Cristina Jorge

Hospital Santa Cruz, San Paulo, São Paulo, Brazil

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Publications (32)58.42 Total impact

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    ABSTRACT: We report the case of an isolated JC virus (JCV) infection, without co-infection by polyoma BK virus (BKV), associated with nephropathy 4 years after kidney transplantation. Clinical suspicion followed the observation of a decrease in estimated glomerular filtration rate (eGFR) and a renal allograft biopsy revealing polyomavirus-associated tubulointerstitial nephritis and positivity for SV40. An in-house real-time polymerase chain reaction assay, targeting the presence of JCV and the absence of BKV in biopsy, confirmed diagnosis. Thirteen months after diagnosis, and following therapeutic measures, eGFR remains stable. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
    Full-text · Article · Jul 2015 · Transplant Infectious Disease
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    ABSTRACT: A 56-year-old African patient received a kidney from a deceased donor with 4 HLA mismatches in April 2013. He received immunosuppression with basiliximab, tacrolimus, mycophenolate mofetil, and prednisone. Immediate diuresis and a good allograft function were soon observed. Six months later, the serum creatinine level increased to 2.6 mg/dL. A renal allograft biopsy revealed interstitial fibrosis and tubular atrophy grade II. Toxicity of calcineurin inhibitor was assumed and, after a switch for everolimus, renal function improved. However, since March 2014, renal function progressively deteriorated. A second allograft biopsy showed no new lesions. Two months later, the patient was admitted due to anuria, haematochezia with anaemia, requiring 5 units of packed red blood cells, and diffuse skin thickening. Colonoscopy showed haemorrhagic patches in the colon and the rectum; histology diagnosis was Kaposi sarcoma (KS). A skin biopsy revealed cutaneous involvement of KS. Rapid clinical deterioration culminated in death in June 2014. This case is unusual as less than 20 cases of KS with gross gastrointestinal bleeding have been reported and only 6 cases had the referred bleeding originating in the lower gastrointestinal tract. So, KS should be considered in differential diagnosis of gastrointestinal bleeding in some kidney transplant patients.
    Full-text · Article · Jan 2015
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    ABSTRACT: Introduction and Aims: The fluid status of hemodialysis patients has been well established as major factor influencing both clinical outcome and treatment costs. So that headway can be made in defining the thresholds for fluid overload, identifying patients at greater risk of fluid overload and the design of optimal treatment strategies, an objective measurement of fluid overload (FO) is necessary. Consequently, a fluid management program (FMP) is being rolled out within NephroCare (Fresenius Medical Care) which operates dialysis services in over 750 clinics in the regions of Europe, Middle East, Africa and Latin America. A hydration status score (HSS) has been incorporated within a NephroCare Balanced ScoreCard (BSC) system to assess treatment quality. Methods: The basis of the FMP is the BCM_Body Composition Monitor. The BCM allows an objective estimation of fluid overload (FO) and each clinic in the NephroCare network performs a measurement on a monthly basis. A patient card allows data to be transferred to a clinical information system. The HSS requires a measure of the relative fluid overload (RelFO) which is determined by dividing the FO by the extracellular water (ECW). This procedure normalises the patient’s fluid status compensating for patients of different body weight. It has been shown previously that there is a survival improvement in those patients where RelFO is maintained below 15%. [Wizemann et al. NDT 2009]. Three ranges for the HSS apply namely less than 15% RelFO, 15% to 20% RelFO and above 15% RelFO. These ranges score the points 1, 0.5 and 0 respectively. We monitored growth of the FMP over the last 2 years and the assessed the recent distribution of FO in those patients measured in the network. Data were interpreted in terms of median and 25th to 75th percentiles. Results: At the time of the August 2013 analysis, with the step rise due to data reported from Latin America the FMP was measuring 32,484 patients with BCM per month, equivalent to >1000 patients/day. See Fig 1. In August 2013, the median, 25th and 75th percentiles of FO were found to be 1.74 L (0.85 L to 2.71 L) as shown in Fig 2. RelFO were 10.74% (5.44% to 15.95%) respectively. Regarding the HSS in August 2013, 71% of patients were <15% RelFO. View larger version: In this window In a new window Download as PowerPoint Slide
    Full-text · Article · May 2014 · Nephrology Dialysis Transplantation
