Tratamiento del rechazo mediado por anticuerpos en pacientes trasplantados renales revisión sistemática

Antecedentes: El trasplante renal es la mejor alternativa terapéutica para la enfermedad renal crónica terminal. Los medicamentos inmunosupresores previenen el rechazo. El rechazo mediado por anticuerpos es frecuente y disminuye la función y duración del injerto. Objetivo: Evaluar sistemáticamente la evidencia disponible relacionada con la eficacia y seguridad del tratamiento para el rechazo mediado por anticuerpos en pacientes trasplantados renales. Metodologia: Revisión sistemática en bases de datos MEDLINE, EMBASE, Scopus y Biblioteca virtual de la salud. Literatura gris google scholar, google academico, www.clinicaltrialsregister.eu, and https://clinicaltrials.gov/. Búsqueda manual referencias artículos pre-seleccionados así como de revisiones previamente publicadas. Se siguieron las recomendacioes guia PRISMA para la identificacion de artículos potenciales, tamizaje y selección teniendo en cuenta los criterios de inclusion. Extracción datos de acuerdo a las variables, revisión calidad de los artículos elegidos utilizando evaluación riesgo de segos de Cochrane. Resultados: Se seleccionaron 9 ensayos clínicos publicados entre 1980 y 2016, incluyeron 222 pacientes (113 brazo de intervención y 109 en el control), seguimiento promedio 16 meses. Intervenciones evaluadas plasmaféresis, inmunoadsorción y rituximab. Hubo una amplia heterogeneidad en la definición de criterios de inclusión, criterios diagnósticos de rechazo y medidas de evaluación de eficacia de las intervenciones. Tres estudios encontraron diferencias estadísticamente significativas entre los grupos de tratamiento. Conclusiones: La evidencia sobre la eficacia de los tratamientos del rechazo mediado por anticuerpos en injertos renales es de baja calidad. Son necesarios ensayos clínicos controlados para poder definir el tratamiento óptimo de estos pacientes.

Adesão ao regime medicamentoso dos adolescentes submetidos a transplante hepático: fatores motivacionais.

Introduction: In liver transplantation the immunosuppression is essential for the survival of the graft and of the receiver. Although characteristics of adolescent development may influence medication non-adherence, the literature on the subject is scarce. The high prevalence and consequences of non-adherence makes it essential to identify the non-adherent adolescent with the intention of promoting medication adherence. Methods: The aim of this descriptive cross-sectional study is to characterize adolescents undergoing liver transplantation, and to determine the degree of medication non-adherence, using the Measure Treatment Adherence (MAT) scale and immunosuppression blood values. Moreover, the study seeks to explore the relationship between adherence and motivation - using the Treatment Self-Regulation Questionnaire (TSRQ), and adherence and competency - using Perceived Competence Scale (PCS). Results: The sample consisted of 32 adolescents (Age M=14,44 (SD=2,66); 56,3% (n=18) male) who underwent liver transplantation at a Portuguese pediatric hospital. Adolescents self-reported medication adherence scores in the MAT were significantly higher (100%) than what was expected based on the mean value of the three blood values of tacrolimus obtained within one year prior to completing the questionnaire (66,7%). As a subjective self-reported measure, the MAT is prone to bias and inflated self assessed adherence is commonly found in the literature. On the other hand, the mean value of the three blood levels of tacrolimus obtained widely and considered objective adherences measure, they may individually vary in terms of pharmacokinetic response and absorption. Adolescents showed a predominantly autonomous motivation to fulfill the medication prescription, being that motivation high (TSRQ autonomous motivation subscale presents an average value of 6.5, in a range of 1 to 7). They showed themselves confident and believing in their capacity to follow the medication regimen, due to the high perceived competence (PCS presents an average value of 6.65, in a range of 1 to 7). Opposed to what was postulated by the Self-determination Theory and other investigation's results, motivation and perceived competence are not related to adherence to the medication regimen in this study (rs=,119 p=,523; rs=,283 p=,123, respectively). Thus, perceived competence seems to have a positive influence on the autonomous motivation of these adolescents (rs=,482 p=,006). Conclusion: This study shows that medication adherence when evaluated subjectively scores higher compared to the blood values of immunosuppression. Also, Motivation and Perceived Competence do not seem to influence the adherence to the medication regimen. More multi-centre studies are needed, based on solid theory to examine adherence behaviour more.