Background: In several countries, patients with end-stage renal disease who are ineligible for dialysis are considered urgency priority (UP) for kidney transplantation (KT) through distinct allocation rules. There are scarce published data on clinical features and outcomes after KT of these patients. Methods: We retrospectively reviewed and compared demographic and clinical pretransplant characteristics and outcomes after KT of all patients transplanted under UP allocation in a single Brazilian transplant center from January 10 to March 16 (n = 74) and 1: 1 patients transplanted under standard allocation in the same period (n = 74). A propensity score (PS) matching analysis was performed to evaluate risk factors for death-censored graft loss. Results: UP KT group presented higher percentage of women (58.1 vs. 33.8%, p = 0.005), higher class I (22.2 ± 32.9 vs. 13.1 ± 25.3%, p = 0.027) and class II panel reactive antibodies (11.5 ± 24 vs. 5.2 ± 19.1%, p = 0.002), higher HLA mismatches (4.9 ± 0.9 vs. 3.7 ± 1.2, p < 0.001), higher percentage of retransplants (27 vs. 4.1%, p < 0.001), and spent longer time on dialysis off the waiting list (WL; 54.5 ± 52.5 vs. 31.2 ± 29.0 months, p = 0.03). After transplantation, UP KT patients presented longer hospital stay (29.3 ± 35.7 vs. 18.5 ± 19.5 days, p = 0.003) and inferior death-censored graft survival at 3 years (82 vs. 95.8%, log rank = 0.016), with 33.3% of graft losses due to vascular thrombosis. In PS-matched multivariable analysis, UP status hazard ratios (HR 4.791, 95% CI 1.052–21.722, p = 0.042) and donor age (HR 1.071, 95% CI 1.003–1.145, p = 0.041) were independent risk factors for death-censored graft loss. Conclusion: Patients transplanted under UP status remained a longer time on dialysis off the WL, suggesting that long-term dialysis led to exhaustion of accesses. After transplantation, outcomes are inferior and UP status was a risk factor for graft loss. These results point to the need for local policies to encourage and monitor the early referral to KT.

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.

ObjectiveTo investigate prognostic factors among critically ill patients with community-acquired bacterial meningitis and acute kidney injury.MethodsA retrospective study including patients admitted to a tertiary infectious disease hospital in Fortaleza, Brazil diagnosed with community-acquired bacterial meningitis complicated with acute kidney injury. Factors associated with death, mechanical ventilation and use of vasopressors were investigated.ResultsForty-one patients were included, with a mean age of 41.6 ± 15.5 years; 56% were males. Mean time between intensive care unit admission and acute kidney injury diagnosis was 5.8 ± 10.6 days. Overall mortality was 53.7%. According to KDIGO criteria, 10 patients were classified as stage 1 (24.4%), 18 as stage 2 (43.9%) and 13 as stage 3 (31.7%). KDIGO 3 significantly increased mortality (OR = 6.67; 95%CI = 1.23 - 36.23; p = 0.028). Thrombocytopenia was not associated with higher mortality, but it was a risk factor for KDIGO 3 (OR = 5.67; 95%CI = 1.25 - 25.61; p = 0.024) and for mechanical ventilation (OR = 6.25; 95%CI = 1.33 - 29.37; p = 0.02). Patients who needed mechanical ventilation by 48 hours from acute kidney injury diagnosis had higher urea (44.6 versus 74mg/dL, p = 0.039) and sodium (138.6 versus 144.1mEq/L; p = 0.036).ConclusionMortality among critically ill patients with community-acquired bacterial meningitis and acute kidney injury is high. Acute kidney injury severity was associated with even higher mortality. Thrombocytopenia was associated with severer acute kidney injury. Higher urea was an earlier predictor of severer acute kidney injury than was creatinine.

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Objetivo: Avaliar os desfechos do transplante renal (TxR) em receptores de rins pareados e analisar os fatores de risco para desfechos inferiores. Métodos: Estudo retrospectivo de centro único incluindo todos os TxR com doador falecido realizados em 2014 em que ambos os rins foram transplantados em receptores do nosso centro. Os pacientes foram divididos em receptores do rim direito ou esquerdo. Foram avaliados os seguintes desfechos: função tardia do enxerto (FTE) rejeição aguda, perda, óbito, taxa de filtração glomerular estimada (TFGe) e incidência do desfecho composto de perda, óbito ou TFG<50mL/min em dois anos. A análise de risco foi feita através de regressão logística binária. Resultados: Os doadores eram predominantemente jovens (29+14 anos), homens (71%), que faleceram por trauma craniano (70%). Apenas dois doadores (6%) eram de critério expandido. Os receptores foram similares quanto à demografia: homens (77 vs. 57%, p=0,126), jovens (35+20 vs. 37+17 anos, p=0,668), com doença renal crônica de etiologia indeterminada (31 vs. 40%, p=0,179), estando em média 31+37 meses em diálise (27+25 vs. 36+47 meses, p=0,311), 7% eram retransplantes (9 vs. 5%, p=0,309) e as médias de PRA de classe I e II foram 6 20% (9+23 vs. 10+19%, p=0,907) e 9+20% (9+25 vs. 5+15%, p=0,476), respectivamente. O tempo médio de isquemia fria foi de 25+9h (24+9 vs. 27+9h, p=0,269) e 66% (66 vs. 66%, p=1,000) foram perfundidos em máquina de perfusão pulsátil. Todos foram induzidos com globulina anti-timócito, 52% (54 vs. 49%, p=0,808) receberam tacrolimo e everolimo como regime imunossupressor inicial e 62% (69 vs. 54%, p=0,319) n o receberam corticoide. Não houve diferença entre os grupos quanto à  incidência de FTE (20 vs. 32%, p=0,282), rejeição aguda (0 vs. 11%, p=0,054), perda (0 vs. 6%, p=0,493), óbito (6 vs. 6%, p=1,000), TFGe (71+28 vs. 72+37 mL/min, p=0,877) ou quanto à  incidência do desfecho composto de perda, óbito ou TFGe<50mL/min em 2 anos (29 vs. 23%, p=0,785). Em análise multivariada, o único fator de risco para o desfecho composto foi FTE (OR 4,120, IC 95% 1,194-14,271, p=0,025). Conclusão: Nesta coorte de TxR com rins pareados, FTE foi o único fator de risco para desfechos inferiores.