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    ABSTRACT: Introduction and Aims: Vertebral Fractures (VFs) are common in the general population and in Chronic Kidney Disease patients. VFs are associated with vascular calcifications (VCs) and to an increased risk of mortality. The Spine Deformity Index (SDI) is a summary measure of the VFs status, incorporating both the number and severity of VFs in a score. The aim of this study was to evaluate the relationships between the classic SDI, laboratory parameters of bone metabolism, and vascular calcifications within the context of the EVERFRACT study. Methods: In 387 hemodialysis patients, aged 64.2 ± 14.1 years, we determined routine biochemical parameters and: 25(OH)vitamin D, total Bone Gla Protein (BGP), undercarboxylated BGP (ucBGP) and total Matrix Gla Protein (MGP). We performed laterolateral x-Rays of the spine (T5 to L4) to evaluate both VFs (defined as reduction > 20% in vertebral body height) by Quantitative Vertebral Morphometry and VCs, aortic (AoVC) and iliac (IaVC), by Witteman’s method. We divided the SDI score by the number of fractures, in order to obtain a more precise index of fracture severity (corrected-SDI: c-SDI). Results: We found a high prevalence (55.3%, n=214) of VFs. The mean SDI was 1.4 ± 1.74. The mean c-SDI was 0.74 ± 0.75. VFs had a grade of severity that was low through T5-T10 and higher through T11-L3. The severity of fractures was highlighted only by c-SDI (see Table). We found 80.6% of AAoC and 55.6% of IAC. SDI was significantly associated with AAoC (OR=1.15, 95% CI 1.02-1.30, p=0.023). A SDI >1 was significantly associated with: sex (male OR 1.86, 95% CI 1.20-2.91, p=0.007), age (OR 1.03, 95% 1.01-1.05, p=0.0003) and albumin ≥ 3.5 g/dL (OR 0.54, 95% CI 0.31-0.93, p=0.026). c-SDI score was significantly associated with AAoC (OR=1.48, 95% CI 1.11-1.98, p=0.0009) and with IAC (OR=1.54, 95% CI 1.06-2.24, p=0.025). A c-SDI >1 was significantly associated with: age (OR 1.05, 95% CI 1.03-1.07, p<0.0001), LDL Cholesterol ≥ 90 mg/dL (OR 1.74, 95% 1.04-2.92, p=0.0354) and ucBGP ≥ 17.2 mcg/L (OR 0.35, 95% CI 0.18-0.70, p=0.0025). Conclusions: SDI and c-SDI score associated with bone and vascular markers. c-SDI score performed better in the evaluation of the grade of fracture severity and it showed a stronger association with VC and vascular markers. This is the first time that the association of SDI with bone biochemical parameters and VC has been reported. View this table: In this window In a new window
    Full-text · Article · May 2014 · Nephrology Dialysis Transplantation
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    Full-text · Article · Mar 2014

  • No preview · Conference Paper · Jan 2014

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  • No preview · Conference Paper · Jan 2014
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    ABSTRACT: Background: Protein-energy wasting (PEW), associated with inflammation and overhydration, is common in haemodialysis (HD) patients and is associated with high morbidity and mortality. Objective: Assess the relationship between nutritional status, markers of inflammation and body composition through bioimpedance spectroscopy (BIS) in HD patients. Methods: This observational, cross-sectional, single centre study, carried out in an HD centre in Forte da Casa (Portugal), involved 75 patients on an HD programme. In all participating patients, the following laboratory tests were conducted: haemoglobin, albumin, C-reactive protein (CRP) and 25-hydroxyvitamin D3 [25(OH)D3]. The body mass index of all patients was calculated and a modified version of subjective global assessment (SGA) was produced for patients on dialysis. Intracellular water (ICW) and extracellular water (ECW) were measured by BIS (Body Composition Monitor®, Fresenius Medical Care®) after the HD session. In statistical analysis, Spearman’s correlation was used for the univariate analysis and linear regression for the multivariate analysis (SPSS 14.0). A P value of <.05 was considered statistically significant. Results: PEW, inversely assessed through the ICW/body weight (BW) ratio, was positively related to age (p<.001), presence of diabetes (p=.004), BMI (p=.01) and CRP (P=.008) and negatively related to albumin (p=.006) and 25(OH)D3 (p=.007). Overhydration, assessed directly through the ECW/BW ratio, was positively related with CRP (p=.009) and SGA (p=.03), and negatively with 25(OH)D3 (p=.006) and BMI (p=.01). In multivariate analysis, PEW was associated with older age (p<.001), the presence of diabetes (p=.003), lower 25(OH)D3 (p=.008), higher CRP (p=.001) and lower albumin levels (p=.004). Overhydration was associated with higher CRP (p=.001) and lower levels of 25(OH)D3 (p=.003). Conclusions: Taking these results into account, the ICW/BW and ECW/BW ratios, assessed with BIS, have proven to be good markers of the nutritional and inflammatory status of HD patients. BIS may be a useful tool for regularly assessing the nutritional and hydration status in these patients and may allow nutritional advice to be improved and adjusted.
