Amiloidose e insuficiência renal crônica terminal associada à hanseníase

O envolvimento renal na hanseníase é diverso, incluindo glomerulonefrites, amiloidose e nefrite túbulo-intersticial. Um homem de 58 anos foi admitido com edema de membros inferiores e dispnéia. Na admissão, havia retenção de escórias nitrogenadas, anemia, hipercalemia e acidose metabólica, com necessidade de hemodiálise. Referia história de hanseníase virchoviana. Foi realizada biopsia renal, compatível com amiloidose. O paciente evoluiu estável, sem recuperação da função renal, permanecendo em tratamento hemodialítico. A hanseníase deve ser investigada em todo paciente com perda de função renal, sobretudo naqueles que apresentam lesões cutâneas ou outras manifestações sugestivas de hanseníase.

A lesão de isquémia/reperfusão em transplante hepático: análise genética, morfológica e correlação clínica

RESUMO: O transplante hepático ortotópico é uma terapêutica aceite para casos selecionados de falência hepática terminal. O procedimento tem-­‐se aperfeiçoado, evidenciado pelo aumento da taxa de sobrevida de 30 para 75% aos 5 anos, mas cerca de 13 a 27% dos enxertos desenvolve falência primária (PNF) ou disfunção primária (DF) após o transplante. As consequências são devastadoras para a sobrevida do doente e do enxerto. A sua etiologia é multifactorial, incluindo factores relacionados com o dador e o receptor, tempos de isquémia, agressões cirúrgicas, bem como características anatomopatológicas do enxerto. A lesão de isquémia/reperfusão mantem-­‐se como um factor de risco intra operatório, com implicações directas sobre toda a evolução do transplante : existe uma relação íntima entre a PNF e a DF, a preservação do enxerto, a lesão de isquémia/reperfusão, e a falência do transplante. Além disso, está comprovada evidência que sugere que a lesão de I/R torna um aloenxerto mais vulnerável por aumento da imunogenicidade, aumentando a probabilidade de episódios de rejeição precoce e tardia. Com base na prática clínica quotidiana do CHBPT HCC, estudaram-­‐se 54 casos de transplante hepático, agrupados segundo grupos por alocação do enxerto respectivo: Grupo 1(n=27): dador cadáver para receptor cirrótico, Grupo 2 (n=15): dador cadáver para receptor PAF, Grupo 3 (n=12): dador PAF para receptor cirrótico. Observaram-­‐se as alterações histológicas e moleculares sobre o enxerto até ao final da operação do receptor, e as suas consequências clínicas,avaliando: -­‐ As diferentes capacidades de resistência e cada enxerto à lesão de isquémia/reperfusão. -­‐ As situações em que os factores do receptor se sobrepõem às do enxerto na definição do prognóstico, e vice versa. -­‐ A relevância das lesões histológicas e moleculares precoces no tecido hepático na evolução do enxerto e do receptor. Foram colhidas biópsias por agulha dos 54 enxertos hepáticos,42 provenientes de cadáver com coração batente(morte cerebral) e 12 provenientes de dador vivo com PAF, em três tempos diferentes do processo de colheita e transplante hepático: ­‐ A primeira(T0)antes da clampagem da aorta do dador -­‐ A segunda (T1) no final da isquémia fria -­‐ A terceira (T2) após a reperfusão do enxerto, durante o encerramento da parede abdominal. A estas amostras foi extraído RNA total, convertido em cDNA por transcrição reversa e feita a análise da expressão dos genes da CTLA4, IL-­‐1β, IL-­‐4, IL-­‐6, IL-­‐13, TNF-­‐α, Perforina, Selectina, (SELE), Fas-­‐ligando, Granzima-­‐B, Heme-­‐Oxigenase 1(HO1)e Óxido Nítrico Sintetase(iNOS2A)por PCR quantitativo segundo o método do Ct comparativo, utilizando como referência a expressão dos genes da amostra não-­‐isquémica –T0. Os fragmentos de todas as biópsias foram seccionados, para envio de amostra comparativa para processamento histológico habitual, sem qualquer alteração ao protocolo seguido habitualmente na Unidade de Transplantação do Hospital Curry Cabral. A presença de alguns parâmetros histológicos definidos, como esteatose, necrose, vacuolização, congestão sinusoidal e infiltração neutrofílica, foi registada e contabilizada numa classificação numérica. O seguimento clínico e laboratorial, bem como o acompanhamento de eventuais complicações, foi registado e correlacionado com os dados das colheitas de órgãos e com os dados das biópsias. Foram