo TMA. The mean follow-up was 572 days (range, 69-1769). Maintenance immunosuppression was prednisone, tacrolimus (TAC), and mycophenolic acid in 14 (82%) patients. Mean age at onset was 40 +/- 15 years, and serum creatinine was 6.1 +/- 4.1 mg/dL. TMA occurred at a median of 25 days (range, 1-1755) after transplantation. Nine (53%) patients developed TMA within 1 month of transplantation and only 12% after 1 year. Clinical features were anemia (hemoglobin < 10 g/dL) in 9 (53%) patients, thrombocytopenia in 7 (41%), and increased lactate dehydrogenase in 12 (70%). Decreased haptoglobin was observed in 64% and schistocytes in 35%. Calcineurin inhibitor (CM) withdrawal or reduction was the first step in the management of 10/15 (66%) patients, and 6 (35%) received fresh frozen plasma (FFP) and/or plasmapheresis. TAC was successfully reintroduced in six patients after a median of 17 days. Eight (47%) patients needed dialytic support after TMA diagnosis and 75% remained on dialysis. At 4 years of follow-up, death-censored graft survival was worse for TMA group (43.0% versus 85.6%, log-rank = 0.001; hazard ratio = 3.74) and there was no difference in patient survival (53.1% versus 82.2%, log-rank = 0.24). Conclusion. De novo TMA after kidney transplantation is a rare but severe condition with poor graft outcomes. This syndrome may not be fully manifested, and clinical suspicion is essential for early diagnosis and treatment, based mainly in CM withdrawal and FFP infusions and/or plasmapheresis.
conferenceObject A NEW RISK-SCORE MODEL TO PREDICT CARDIOVASCULAR EVENTS IN RENAL TRANSPLANT CANDIDATES(2012) GOWDAK, Luis Henrique Wolff; PAULA, Flavio J. de; CESAR, Luiz Antonio M.; LIMA, Jose Jayme G. deBackground Renal transplant candidates (RTC) are at increased risk for cardiovascular events (MACE). We developed a new risk-score model to predict MACE in pt with end-stage renal disease (ESRD). Methods 1,057 RTC (61% men, 53±11 years) were prospectively enrolled. The median follow-up was 16 (1 – 107) months. A logistic regression model was built from three clinically relevant co-variates as defined by the American Society of Transplantation (age, diabetes, and known CVD); the occurrence of the first or new fatal/non-fatal MACE (sudden death, acute myocardial infarction or unstable angina, stroke, peripheral artery disease, or overt heart failure) was regarded as the dependent variable. The logistic regression coefficient B for each variable was multiplied by 10 and rounded to the next whole number, allowing that, for each patient, a correspondent risk-score could be assigned. The receiver-operating-characteristic curve (ROC) was constructed to estimate the accuracy of the new-score. Finally, the prevalence of significant CAD for each risk-score was determined and a linear regression model between risk-score and the probability of MACE was calculated. Results There were 209 events during follow-up. The B coefficients for age, diabetes and CVD were 0.03, 0.62, and 0.89 (all P<.01), respectively. Thus, the risk-score could be calculated by the equation: Risk-Score = (Age * 0.3) + (DM * 6.2) + (CVD * 8.9). The respective area under the curve (ROC) was 0.70 (P=.0001) and the final equation relating the risk-score with the expected probability of the first occurrence of MACE was: Probability of MACE = (Risk-Score *1.45) – 14.2 (R2 = 0.94; P<.0001). As an example, a non-diabetic 40-year old RTC with no evidence of CVD will have an expected probability of suffering a first MACE of 3.2% whereas a 65-year old diabetic pt with peripheral artery disease will have an expected probability of 36.0%. Conclusions We developed and validated a new, simple risk-score to predict the occurrence of the first or new MACE among potential renal transplant recipients. This model should help cardiologists to better identify high-risk RTC, so that a cardiovascular risk reduction program can be aggressively implemented. ACC Moderated Poster Contributions McCormick Place South, Hall A Sunday, March 25, 2012, 11:00 a.m.-Noon Session Title: Prevention Abstract Category: 9. Prevention: Clinical Presentation Number: 1181-155- Recipient of kidney from donor with asymptomatic infection by Paracoccidioides brasiliensis(2012) BATISTA, Marjorie V.; SATO, Paula K.; PIERROTTI, Ligia C.; PAULA, Flavio J. de; FERREIRA, Gustavo F.; RIBEIRO-DAVID, Daisa S.; NAHAS, William C.; DUARTE, Maria I. S.; SHIKANAI-YASUDA, Maria A.The increase in solid organ transplantations may soon create a rise in the occurrence of endemic fungal diseases, such as paracoccidioidomycosis, due to the lack of rigorous screening of donors from endemic areas. Here we present the first case of an immunocompetent and asymptomatic kidney donor who had Paracoccidioides brasiliensis infected-adrenal tissue but no glandular dysfunction.