    Full-text · Article · Sep 2013 · Nefrologia: publicacion oficial de la Sociedad Espanola Nefrologia
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    ABSTRACT: Protein-energy malnutrition (PEM) and overhydration are frequent among patients undergoing hemodialysis (HD), both of which are risk factors for mortality. The aim of this study was to investigate if poor nutritional status and overhydration, assessed by bioimpedance spectroscopy (BIS), are associated with a compromise of long-term survival in chronic HD patients. In this 48-month longitudinal prospective, single-center study we assessed body cell mass (BCM), intracellular water (ICW) and extracellular water (ECW) with BIS after HD and correlated them with mortality. We studied 68 prevalent HD patients, with mean age of 63.9±14.9 years, 46% female, 32% diabetics and with mean HD time of 31±26.1 months. Survival analysis was performed by Kaplan-Meier and Cox-regression and a p< 0.05 was considered significant. Patients with BCM < 26.5 Kg (p=0.007) and with ICW/body weight (BW) ratio (inversely associated with PEM) < 0.22 L/Kg (p=0.019) had a significant lower survival. Moreover, patients with ECW/BW ratio (directly associated with overhydration) > 0.21 L/Kg (p=0.04) had a lower survival. After adjustment for baseline characteristics, such as age, diabetes mellitus, HD vintage and albumin, BCM (HR: 0.24; 95% CI: 0.17-0.56), ICW/BW (HR: 0.28; 95% CI: 0.13-0.61) and ECW/BW (HR: 2.6; 95% CI: 1.5-4-6) remained independent predictors of mortality. According to these data, lower BCM, lower ICW/BW ratio and higher ECW/BW ratio, assessed by BIS, are independent predictors of mortality in chronic HD patients. Therefore, measuring body compartments with BIS in HD patients is an important tool to routinely monitor both nutritional and hydration status and to predict these patients prognosis.
    Full-text · Conference Paper · Jun 2013
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    ABSTRACT: Introduction and Aims: Renal allograft recipients with thrombophilia are at higher risk for early allograft loss, microvascular occlusion and acute rejection with major consequences for allograft survival. The aim of the present study was to evaluate the prevalence of prothrombotic risk factors in patients awaiting renal transplantation and its contribution to patient and transplant outcomes. Methods: 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. Results: 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. Conclusions: 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.
    Full-text · Article · May 2013 · Nephrology Dialysis Transplantation
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    ABSTRACT: Background: Hypomagnesaemia is a cardiovascular (CV) risk factor in the general population. The aim of this study was to evaluate the relationship between pre-dialysis magnesium (Mg) and CV risk markers, [including pulse pressure (PP), left ventricular mass index (LVMI) and vascular calcifications (VC)], and mortality in haemodialysis (HD) patients. Methods: We performed a 48-month prospective study in 206 patients under pre-dilution haemodiafiltration with a dialysate Mg concentration of 1 mmol/l. Results: Lower Mg concentrations were predictors of an increased PP (≥65 mm Hg) (p = 0.002) and LVMI (≥140 g/m(2)) (p = 0.03) and of a higher VC score (≥3) (p = 0.01). Patients with Mg <1.15 mmol/l had a lower survival at the end of the study (p = 0.01). Serum Mg <1.15 mmol/l was an independent predictor of all-cause (p = 0.01) and CV mortality (p = 0.02) when adjusted for multiple CV risk factors. Conclusions: Lower Mg levels seem to be associated with increased CV risk markers, like PP, LVMI and VC, and with higher mortality in HD patients.
