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
10 resultados
Resultados de Busca
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- Prioritization Due to Dialysis Access Failure Impacts on Patient Survival after Kidney Transplantation(2013) REUSING JR., J.; SOUZA, P.; GALANTE, N.; AGENA, F.; PAULA, F. de; NAHAS, W.; DAVID-NETO, E.Dialysis vascular access failure, recipient of a non-renal solid organ transplantation and previous kidney donation are current indications of priority allocation (PA) for kidney transplant (KT) at our centre. Mortality among PA patients under dialysis is high and risk factors for long-term patient outcomes after transplantation remain largely elusive. In this study we analyzed a cohort of patients that received KT from Jan/2007 to Dec/2011. Long-term patient survival was compared between PA and non PA recipients transplanted in this period of time and clinical relevant data were analyzed. Data were recorded as of Aug/2012. Results: 948 KT were performed at our institution and 93 (9.8%) were included in our PA program. Most PA patients (n=86) had access failure. The mean follow up time was 32 (0 – 69) months. 5-year patient survival was lower in PA patients (76vs 86%, p=0.001). Twenty (21.5%) PA patients died and all deaths occurred in those with access failure, being 70% of them in the first 3 months. Causes of death were infection in 10 patients, bleeding complications (n=6), uremia (n=1), mesenteric ischemia (n=1) and unspecified shock (n=2). Considering this high mortality rate in the first 3 months after transplantation, we compared patients who died in this period of time (group A) vs. those who survived more than 3 months (group B). Age, gender, previous kidney transplants, sensitization, number of HLA mismatches, pre-transplant DSA, pre-transplant diabetes, induction therapy, DGF, rejection, use of heparin, IVIg and time from inscription in the PA program to transplantation were not statistically different between groups. Among 47 patients who were screened for thrombophilia, 83.3% from group A were positive vs. 31.7% from group B (p=0.01). Infection after transplantation and hemorrhagic complications were more frequent in group A. Groups were not different regarding causes of death. PA patients have a lower survival and this excessive death rate occur in the first three months after transplantation mainly due to infections and bleeding. Thrombophilia is very frequent in PA patients with HR....... for death.
conferenceObject Early Protocol Biopsies Can Identify Antibody-Mediated Rejection in Sensitized Patients(2013) SOUZA, P.; MACHADO, D.; AGUIRRE, A.; DAVID, D.; BARBOSA, E.; PAULA, F. de; NAHAS, W.; DAVID-NETO, E.; CASTRO, M.HLA sensitized patients are at risk for antibody-mediated rejection (ABMR). Our purpose was to evaluate the importance of early protocol biopsies. From Jul/2010 to Jun/2012, 101 sensitized patients defined as PRA>10% (class I and/or II by Flow-PRA) were transplanted at our institution. Out of them, 60 performed donor-specific antibodies (DSA) at transplant and a protocol-bx at day 7 (D7) and were included in this study. A second for cause indication biopsy (IB) was done at the physician’s discretion in 18 patients without previous acute rejection (AR) diagnosis. DSA were analyzed by single antigen bead assays at the time of biopsies (classified according to Banff’09 criteria). Patients (pts) mean age was 48±12 years, 48 were female (80%),45 first transplant (75%) and 42 (70%) received a kidney from deceased donor. 34 pts never presented AR episodes while 26 did. 20/26 (77%) of AR were diagnosed in the first 3 weeks after transplantation (median 13 days). Day 7 protocol biopsies (PB) showed AR in 12/26 (46%): 10 (85%) ABMR and 2 (15%) T-cell-mediated rejection (TCMR). The IB (n=18) done at a median of 11 days from the PB (range 3-112), showed AR in another 14 pts (56%): 10(71%) ABMR and 4 (29%) TCMR, as presented in Table 1 Pre-Tx mean MFI in ABMR pts did not differ among PB: 6001 (1596-11181) vs IB 2304 (840-14600)(p=NS). It also did not differ at the time of biopsy (2823 vs. 2277 in PB vs IB, respectively; p=NS). Patients with early ABMR diagnosis at PB had a trend to higher long-term MDRD (49±12mL/min) compared to patients with ABMR at IB (41±11mL/min) and similar to the whole non-ABMR patients (50±17mL/min). In conclusion, protocol biopsy is useful to diagnosis ABMR as early as in the first week pos-Tx. Early recognition of ABMR allows earlier treatment and possibly better long-term graft function in sensitized patients.conferenceObject DIAGNOSIS OF ANTIBODY-MEDIATED REJECTION THROUGH EARLY PROTOCOL BIOPSIES IN SENSITIZED PATIENTS(2013) SOUZA, Patricia S.; MACHADO, David; AGUIRRE, Anna Rita; DAVID, Daisa; BARBOSA, Erick; PAULA, Flavio Jota de; NAHAS, Willian; DAVID-NETO, Elias; CASTRO, Maria Cristina R.conferenceObject Screening for Inherited and Acquired Thrombophilia Prior to Renal