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Clinical Sciences
Cholelithiasis in patients on the kidney transplant waiting list
André Thiago Scandiuzzi BritoI, Luiz Sergio AzevedoII, Willian Carlos NahasII, André Siqueira MatheusI, José JukemuraI
I Disciplina de Cirurgia do Aparelho Digestivo, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
II Unidade de Transplante Renal, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil., Tel.: 55 11 3283.3670,
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Cholelithiasis is one of the most common gastrointestinal diseases&#46; Complications due to cholelithiasis and subsequent hospital admissions are responsible for enhanced morbidity and mortality in addition to large expenses and large numbers of hospital beds needed by these patients&#46; For most surgeons&#44; asymptomatic lithiasis does not require surgical treatment&#44; which is only required in the presence of pain or complications such as cholecystitis&#44; cholangitis&#44; jaundice or pancreatitis&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> However&#44; more severe complications may occur in solid organ transplant patients compared to the normal population&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib6">6</a> The immunosuppression experienced by transplant patients &#40;including the intensity of immunosuppression and type of immunosuppressant drug used&#41; is responsible for this increase in complications&#46;<a class="elsevierStyleCrossRef" href="#bib7">7</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib8">8</a> Based on these data&#44; some authors suggest prophylactic cholecystectomy in asymptomatic patients before they undergo transplants&#44; thereby avoiding serious morbidity and increased mortality&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">The purpose of this paper is to evaluate the prevalence of cholecystopathy in chronic renal patients awaiting kidney transplants&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">PATIENTS AND METHODS</span><p id="para30" class="elsevierStylePara elsevierViewall">We retrospectively reviewed the charts of patients on the waiting list for kidney transplants in our unit&#46; The analysis was performed until December 2007 and included 342 patients from whom routine complete abdominal ultrasound results could be recovered&#46; This ultrasound is performed on all patients as part of the initial evaluation before entering the list&#46; We looked for the presence of gall bladder disease and past history of symptoms of biliary lithiasis&#44; jaundice&#44; pancreatitis or cholecystectomy as well as previous abdominal surgery&#46; We also collected general data&#44; such as gender&#44; age&#44; body mass index&#44; and number of pregnancies&#46; When data were not available from patient charts&#44; personal contact by phone was made to obtain missing data&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">RESULTS</span><p id="para40" class="elsevierStylePara elsevierViewall">Forty-one out of 342 patients &#40;12&#37;&#41; had cholelithiasis&#46; Of these&#44; 12 &#40;29&#37;&#41; had a past history of cholecystectomy due to symptomatic cholelithiasis and 29 &#40;71&#37;&#41; showed current lithiasis&#46; Among the 29 patients who had not undergone operations&#44; 5 were symptomatic&#46; Overall of the 41 patients with cholelithiasis&#44; 17 &#40;41&#46;6&#37;&#41; were symptomatic&#46; Eight patients showed signs of chronic hepatopathy&#44; as shown by enhanced liver echogenicity or portal or hepatic vein size&#46; Only 4 patients had undergone previous abdominal surgeries &#40;appendectomies&#41;&#46;</p><p id="para50" class="elsevierStylePara elsevierViewall">Twenty-five &#40;61&#37;&#41; out of the 41 above mentioned patients were female&#46; Their mean age was 54 years old &#40;range 32&#8211;74&#41;&#44; and their mean body mass index was 25&#46;4&#46; Nineteen women &#40;76&#37;&#41; had previously been pregnant&#44; with an average of 3&#46;6 full-term pregnancies per woman &#40;average of 4&#46;5 pregnancies when abortions were included&#41;&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">DISCUSSION</span><p id="para60" class="elsevierStylePara elsevierViewall">Few studies in Brazil have evaluated the frequency of cholelithiasis&#46; Coelho et al&#46;<a class="elsevierStyleCrossRef" href="#bib9">9</a> studied 1&#44;000 normal adults &#40;who were randomly selected in shopping centers&#41; by abdominal ultrasound and found a gallstone prevalence of 9&#46;3&#37; &#40;12&#46;9&#37; in women and 5&#46;4&#37; in men&#41;&#44; with marked age-dependent differences &#40;2&#46;4&#37; of people 20&#8211;29 years of age vs&#46; 27&#46;5&#37; of people over 70 years old&#41;&#46; Torres et al&#46;<a class="elsevierStyleCrossRef" href="#bib10">10</a> studied 500 people who had undergone an ultrasound and whose complaints were unrelated to the biliary system and found a gallstone frequency of 18&#46;4&#37; &#40;20&#46;8&#37; in women and 16&#37; in men&#41;&#46; These data&#44; as well as data from the international literature&#44; point to a high frequency of asymptomatic