consideradas as seguintes variáveis, como as mais relevantes e objectivas para a interpretação da evolução clínica, tendo sido comparadas estatisticamente com os dados recolhidos, laboratoriais e clínicos: disfunção do enxerto, 207 pós operatórias, número de internamentos igual ou superior a 2 e rejeição crónica e/ou morte do receptor. Foram identificadas características clínicas menos favoráveis, a considerar, nalgumas circunstâncias: género feminino do receptor (sobretudo associado a enxerto masculino, p=0,077), isquémia fria superior a 500 minutos (p=0,074), isquémia quente superior a 90 minutos (p=0,099). Na análise laboratorial, distinguiram-­‐se duas características histológicas desfavoráveis e irreversíveis, como índice de mau prognóstico: a necrose e a balonização (p=0,029); no painel genético escolhido neste estudo,a expressão basal de IL-­‐1β(p=0,028), de SELE p=0,013)e de FAS-­‐L (p=0,079)relacionaram-­‐se com pior prognóstico. Algumas características protectoras intrínsecas dos enxertos só se revelaram indirectamente, como menor infiltração neutrofílica e maior expressão de HO1 e de iNOS nos enxertos PAF, não tendo sido possível provar uma interferência directa nos resultados clínicos. Não se obteve expressão mensurável de genes anti-­‐ inflamatórios nas biopsias hepáticas processadas neste estudo, como a IL13 e a I 4: assim, com a metodologia utilizada, não foi possível obter um perfil de expressão genética associado a boa evolução clínica. O perfil inverso foi sugerido apenas pela expressão basal dos 3 genes mencionados (FAS-­‐L,IL-­‐1β e SELE)no mesmo painel, com o protocolo seguido neste conjunto de 54 doentes. As características do receptor sobrepuseram-­‐se às do enxerto no caso de: -­‐ diagnóstico de PAF no receptor, que determinou uma maior predisposição para a disfunção do enxerto, o que, por sua vez, determina uma menor sobrevida. No entanto, o diagnóstico de PAF no receptor exibe uma curva de sobrevida mais favorável. -­‐ receptores com um baixo balanço de risco (BAR)definiram características favoráveis para enxertos com níveis baixos e moderados de esteatose, fazendo que esta característica, definida como um risco acrescido, não só não se manifestasse clinicamente,como parecesse um factor favorável. As características do enxerto sobrepuseram-­‐se às do receptor no caso de: -­‐ tempo de isquémia fria superior a 500 minutos -­‐ balonização, necrose, FAS-­‐L,IL-­‐1β e SELE em T0 A integração dos resultados moleculares e morfológicos com a evolução clínica, realça o papel da mobilização precoce de neutrófilos nos desempenhos menos favoráveis do enxerto hepático. -------------ABSTRACT: Orthotopic liver transplantation is na accepted therapeutic procedure for selected cases of terminal liver failure. The procedure has been improved, evidenced by the rise of survival rates from 30 to 70% at 5 years, but 13 to 27% of the liver grafts develops primary non function (PNF) or primary dysfunction (PDF) after transplantation. The consequences are devastating for the survival of the patient and of the graft. Its etiology is multifactorial, including factos related with the donor and with the recipient, ischemic times, surgical aggressions, as well as the histological characteristics of the graft. The ischemia/reperfusion lesion is still an intraoperative risk factor, with direct implications in the whole transplant outcome: there is a close interrelation between PNF and DF, graft preservation, ischemia / reperfusion lesion and graft failure. Beyond his, there is proved evidence that suggests that I/R lesion turns the allograft more vulnerable by increasing its immunogenity, increasing the probability of precocious and late rejection episodes. Based on the daily clinical practice at CHBPT /HCC, 54 cases of hepatic transplantation have been studied, grouped by allocation of each graft: Group (n=27):deceased do nortocirrhotic recipient, Group 2 (n=15): deceased donor to FAP recipient, Group 3 (n=12): FAP living donor to cirrhotic recipient. The histologic and molecular changes in the liver graft were observed until the end of the recipiente operation,together with its clinical consequences, evaluating:-­‐The different capacity of resistance of each graft to the ischemia / reperfusion lesion -­‐ The situations where the recipiente factos overlap the ones of the graft, in the definition of prognosis, and vice versa.