Transplantation(2013) SILVA, R.; MORAES, C.; MARQUES, I.; PAULA, F. de; DAVID-NETO, E.All patients with a history of a thromboembolic event, early or recurrent vascular access thrombosis, family history of thrombosis, or multiple miscarriages underwent laboratory screening for thrombophilia. Since the introduction of the screening for hypercoagulable risk factors, 156 candidates for renal transplantation underwent laboratory evaluation. Eighty-eight patients (56%) exhibited at least one prothrombotic laboratory parameter, besides of isolated hyperhomocysteinemia, which confirmed a thrombophilic state. Lupus anticoagulant, anticardiolipin and beta-2-glycoprotein was present in 30%, 18% and 13%, and antithrombin III, protein C and protein S deficiencies in 11%, 8% and 10%, respectively. Factor V Leiden mutation was present in only one patient and prothrombin gene G20210 mutation was not found. Among the 156 patients, 30 underwent renal transplantation and were followed for a median of 199 days (range, 9 – 418). All patients were on triple immunosuppressive regimen compromising mycophenolate, tacrolimus and prednisone. Thrombophilia was identified in 16 (53%). Seventeen (57%) received perioperative anticoagulation with unfractionated heparin (9 patients with thrombophilia and 8 without laboratory confirmed thrombophilia). Five (30%) of these patients developed perinephric hematomas. Three patients with thrombophilia developed thrombotic complications (2 upper limbs deep-vein thrombosis and 1 allograft artery thrombosis) and 1 patient without thrombophilia developed allograft vein thrombosis, p=0.35. Nine patients developed acute rejection (5 in the group with thrombophilia and 4 in the group without thrombophilia, p=0.87). Mean glomerular filtration rate was similar between thrombophilic and non-thrombophilic patients in the last follow-up (54±27 vs. 47±22 mL/min/1.73m², p=0.35). One graft loss and 1 patient death were observed in each group. In conclusion, prothrombotic risk factors, especially antiphospholipid antibodies, are highly prevalent in patients awaiting renal transplantation with a clinical or familial history suggestive of thrombophilia, including early and recurrent vascular access failure. Despite pre-transplant screening and perioperative treatment and/or monitoring, thrombotic and bleeding complications are still frequent and severe.conferenceObject THROMBOPHILIA AND PRIORITIZATION DUE TO DIALYSIS ACCESS FAILURE IMPACT EARLY ON PATIENT SURVIVAL AFTER KIDNEY TRANSPLANTATION(2013) REUSING JR., Jose O.; SOUZA, Patricia S.; GALANTE, Nelson Z.; AGENA, Fabiana; PAULA, Flavio J.; NAHAS, William Carlos; DAVID-NETO, EliasconferenceObject DEFINING PP65ENEMIA AND QPCR CUT-OFFS FOR PRE-EMPTIVE THERAPY OF CMV DISEASE IN LOW-RISK RENAL TRANSPLANTED RECIPIENTS(2013) DAVID-NETO, Elias; LEMOS, Angelica Dias; BOAS, Lucy Santos Vilas; LATIF, Acram Zahredine Abdul; AGENA, Fabiana; PAULA, Flavio Jota de; PIERROTI, Ligia; LEMOS, Francine; NAHAS, William Carlos; CAIAFFA FILHO, Helio; PANNUTI, Claudio SergioconferenceObject Defining pp65 Enemia and qPCR Cut-Offs for Pre-Emptive Therapy of CMV Disease in Low-Risk, Seropositive Renal Transplanted Recipients(2013) DAVID-NETO, E.; LEMOS, A.; BOAS, L. Vilas; LATIF, A.; AGENA, F.; PAULA, F. Jota de; PIERROTI, L.; LEMOS, F.; NAHAS, W.; CAIAFFA FILHO, H.; PANUTTI, C.CMV disease mostly invasive gastro-intestinal with low viremia occurs in approximately 16% of CMV seropositive renal transplant recipients not receiving Thymoglobuline (ATG). Pre-emptive therapy (PETh) to avoid disease in this group should cover the majority of patients at risk (high Negative Predictive Value – NPV). To define cut-offs for whole blood real-time quantitative PCR (qPCR) and antigenemia (pp65) assays and use PETh for CMV disease we collected blood samples weekly from day 7 to 120 after TX in pts CMV IgG+/ IgG+ donors who did not receive ATG. Results remained blinded. A suspicion of CMV disease required new qPCR/pp65 or biopsy. The highest value of pp65 and qPCR in pts without CMV disease one week before disease were used in ROC curves. As for Nov 2012, 92 pts had completed the collections or developed disease. They were males (54%), caucasians (69%), mean age 45±14y, 61% deceased donors, all under TAC/MPA/ Prednisone. Overall 12 pts (13%) had CMV disease (11 invasive gastro-intestinal/ 1 syndrome), at 64±21 days (31-98), and 80 did not. Of these 80 pts, 45 (56%) presented at least one episode of asymptomatic viremia and cleared it spontaneously (8 (18%) had PCR+/pp65+; 26 (56%) Pp65+/qPCR- and 11 (24%) qPCR+/Pp65-). Among pts with viremia or disease there was a trend for a higher pp65+ cells for disease than for viremia (152±352vs31±131/10 6 cells, p=0.073,) detected earlier for disease than viremia (64±21vs80±25 days, p=0.049). ROC curves (area 0.902±0.036, p=0.0001) revealed that pp65 of 4 cells had 83% sensitivity and 83% specificity to predict CMV disease. Using this cut-off, the NPV was 