conferenceObject Which Induction Therapy Should Be Used in Kidney Transplants with Prolonged Cold Ischemia Time?(2012) ARAUJO, M. J. C. L. N.; ONUSIC, V. L.; BATTAINI, L. C.; BARBOSA, E. A.; BOJIKIAN, R. T.; DAVID, D. R.; ANTONOPOULOS, I. M.; PAULA, F. Jota de; NAHAS, W. C.; NETO, E. D.; LEMOS, F. B. C.; CASTRO, M. C. Ribeiro de- Which patients are more likely to benefit from renal transplantation?(2012) LIMA, Jose Jayme Galvao De; GOWDAK, Luis Henrique Wolff; PAULA, Flavio Jota de; CESAR, Luiz Antonio Machado; RAMIRES, Jose Antonio Franchini; BORTOLOTTO, Luiz A.Background: We evaluated whether the advantages conferred by renal transplantation encompass all individuals or whether they favor more specific groups of patients. Methods: One thousand and fifty-eight patients on the transplant waiting list and 270 receiving renal transplant were studied. End points were the composite incidence of CV events and death. Patients were followed up from date of placement on the list until transplantation, CV event, or death (dialysis patients), or from the date of transplantation, CV event, return to dialysis, or death (transplant patients). Results: Younger patients with no comorbidities had a lower incidence of CV events and death independently of the treatment modality (log-rank = 0.0001). Renal transplantation was associated with better prognosis only in high-risk patients (p = 0.003). Conclusions: Age and comorbidities influenced the prevalence of CV complications and death independently of the treatment modality. A positive effect of renal transplantation was documented only in high-risk patients. These findings suggest that age and comorbidities should be considered indication for early transplantation even considering that, as a group, such patients have a shorter survival compared with low-risk individuals.
conferenceObject Cardioprotective Drugs and Acute Coronary Syndrome in Patients on the Waiting List for Renal Transplantation(2012) LIMA, J. J. G. De; GOWDAK, L. H. W.; PAULA, F. J. de; CESAR, L. A. M.; BORTOLOTTO, L. A.Background: The incidence of Acute Coronary Syndrome (ACS) in patients (pts) with advanced CKD is close to 30/1000 pts-year (Kidney Int 2002; 62: 1799). The effect of cardioprotective medications on the incidence of ACS on the waiting-list pts is poorly understood. Objective : to assess the incidence and risk factors for ACS in a cohort of 1522 hemodialysis pts on the waiting list for renal transplantation prospectively treated with aspirin, b-blockers, statins and renin-angiotensin inhibitors irrespectively of risk strati fi cation starting on inception and maintained before and after transplantation. Results: 83 pts (57±8 yo, 65% males, 65% Caucasians, 53% diabetics and 49% with associated CV disease) developed ACS (5.4/1000 pts-year): myocardial infarction (MI) = 53 (66%) and unstable angina (UA) = 28 (34%). The median time for the occurrence of ACS was 52 months. Compared to pts who did not develop CV events, ACS pts were older and had more angina, diabetes, associated CV disease, higher serum total-cholesterol, LV mass index and abnormal myocardial scan. The sole independent predictor of ACS was an altered myocardial scan (p=0.0009, 95% CI 0.21-0.80, HR 0.50). 35 out of 53 pts with MI (66%) died during hospitalization; UA was not associated with in-hospital deaths. Mortality was higher in pts with ACS compared to controls (55% versus 20%, p=0.0001, HR 0.28, 95% CI 0.20- 0.39). 8 pts with ACS underwent renal transplantation. There were 2 deaths caused by MI 1.6 and 12 months after operation. In the control group (n= 360) there were 4 MI-related deaths. Overall post-transplant mortality was comparable in ACS and in controls (p=0.29). Conclusions: the incidence of ACS appears to be reduced in this cohort prospectively treated with cardioprotective medications. Risk factors do not differ from those in the general population. Myocardial scan is useful to detect pts at higher risk of ACS. The incidence of ACS was not increased by renal transplantation in pts with previous ACS. The in-hospital mortality by MI is very high.