-­‐ The relevance of the precocious histologic and molecular lesions of the hepatic tissue in the clinical outcome of the graft and the recipient. Needle biopsies were obtained from 54 liver grafts, 42 deceased brain dead donors and 12 from FAP living donors, at three diferente times of the harvesting and the hepatic transplantation: The first one (T0) before clamping the donor aorta -­‐ The second one (T2) in the end of cold ischemia time -­‐ The third one (T) after the reperfusion of the graft, during the closure of the abdominal wall. Total RNAwas extracted to these samples, converted to cDNA by reverse transcription and the analysis of gene expression was made for CTLA4,IL-­‐1β,IL-­‐4,IL-­‐6,IL-­‐13,TNF-­‐α,Perforin,E Selectin (SELE),Fas-­‐ligand,Granzyme-­‐B,Heme-­‐oxigenase 1 (HO1) and Nitric Oxide Sintetase (iNOS2A) by quantitative PCR, according with the Ct comparative method, using the expression of the non ischemic sample – T0. The fragments of all the biopsies were divided, to send a comparative sample to the usual histologic processement, keeping the same usual protocol at the Transplantation Unit of Curry Cabral Hospital. The presence of some defined histologic parameters, such as steatosis, necrosis, vacuolization, sinusoidal congestion and neutrophilic infiltration, was registered and catalogued in a numeric classification. The clinical and laboratory follow-­‐up, as well as the following of eventual complications, was registered and correlated with the data from organ procurement operations and with the data from the biopsies. The following variables were considered as the most relevant and objective ones, to the interpretation of the clinical evolution, being statistically compared with the clinical and laboratorial collected data: graft dysfunction, post-­‐operative complications, number of readmissions of 2 or more and chronic rejection and /or recipiente death. There were identified some unfavorable clinical characteristics, to be considered under certain circumstances: recipiente female gender (specially associated with malegraft, p=0,077), cold ischemia time of more than 500 minutes (p=0,074), warm ischemia time of more than 90 minutes (p=0,099). In the laboratory analysis, two histologic characteristics were identified as unfavorable and irreversible, associated with bad prognosis: necrosis and balonization (p=0,029); in the gene panel selected in this study, the basal expression of IL-­‐1β (p=0,028), SELE (p=0,013) and FAS-­‐L (p=0,079)were related with worse prognosis.Some intrinsic protective characteristics of the grafts were only indirectly revealed, such as less neutrophilic infiltration and bigger expression of HO1 and iNOS in FAP grafts, being impossible to prove any direct inte ference in the clinical results. A relevant and measurable expression of the anti inflammatory genes IL13 and IL4 was not obtained: with the used methodology, it was impossible to obtain a gene expression profile associated with a favorable clinical outcome.The inverse profile was suggested only by the basal expression of the three mentioned genes (FAS-­‐L, IL-­‐ 1β e SELE) in the same gene panel, according with the followed protocol in this group of 54 patients. The characteristics of the recipient overlapped those from the graft, in the case of :-­‐ FAP diagnosis in the recipient, which determined a bigger predisposition to graft dysfunction, which by itself determines a shorter survival. However, FAP diagnosis in the recipiente depicts a more favorable survival curve. -­‐ Recipients with a low balance risk índex (BAR) defined favorable characteristics to grafts with low and moderate grades of steatosis, making that this characteristic, associated with bad prognosis, looked like a favorable factor, and with no clinical interference. The graft characteristics overlapped those from the receptor in the case of: -­‐ Cold ischemic time more than 500 minutes -­‐ Balonization, necrosis, FAS-­‐L, IL-­‐1β and SELE at T0. The integration of molecular and morphologic results with the clinical evolution, stresses the role of a precocious neutrophils mobilization in the worse outcomes of liver grafts.