97%. The CMV copies detected by qPCR was higher for disease than for viremia (46657±50671 vs 5438±16681 copies, p=0.001) but time for detection was similar for both (74±25 vs 59±18 days, p=NS). ROC curve (area 0.903±0.056,p=0.0001) revealed that qPCR=844 copies had 83% sensitivity and 86% specificity to predict disease with the same NPV of 97%. These data indicate that both methods are adequate to detect CMV disease prior to its development in this low-risk population. Blood samples collection should start at day 30 and then weekly until day 120. When these cut-offs are reached, starting pre-emptive therapy would lead untreated only 3% of patients who would develop CMV disease.conferenceObject Blood pressure level imposes different cardiovascular risk on renal transplant candidates in the presence of previous stroke or myocardial infarction(2013) GOWDAK, L. H. W.; PAULA, F. J. De; CESAR, L. A. M.; BORTOLOTTO, L. A.; LIMA, J. J. G. De- Clinical features and outcomes of tuberculosis in kidney transplant recipients in Brazil: a report of the last decade(2013) MARQUES, Igor D. B.; AZEVEDO, Luiz S.; PIERROTTI, Ligia C.; CAIRES, Renato A.; SATO, Victor A. H.; CARMO, Lilian P. F.; FERREIRA, Gustavo F.; GAMBA, Cristiano; PAULA, Flavio J. de; NAHAS, William C.; DAVID-NETO, EliasBackground Among kidney transplant recipients (KTRs), tuberculosis is one of the most common opportunistic infections and is associated with high morbidity and mortality. The aim of this study was to describe the incidence, clinical features, and prognosis of tuberculosis in KTRs. Methods Retrospective single-center observational study involving all cases of tuberculosis in KTRs between 2000 and 2010. Results Of the 1549 KTRs evaluated, 43 (2.8%) developed tuberculosis, translating to an annual incidence of 803 cases/100000 patients, considerably higher than that reported for the general population of Brazil. The median time to tuberculosis (TB) onset after transplantation was 196d (range, 193626d). Of the KTRs with tuberculosis, 67% became infected within the first year post-transplant, 74% had pulmonary tuberculosis, and 7% had a previous history of active tuberculosis. No tuberculosis prophylaxis was employed before or after transplantation. The most common symptoms were fever (in 79%), cough (in 35%), and dyspnea (in 16%). The median time from the onset of symptoms to the start of treatment was 28d. The median duration of antituberculosis therapy was 196d. In 15 patients (35%), the immunosuppressive therapy was reduced, and the incidence of acute rejection was higher in patients with tuberculosis than in those without (44% vs. 28%). Mortality during tuberculosis treatment was 12% (5 cases), and all five deaths were attributed to tuberculosis. Ten-yr death-censored graft survival and patient survival were similar between patients with tuberculosis and those without. Conclusion Among KTRs, symptoms of tuberculosis are often attenuated, which leads to delayed diagnosis, and tuberculosis-related mortality remains high.
- Evolução clínica após intervenção coronária percutânea em indivíduos com transplante renal prévio(2013) TRENTIN, Fábio; MELO, Eduardo França Pessoa de; SANTO, Carlos Vinicius Abreu do Espírito; PAULA, Flavio Jota de; NAHAS, William Carlos; SPADARO, André Gasparin; LIMA, Jose Jayme de; GOWDAK, Luiz Henrique; CAMPOS, Carlos Augusto Homem de Magalhães; LEMOS NETO, Pedro AlvesBACKGROUND: Coronary artery disease is a major cause of death in patients with chronic kidney disease. Moreover, due to the high prevalence of risk factors for atherosclerosis, many of these patients require percutaneous coronary intervention (PCI) even after renal transplantation. The aim of this study is to report the late follow-up of patients with renal transplantation treated with PCI and stenting. METHODS: Patients > 18 years of age, with prior kidney transplantation, and treated with PCI were included. Clinical follow-up was evaluated by medical record analysis and telephone contact. The study endpoint was the incidence of major adverse cardiac events (MACE) during follow-up. RESULTS: Twenty-nine patients were included. Mean age was 54.8 ± 8 years and the majority male (72.4%). The prevalence of hypertension was 89.7%, dyslipidemia 69% and diabetes 51.7%. Most of them had multivessel disease (2-vessel: 44.8%; 3-vessel: 41.4%). Lesion complexity was high, being 84.3% type B2 or C lesions and 27.5% bifurcation lesions. Procedural success rate was 100%. Bare metal stents were used in 96.6% of cases. The follow-up time was 1,378 ± 977 days. The mortality rate was 25.1%, target vessel revascularization rate was 15.9% and none of the patients presented non-fatal infarction. The incidence of MACE during follow-up was 34.5%. CONCLUSIONS: Late follow-up after PCI in renal transplantation patients demonstrated a high probability of clinical events. However, the study population was a sample of high clinical and angiographic complexity.