    No preview · Conference Paper · Jan 2013
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    ABSTRACT: Background: Protein-energy wasting (PEW), associated with inflammation and overhydration, is common in haemodialysis (HD) patients and is associated with high morbidity and mortality. Objective: Assess the relationship between nutritional status, markers of inflammation and body composition through bioimpedance spectroscopy (BIS) in HD patients. Methods: This observational, cross-sectional, single centre study, carried out in an HD centre in Forte da Casa (Portugal), involved 75 patients on an HD programme. In all participating patients, the following laboratory tests were conducted: haemoglobin, albumin, C-reactive protein (CRP) and 25-hydroxyvitamin D3 [25(OH)D3]. The body mass index of all patients was calculated and a modified version of subjective global assessment (SGA) was produced for patients on dialysis. Intracellular water (ICW) and extracellular water (ECW) were measured by BIS (Body Composition Monitor®, Fresenius Medical Care®) after the HD session. In statistical analysis, Spearman´s correlation was used for the univariate analysis and linear regression for the multivariate analysis (SPSS 14.0). A P value of <.05 was considered statistically significant. Results: PEW, inversely assessed through the ICW/body weight (BW) ratio, was positively related to age (p<.001), presence of diabetes (p=.004), BMI (p=.01) and CRP (P=.008) and negatively related to albumin (p=.006) and 25(OH)D3 (p=.007). Overhydration, assessed directly through the ECW/BW ratio, was positively related with CRP (p=.009) and SGA (p=.03), and negatively with 25(OH)D3 (p=.006) and BMI (p=.01). In multivariate analysis, PEW was associated with older age (p<.001), the presence of diabetes (p=.003), lower 25(OH)D3 (p=.008), higher CRP (p=.001) and lower albumin levels (p=.004). Overhydration was associated with higher CRP (p=.001) and lower levels of 25(OH)D3 (p=.003). Conclusions: Taking these results into account, the ICW/BW and ECW/BW ratios, assessed with BIS, have proven to be good markers of the nutritional and inflammatory status of HD patients. BIS may be a useful tool for regularly assessing the nutritional and hydration status in these patients and may allow nutritional advice to be improved and adjusted.
    No preview · Article · Dec 2012 · Nefrologia: publicacion oficial de la Sociedad Espanola Nefrologia
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    ABSTRACT: The new law implemented in August 2007 changed the criteria to select renal transplantation (RT) candidates in Portugal, favoring hyperimmunized subjects and those on the waiting list for a longer time, making human leukocyte antigen (HLA) compatibilities less important. The authors compared patients who received a deceased donor kidney between 2005 and 2010. Patients were divided in group A who underwent transplantation before August 2007 (n = 132) and group B (n = 125) after that date. We considered a value of P < .05. Overall mean age at RT was 46.6 ± 13.9 years with 58.8% men, 88% on hemodialysis (HD), with a mean dialysis time of 82.8 ± 119 months. Also, 10.5% of patients underwent a previous transplantation. The mean follow-up was 35 ± 17.1 months. Group B showed significant adverse differences, including dialysis time (50.9 vs 117 months), length of hospitalization (14.4 vs 23.2 days), need for HD (1 vs 3.4 days), HLA match (3.3 vs 1.4 compatibilities), previous sensitization (4.4% vs 21.7%), acute rejection episodes in the 1st year (23% vs 37%), greater use of immunosuppressive drugs, higher costs of induction therapy (2790 vs 4360ϵ), and greater costs of drugs during first hospitalization (3456 vs 7144ϵ). Among the 16 subjects who lost their grafts, 7 were in group A (3 in the first year) and 9 in group B all in the first year. There was a 5.1% decrease in graft survival at 12 months (P = .07). Univariate analysis showed an association of acute rejection episodes with HLA mismatches, hyperimmunized patients, absence of immediate graft function, hospitalization time, longer HD need, and higher creatinine level at months 1, 2, 3, and 6. Multivariate analysis revealed acute rejection episodes to be associated with a lower number of HLA compatibilities (odds ratio = 0.65; 95% confidence interval, [0.46-0.9]). Application of the law has led to a greater number of acute rejection episodes in the first year and increased costs.
    Full-text · Article · Oct 2012 · Transplantation Proceedings
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    Full-text · Conference Paper · Aug 2012
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    ABSTRACT: The improvement of combined antiretroviral therapy regimens has made solid organ transplantation a therapeutic option for patients with human immunodeficiency virus (HIV) infection. Generally, HIV-2 infectionpresents a slower clinical progression and immunological degradation than HIV-1. HIV-2 infection treatment can be challenging when a complex immunosuppressive regimen is combined with antiretroviraltherapy. The authors report the first case in Portugal of renal transplantation in an HIV-2 patient.
    No preview · Article · Apr 2012
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    ABSTRACT: Background: Transoesophageal echocardiography (TOE) is a widely used imaging modality in ambulatory patients, with a reportedly low complication rate. TOE is frequently performed under conscious sedation. It is the imaging modality of choice for assessment of aortic valve morphology and size prior to trans-catheter aortic valve implantation (TAVI). However, the population of patients undergoing workup for TAVI differs from the general TOE population, as they have been turned down for conventional surgery due to high operative risk. Therefore, we sought to establish whether the complication rate for patients undergoing TOE as part of TAVI work-up is higher than the risk for the general TOE population. Methods: We reviewed the registry of all patients who underwent TAVI work up at our institution and identified patients who underwent TOE as part of TAVI work up. TOE was performed by a cardiologist assisted by a nurse and an echocardiographer. When sedation was used, it was administered by the cardiologist. We calculated logistic Euroscore as a measure of patient risk and reviewed the TOE records for sedation use and major complications (failed procedure, arrhythmia, desaturation, laryngospasm, reversal of sedation, major upper GI bleeding or trauma, death). Minor complications such as sore throat were not recorded. Where there was doubt as to outcome or a complication was documented, a full review of the medical record was performed. Results: We identified 77 patients who underwent TOE during TAVI workup between November 2007 and May 2011. Mean patient age was 83.3 ±6.6 years and 37 (48.1%) patients were aged ≥85y. Median Euroscore was 23.0% (Range 6-69%). Mean FEV1/FVC was 64±12.3%. 44 (57.1%) patients had moderate or severe COPD, defined as FEV1/FVC ratio <70%. 82% of patients underwent TOE under conscious sedation. Median dose of Midazolam administered was 2mg. The TOE probe could not be inserted in 2 (2.6%) patients. No other complications occurred. Conclusion: TOE may safely be performed under sedation in high risk patients undergoing TAVI work up.
    Full-text · Article · Dec 2011 · European Heart Journal – Cardiovascular Imaging

  • No preview · Conference Paper · Jun 2010
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    ABSTRACT: Vitamin D deficiency is highly prevalent in chronic kidney disease. The aim of this study was to evaluate the effects of oral cholecalciferol supplementation on mineral metabolism, inflammation, and cardiac dimension parameters in long-term hemodialysis (HD) patients. This 1-year prospective study included 158 HD patients. Serum levels of 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D [1,25(OH)(2)D], intact parathyroid hormone, and plasma brain natriuretic peptide as well as circulating bone metabolism and inflammation parameters were measured before and after supplementation. Baseline 25(OH)D and 1,25(OH)(2)D levels were measured twice (end of winter and of summer, respectively). Therapy with paricalcitol, sevelamer, and darbepoietin was evaluated. There was an increase in serum 25(OH)D and 1,25(OH)(2)D levels after supplementation. Conversely, serum calcium, phosphorus, and intact parathyroid hormone were decreased. There was a reduction in the dosage and in the number of patients who were treated with paricalcitol and sevelamer. Darbepoietin use was also reduced, with no modification of hemoglobin values. Serum albumin increased and C-reactive protein decreased during the study. Brain natriuretic peptide levels and left ventricular mass index were significantly reduced at the end of the supplementation. Oral cholecalciferol supplementation in HD patients seems to be an easy and cost-effective therapeutic measure. It allows reduction of vitamin D deficiency, better control of mineral metabolism with less use of active vitamin D, attenuation of inflammation, reduced dosing of erythropoiesis-stimulating agents, and possibly improvement of cardiac dysfunction.
    No preview · Article · Mar 2010 · Clinical Journal of the American Society of Nephrology

  • No preview · Conference Paper · Jan 2010