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Rejeição Aguda

Explore acute rejection in renal transplant patients through a timeline analysis and risk assessment. Understand the impact of viral infections, diabetes, and immunosuppressants on patient outcomes.

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Rejeição Aguda

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  1. Rejeição Aguda Gustavo Ferreira Médico-Residente Nefrologia HCFMUSP

  2. Risco igual Cronologia dos Eventos no Transplante Renal Risco Relativo de Morte 4,00 2,84 1,00 % n = 23.275 50 40 30 20 10 Rejeição aguda Infecções virais 0,32 0,25 Diabetes mellitus 0 106 183 365 548 Dias após o transplante 1 3 6 12 2 3 4 5 6 7 8 9 10 11 12 meses anos Wolfe, N Engl J Med 1999

  3. Evolução dos Imunossupressores

  4. Rejeição aguda Cronologia dos Eventos no Transplante Renal Cronologia dos Eventos no Transplante Renal % 50 40 30 20 10 1 3 6 12 2 3 4 5 6 7 8 9 10 11 12 meses anos

  5. Tempo para Ocorrência de Rejeição Aguda (Kaplan-Meier) 0,5 n = 141 0,4 0,3 0,2 0,1 0 0 30 60 90 120 180 240 300 360 dias pós transplante

  6. Rejeição Aguda no Primeiro Ano 0,7 1997 0,6 1999 0,5 1998 0,4 2000 0,3 0,2 0,1 0 0 30 60 90 180 240 300 360 dias após o transplante

  7. Rejeição e Imunossupressão

  8. n = 63.045 5,2 4,98 3,4 2,35 1,67 Com Rejeição Risco de Perda Tardia em Pacientes com Rejeição Aguda Risco Relativo 6 5 4 3 2 1 1,53 1,37 1,31 1,14 1 Sem Rejeição 0 96-97 94-95 92-93 90-91 88-89 Biênios Meier Kriesche, Transplantation 2000

  9. sem Rejeição Aguda com Rejeição Aguda Sobrevida do Enxerto (excluídos os óbitos com rim funcionante) 1997 - 2000 1,0 0,9 0,8 n = 305 0,7 p = 0,01 0,6 0,5 0,4 0,3 0,2 0,1 0 0 365 730 1095 1460 1825 2190 2555 2920 dias pós-transplante

  10. Immunofluorecence microscopy shows C4d deposits along peritubular capillaries (green, arrowheads) and collagen type IV accumulations along tubular basement membranes (red, arrows). A tangentially cut glomerulus (G) only shows non-specific C4d deposits in mesangial regions. Double incubations performed on fresh frozen tissue sample

  11. Inrenal allograft biopsies, C4d can be detected in association with different histological changes and even in the setting of normal histology. Statistical significant is the correlation between C4d and ‘acute cellular rejection’, in particular transplant glomerulitis. Only a minority of C4d-positive biopsies represent ‘pure humoral rejection’.

  12. Criteria for acute antibody-mediated rejection in renal allografts include 3 cardinal features • Morphologic evidence of acute tissue injury, such as: (a) acute tubular injury, (b) neutrophils and/or mononuclear cells in peritubular capillaries and/or glomeruli, and/or capillary thrombosis; or (c) intimal arteritis/fibrinoid necrosis/intramural or transmural inflammation in arteries. • Immunopathologic evidence for antibody action, such as: (a) C4d and/or (rarely) immunoglobulin in peritubular capillaries or (b) immunoglobulin and complement in arterial fibrinoid necrosis • Serologic evidence of circulating antibodies to donor HLA or other anti-donor endothelial antigens.

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