cholelithiasis&#44; which may remain quiescent for many years&#46; Therefore&#44; many surgeons suggest a follow-up assessment&#44; indicating surgery only in symptomatic or complicated cases&#46;<a class="elsevierStyleCrossRef" href="#bib11">11</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib14">14</a></p><p id="para70" class="elsevierStylePara elsevierViewall">Laparoscopic cholecystectomy is considered the gold standard for symptomatic uncomplicated cholelithiasis&#46; After its use became widespread&#44; laparoscopic cholecystectomy was shown to have a remarkably lower rate of morbidity and mortality compared to surgery in patients with complicated cholelithiasis&#59; thus&#44; many surgeons proposed laparoscopic surgery for asymptomatic patients in good clinical condition&#46;<a class="elsevierStyleCrossRef" href="#bib15">15</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib17">17</a> This is the policy in our department&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall">Cholecystectomy in asymptomatic candidates and organ transplant patients is also controversial&#46;<a class="elsevierStyleCrossRef" href="#bib18">18</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib23">23</a> Kao et al&#46;<a class="elsevierStyleCrossRef" href="#bib22">22</a> performed an extensive review of the literature on organ transplantation and cholelithiasis&#46; They emphasized a scarcity of data and an absence of controlled studies&#46; These authors pointed out an increased prevalence of gallstones in cardiac patients and patients using cyclosporine &#40;8&#37; when CsA was not used compared to 22&#37; after 2 years of use&#41;&#46; They also reported no difference in diabetic <span class="elsevierStyleItalic">versus</span> non-diabetic patients&#46; The overall prevalence of gallstones in pre-transplant &#40;heart&#44; lung&#44; pancreas&#44; and kidney&#41; patients ranged widely&#44; from 6&#46;9&#37; to 43&#46;8&#37;&#46; In patients receiving a pancreas or kidney alone&#44; the frequency was 9&#46;9&#37;&#46; As the prevalence of gallstones in the general population is estimated to be 10&#8211;20&#37;&#44; it seems that the prevalence of gallstones in kidney transplant candidates is not different from that of the general population&#46; However&#44; the aggregate prevalence of new post-transplant &#40;kidney and pancreas&#41; gallstones is 12&#37;&#46; Pre-transplant elective cholecystectomy in non-cardiac solid organ candidates leads to no enhanced morbidity or mortality&#46; However&#44; when performed in the post-transplant period&#44; the risk of cholecystectomy complications rises to an average of 11&#46;8&#37; morbidity and 1&#46;5&#37; mortality &#40;0&#37; in one study and 6&#46;3&#37; in another&#41;&#44; especially when performed during emergencies&#46; Graham et al&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a> evaluated 551 patients on a transplant waiting list &#40;kidney and pancreas&#41; and found a pre-transplant cholelithiasis prevalence of 10&#37;&#46; Patients who submitted to prophylactic pre-transplant cholecystectomy showed no morbidity or mortality&#46; By contrast&#44; 18&#37; of patients who did not undergo pre-transplant surgery presented biliary complications and were submitted to urgent surgery&#44; resulting in 14&#37; morbidity and 7&#37; mortality&#46; Greenstein et al&#46;<a class="elsevierStyleCrossRef" href="#bib23">23</a> evaluated 211 asymptomatic kidney transplant patients and found a cholelithiasis prevalence of 7&#46;11&#37;&#59; 87&#37; of these patients had remained asymptomatic for five years&#46; Two patients developed acute cholecystitis and underwent uneventful laparoscopic surgeries&#46; They concluded that prophylactic cholecystectomy is not justified in these cases&#46; Melvin et al&#46;<a class="elsevierStyleCrossRef" href="#bib24">24</a> evaluated 662 kidney transplant patients&#59; 144 &#40;21&#46;7&#37;&#41; had previous or current history of biliary tract symptoms or identified gallstones&#46; Sixty nine &#40;48&#37;&#41; out of those had undergone pre-transplant cholecystectomies&#46; Fourteen patients with asymptomatic gallstones had been followed without surgery&#46; Fifty four &#40;37&#37;&#41;&#44; all symptomatic&#44; had undergone cholecystectomy in the post-transplant period&#58; 30 patients &#40;55&#46;5&#37;&#41; laparoscopic&#44; 20 &#40;37&#37;&#41; open cholecystectomy and 2 underwent conversion from laparoscopic to open surgery&#46; Six patients had minor surgical complications with no mortality&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">Our data showed a 12&#37; prevalence of cholelithiasis&#44; a large percentage of these patients were symptomatic &#40;17&#8211;41&#46;6&#37;&#41;&#46; This patient group was at risk for developing post-transplant surgical complications&#44; which may become very serious due to immunosuppression&#46; The purpose of this paper was not to study post-transplant complications due to cholelithiasis&#46; However&#44; it seems logical to perform routine pre-transplant cholecystectomies&#46; These cholecystectomies should be accomplished through laparoscopic methods&#44; which have a very low frequency of morbidity and almost no associated mortality&#46; This practice would prevent potentially serious post-transplant complications&#46; A multicenter randomized trial is recommended to establish the best way to deal with chronic renal failure patients with cholelithiasis&#46;</p></span></span>"