Bioprocess design of canine adenovirus vectors for gene therapy applications

The potential of human adenovirus vectors as vehicles for gene transfer with clinical applications in vaccination, cancer treatment and in many monogenic and acquired diseases has been demonstrated in several studies and clinical trials. However, the clinical use of these vectors can be limited by pre-existing humoral and cellular anti-capsid immunity. One way to circumvent this bottleneck while keeping the advantages of using adenovirus vectors is using non-human viruses such as Canine Adenovirus type 2 (CAV-2). Moreover, CAV-2 vectors present attractive features to develop potential treatment of neurodegenerative and ocular disorders. While the interest in CAV-2 vectors increases, scalable and robust production processes are required to meet the need for preclinical and possibly clinical uses.(...)

Is there space to build one more transshipment terminal within Portuguese territory?

NSBE - UNL

Hepatitis B virus infection in children, adolescents, and their relatives: genotype distribution and precore and core gene mutations

INTRODUCTION:The objectives of this study were evaluate hepatitis B virus (HBV) serological markers in children and adolescents followed up at the Child Institute of the Hospital das Clínicas, Faculdade de Medicina de São Paulo, Universidade de São Paulo; identify chronic HBV carriers and susceptible individuals in the intrafamilial environment; characterize HBV genotypes; and identify mutations in the patients and household contacts. METHODS: Ninety-five hepatitis B surface antigen-positive children aged <19 years and 118 household contacts were enrolled in this study. Commercial kits were used for the detection of serological markers, and PCR was used for genotyping. RESULTS: Hepatitis B e antigen (HBeAg) was detected in 66.3% (63/95) of cases. Three of the 30 HBeAg-negative and anti-HBeAg-positive patients presented with precore mutations and 11 presented with mutations in the basal core promoter (BCP). Genotype A was identified in 39 (43.8%) patients, genotype D in 45 (50.6%), and genotype C in 5 (5.6%). Of the 118 relatives, 40 were chronic HBV carriers, 52 presented with the anti-HBc marker, 19 were vaccinated, and 7 were susceptible. Among the relatives, genotypes A, D, and C were the most frequent. One parent presented with a precore mutation and 4 presented with BCP mutations. CONCLUSIONS: Genotypes A and D were the most frequent among children, adolescents, and their relatives. The high prevalence of HBV in the families showed the possibility of its intrafamilial transmission.

Distribution of QPY and RAH haplotypes of granzyme B gene in distinct Brazilian populations

INTRODUCTION: The cytolysis mediated by granules is one of the most important effector functions of cytotoxic T lymphocytes and natural killer cells. Recently, three single nucleotide polymorphisms (SNPs) were identified at exons 2, 3, and 5 of the granzyme B gene, resulting in a haplotype in which three amino acids of mature protein Q48P88Y245 are changed to R48A88H245, which leads to loss of cytotoxic activity of the protein. In this study, we evaluated the frequency of these polymorphisms in Brazilian populations. METHODS: We evaluated the frequency of these polymorphisms in Brazilian ethnic groups (white, Afro-Brazilian, and Asian) by sequencing these regions. RESULTS: The allelic and genotypic frequencies of SNP 2364A/G at exon 2 in Afro-Brazilian individuals (42.3% and 17.3%) were significantly higher when compared with those in whites and Asians (p < 0.0001 and p = 0.0007, respectively). The polymorphisms 2933C/G and 4243C/T also were more frequent in Afro-Brazilians but without any significant difference regarding the other groups. The Afro-Brazilian group presented greater diversity of haplotypes, and the RAH haplotype seemed to be more frequent in this group (25%), followed by the whites (20.7%) and by the Asians (11.9%), similar to the frequency presented in the literature. CONCLUSIONS: There is a higher frequency of polymorphisms in Afro-Brazilians, and the RAH haplotype was more frequent in these individuals. We believe that further studies should aim to investigate the correlation of this haplotype with diseases related to immunity mediated by cytotoxic lymphocytes, and if this correlation is confirmed, novel treatment strategies might be elaborated.

The first report of infection with Klebsiella pneumoniae carrying the bla kpc gene in State of Mato Grosso do Sul, Brazil

The increased frequency and dissemination of enterobacteria resistant to various antimicrobials is currently worldwide concern. In January 2010, a 94-year-old patient with chronic lymphocytic leukemia was admitted to the University Hospital. This patient died 21 days after hospitalization due to the clinical worsening. Klebsiella pneumoniae producing of extended-spectrum β-lactamases (ESBLs) was isolated of urine culture. This bacterium demonstrated resistance to ceftazidime, ciprofloxacin, levofloxacin, ertapenem and imipenem. Susceptibility to cefoxitin, cefepime, meropenem, colistin and tigecycline. This study reports the first case of infection by Klebsiella pneumoniae carrying the bla kpc gene in the State of Mato Grosso do Sul, Brazil.