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        "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">OBJECTIVES</span><p id="spara10" class="elsevierStyleSimplePara elsevierViewall">To evaluate the prevalence of cholecystopathy in chronic renal patients awaiting kidney transplants&#46;</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">INTRODUCTION</span><p id="spara20" class="elsevierStyleSimplePara elsevierViewall">The prevalence and management of cholelithiasis in renal transplant patients is not well established&#46;</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">METHODS</span><p id="spara30" class="elsevierStyleSimplePara elsevierViewall">A total of 342 chronic renal failure patients on the waiting list for a kidney transplant were studied&#46; Patients were evaluated for the presence of cholelithiasis and related symptoms&#44; previous cholecystectomies and other abdominal surgeries&#44; time on dialysis&#44; and general data &#40;gender&#44; age&#44; number of pregnancies&#44; and body mass index&#41;&#46;</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">RESULTS</span><p id="spara40" class="elsevierStyleSimplePara elsevierViewall">Cholelithiasis was found in 41 out of 342 patients &#40;12&#37;&#41;&#46; Twelve of these patients&#44; all symptomatic&#44; had previously undergone cholecystectomies&#46; Five out of 29 patients who had not undergone surgery were symptomatic&#46; Overall&#44; 17 patients &#40;41&#46;5&#37;&#41; were symptomatic&#46; Their mean age was 54 &#40;range 32&#8211;74&#41; years old&#59; 61&#37; were female&#44; and their mean body mass index was 25&#46;4&#46; Nineteen &#40;76&#37;&#41; out of 25 women had previously been pregnant&#44; with an average of 3&#46;6 pregnancies per woman&#46;</p></span> <span id="ceabs50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle50">CONCLUSIONS</span><p id="spara50" class="elsevierStyleSimplePara elsevierViewall">The frequency of cholelithiasis was similar to that reported in the literature for the general population&#46; However&#44; the high frequency of symptomatic patients points toward an indication of routine pre-transplant cholecystectomy to avoid serious post-transplant complications&#46;</p></span>"
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      "titulo" => "REFERENCES"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Asymptomatic Cholelithiasis&#58; Is Cholecystectomy Really Needed&#63; A Critical Reappraisal 15 Years After the Introduction of Laparoscopic Cholecystectomy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
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                            2 => """
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                      "doi" => "10.1007/s10620-006-9107-3"
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                        "tituloSerie" => "Dig Dis Sci"
                        "fecha" => "2007"
                        "volumen" => "52"
                        "paginaInicial" => "1313"
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                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17390223"
                            "web" => "Medline"
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            1 => array:3 [
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              "etiqueta" => "2"
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                      "autores" => array:1 [
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                      "Revista" => array:6 [
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                        "volumen" => "169"
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                            "web" => "Medline"
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            2 => array:3 [
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              "etiqueta" => "3"
              "referencia" => array:1 [
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                      "autores" => array:1 [
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                      "Revista" => array:6 [
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                        "fecha" => "2000"
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                      "autores" => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
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                            0 => """
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            7 => array:3 [
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              "referencia" => array:1 [
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                      "autores" => array:1 [
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos