Critical analysis of graft loss and death in kidney transplant recipients treated with mTOR inhibitors / Análise crítica da perda do enxerto e óbito em receptores de transplante renal tratados com inibidores da mTOR

Abstract Registry studies and systematic reviews have shown higher risk for mortality and graft loss in patients in use of mTOR inhibitors (mTORi) compared to calcineurin-based (CNI) immunosuppressive regimens. The majority of these studies pooled data from early trials using different strategies such as "de novo" combination of the high dose mTOR inhibitors with standard dose of CNI or high dose mTORi combined with mycophenolate. The large heterogeneity of these initial exploratory studies, many of them no longer in use, turns difficult any comparison with a well-defined standard of care regimen. The new strategies using concentration controlled reduced exposure of mTORi and CNI or early conversion from CNI to mTORi use have shown comparable patient and graft survival. Nevertheless, considering the central role of mTOR in health and disease states, more research is necessary to mitigate the adverse events and to explore further the potential beneficial effects of mTOR inhibitors.

Resumo Estudos de registro e revisões sistemáticas mostraram um aumento de mortalidade e perda do enxerto nos pacientes em uso dos inibidores da mTOR (imTOR) em comparação a regimes baseados nos inibidores de calcineurina (iCN). A maioria destes estudos reuniu dados de ensaios clínicos iniciais utilizando diferentes estratégias, tais como a combinação "de novo" de altas doses de imTOR com doses padrão de iCN ou altas doses de imTOR combinado com micofenolato. A grande heterogeneidade destes estudos exploratórios iniciais, muitos deles não mais em uso, tornam difícil qualquer comparação. As novas estratégias que utilizam a concentração controlada e reduziram a exposição tanto de imTOR quando de iCN mostraram sobrevida do paciente e enxerto comparáveis. No entanto, considerando o papel central dos imTOR nos estados de saúde e doença, é necessária mais investigação para mitigar os eventos adversos e explorar melhor seus potenciais efeitos benéficos.

Immunosuppression status of liver transplant recipients with hepatitis C affects biopsy-proven acute rejection

BACKGROUND/AIMS: The relationship between patient survival and biopsy-proven acute rejection (BPAR) in liver transplant recipients with hepatitis C remains unclear. The aims of this study were to compare the characteristics of patients with and without BPAR and to identify risk factors for BPAR. METHODS: We retrospectively reviewed the records of 169 HCV-RNA-positive patients who underwent LT at three centers. RESULTS: BPAR occurred in 39 (23.1%) of the HCV-RNA-positive recipients after LT. The 1-, 3-, and 5-year survival rates were 92.1%, 90.3%, and 88.5%, respectively, in patients without BPAR, and 75.7%, 63.4%, and 58.9% in patients with BPAR (P<0.001). Multivariate analyses showed that BPAR was associated with the non-use of basiliximab and tacrolimus and the use of cyclosporin in LT recipients with HCV RNA-positive. CONCLUSION: The results of the present study suggest that the immunosuppression status of HCV-RNA-positive LT recipients should be carefully determined in order to prevent BPAR and to improve patient survival.

Meaning of leprosy for people who have experienced treatment during the sulfonic and multidrug therapy periods / Significado da hanseníase para pessoas que viveram o tratamento no período sulfônico e da poliquimioterapia / Significado de la lepra para personas que experimentaron el tratamiento en el período sulfónico y de poliquimioterapia

AbstractObjective: to analyze the meanings of leprosy for people treated during the sulfonic and multidrug therapy periods.Method: qualitative nature study based on the Vigotski's historical-cultural approach, which guided the production and analysis of data. It included eight respondents who have had leprosy and were submitted to sulfonic and multidrug therapy treatments. The participants are also members of the Movement for Reintegration of People Affected by Leprosy.Results: the meanings were organized into three meaning cores: spots on the body: something is out of order; leprosy or hanseniasis? and leprosy from the inclusion in the Movement for Reintegration of People Affected by Leprosy.Conclusion: the meanings of leprosy for people submitted to both regimens point to a complex construction thereof, indicating differences and similarities in both treatments. Health professionals may contribute to the change of the meanings, since these are socially constructed and the changes are continuous.

ResumoObjetivo:analisar significados da hanseníase para as pessoas que foram tratadas no período sulfônico e no período da poliquimioterapia.Método:estudo de natureza qualitativa fundamentado na abordagem histórico-cultural de Vigotski, a qual orientou a construção e análise dos dados. Foram incluídos oito entrevistados que já tiveram hanseníase e que realizaram tratamento no período sulfônico e da poliquimioterapia, sendo participantes do Movimento de Reintegração das Pessoas Atingidas pela Hanseníase.Resultados:os significados foram organizados em três núcleos de significação: manchas no corpo: alguma coisa está fora de ordem; lepra ou hanseníase? e hanseníase a partir da inserção no Movimento de Reintegração das Pessoas Atingidas pela Hanseníase.Conclusão:os significados de hanseníase para pessoas tratadas nos dois períodos apontam para a construção complexa dos mesmos, indicando diferenças e semelhanças nos dois períodos. Os profissionais de saúde podem contribuir para a mudança de significados, pois esses são socialmente construídos e as transformações são contínuas.

ResumenObjetivo:analizar los significados de la lepra para las personas que fueron tratadas en el período sulfónico y en el período de poliquimioterapia.Método:estudio de naturaleza cualitativa fundamentado en el abordaje histórico cultural de Vygotsky, el cual orientó la construcción y análisis de los datos. Fueron incluidos ocho entrevistados que ya tuvieron lepra y que realizaron tratamiento en el período sulfónico y de poliquimioterapia, siendo participantes del Movimiento de Reintegración de Personas Afectadas por la Lepra.Resultados:los significados fueron organizados en tres núcleos de significación: manchas en el cuerpo: alguna cosa está fuera de orden; ¿Lepra o enfermedad de Hansen?; y lepra a partir de la inserción en el Movimiento de Reintegración de Personas Afectadas por la Lepra. Conclusión: los significados de la lepra para las personas tratadas en los dos períodos apuntan para la construcción compleja de los mismos, indicando diferencias y semejanzas en los dos períodos. Los profesionales de la salud pueden contribuir para el cambio de significados, ya que estos son socialmente construidos y las transformaciones son continuas.

Accuracy of the Timed Up and Go test for predicting sarcopenia in elderly hospitalized patients

OBJECTIVES: The ability of the Timed Up and Go test to predict sarcopenia has not been evaluated previously. The objective of this study was to evaluate the accuracy of the Timed Up and Go test for predicting sarcopenia in elderly hospitalized patients. METHODS: This cross-sectional study analyzed 68 elderly patients (≥60 years of age) in a private hospital in the city of Salvador-BA, Brazil, between the 1st and 5th day of hospitalization. The predictive variable was the Timed Up and Go test score, and the outcome of interest was the presence of sarcopenia (reduced muscle mass associated with a reduction in handgrip strength and/or weak physical performance in a 6-m gait-speed test). After the descriptive data analyses, the sensitivity, specificity and accuracy of a test using the predictive variable to predict the presence of sarcopenia were calculated. RESULTS: In total, 68 elderly individuals, with a mean age 70.4±7.7 years, were evaluated. The subjects had a Charlson Comorbidity Index score of 5.35±1.97. Most (64.7%) of the subjects had a clinical admission profile; the main reasons for hospitalization were cardiovascular disorders (22.1%), pneumonia (19.1%) and abdominal disorders (10.2%). The frequency of sarcopenia in the sample was 22.1%, and the mean length of time spent performing the Timed Up and Go test was 10.02±5.38 s. A time longer than or equal to a cutoff of 10.85 s on the Timed Up and Go test predicted sarcopenia with a sensitivity of 67% and a specificity of 88.7%. The accuracy of this cutoff for the Timed Up and Go test was good (0.80; IC=0.66-0.94; p=0.002). CONCLUSION: The Timed Up and Go test was shown to be a predictor of sarcopenia in elderly hospitalized patients. .

Predictive factors of early graft loss in living donor liver transplantation / Fatores preditivos da perda precoce do enxerto hepático em transplante hepático intervivos

CONTEXT: Living donor liver transplantation has become an alternative to reduce the lack of organ donation. OBJECTIVE: To identify factors predictive of early graft loss in the first 3 months after living donor liver transplantation. METHODS: Seventy-eight adults submitted to living donor liver transplantation were divided into group I with 62 (79.5%) patients with graft survival longer than 3 months, and group II with 16 (20.5%) patients who died and/or showed graft failure within 3 months after liver transplantation. The variables analyzed were gender, age, etiology of liver disease, Child-Pugh classification, model of end-stage liver disease (MELD score), pretransplantation serum sodium level, and graft weight-to-recipient body weight (GRBW) ratio. The GRBW ratio was categorized into < 0.8 and MELD score into >18. The chi-square test, Student t-test and uni- and multivariate analysis were used for the evaluation of risk factors for early graft loss. RESULTS: MELD score <18 (P<0.001) and serum sodium level > 135 mEq/L (P = 0.03) were higher in group II than in group I. In the multivariate analysis MELD scores > 18 (P<0.001) and GRBW ratios < 0.8 (P<0.04) were significant. CONCLUSIONS: MELD scores >18 and GRBW < 0.8 ratios are associated with higher probability of graft failure after living donor liver transplantation.

CONTEXTO: O transplante hepático intervivos constitui alternativa para amenizar a falta de doação de órgãos. OBJETIVO: Identificar os fatores preditivos da perda precoce do enxerto hepático nos 3 primeiros meses após transplante hepático intervivo. MÉTODOS: Setenta e oito adultos submetidos ao transplante de fígado intervivos foram divididos em grupo I com 62 (79,5%) doentes com sobrevivência do enxerto superior a 3 meses, e grupo II com 16 (20,5%) que faleceram e/ou apresentaram falha do enxerto até 3 meses após o transplante hepático. As variáveis analisadas foram: sexo, idade, origem da doença hepática, classificação de Child-Pugh, critério MELD, nível sérico de sódio pré-transplante e relação GRBW. O critério MELD foi categorizado em > 18 e a relação GRBW em < 0,8. Na avaliação dos fatores de risco para perda precoce do enxerto hepático foi utilizada a análise uni e multivariada. RESULTADOS: Critério MELD <18 (P = 0,001) e nível sérico de sódio >135 mEq/L (P = 0,03) foram maiores nos doentes do grupo II. A probabilidade de perda do enxerto no transplante hepático intervivos teve como variáveis independentes o índice MELD > 18 e a relação GRBW< 0,8. CONCLUSÃO: Os valores de MELD >18 e GRBW <0,8 estão associados com maior probabilidade de insucesso no transplante hepático intervivos.

Causas de muerte en pacientes con un injerto renal funcionante: ¿Han ocurrido cambios en las últimas décadas? / Causes of death with a functioning graft among kidney allograft recipients

Background: Death with a functioning graft (DWGF) is now one of the main causes of renal transplant (RTx) loss. Aim: To determine whether the causes of DWGF, characteristics of donors and recipients and complications of RTx have changed in the last two decades. Subjects and Methods: Cooperative study of a cohort of 418 kidney grafts performed between 1968 and 2010. Patients were divided into two groups according to whether their kidney transplants were performed between 1968 and 1992 (Group 1) or 1993 and 2010 (Group 2). Results: Sixty eight patients experienced DWGF. Infections were the leading cause of DWGF in both groups (38 and 41%, respectively), followed by cardiovascular diseases (24 and 23% respectively), gastrointestinal disorders (21 and 26% respectively) and cancer (17 and 10% respectively). There were no significant differences in causes of death between the two groups according to the time elapsed since the renal transplantation. In patients in Group 1, the interval between diagnosis of renal failure and dialysis (HD) and the interval between the start of HD and kidney transplantation were significantly lower than in Group 2. The former had also an increased number of acute rejections in the first five years of kidney transplantation (p < 0.001). In Group 2, patients more often received their kidneys from deceased donors, had previous kidney transplantation, higher rate of antibodies to a panel of lymphocytes and an increased incidence of cardiovascular disorders after five years of RTx. Conclusions: The proportion of graft loss due to DWGF has increased over the last 2 decades, but its causes have not changed significantly. Infections are the most common causes of DWGF followed by cardiovascular and digestive diseases.

Prospective Controlled Protocol for Three Months Steroid Withdrawal with Tacrolimus, Basiliximab, and Mycophenolate Mofetil in Renal Transplant Recipients

During the past few years, new immunosuppressants, such as tacrolimus, mycophenolate mofetil (MMF) and basiliximab, have been shown to successfully decrease the incidence of acute rejection, possibly acting as potent substrates for safe steroid withdrawal. Therefore, clinical outcome of 3 months steroid withdrawal, while using the above immunosuppressants, was analyzed. Clinical trial registry No. was NCT 01550445. Thirty de novo renal transplant recipients were enrolled, and prednisolone was slowly withdrawn 3 months post-transplantation by 2.5 mg at every two weeks, until 8 weeks. During steroid withdrawal, 10 patients (30.0%) discontinued the protocol and they were maintained on steroid treatment. Among 20 steroid free patients, 8 patients (40.0%) re-started the steroid within 12 months post-transplantation. By the study endpoint, 12 (40%) recipients did not take steroid and survival of patients and grafts was 100%. In conclusion, in kidney transplant patients, 3 months steroid withdrawal while taking tacrolimus, basiliximab and mycophenolate mofetil was not associated with increased mortality or graft loss. Despite various causes of failure of steroid withdrawal during the follow-up period, it is a strategy well advised for kidney transplant recipients with regard to long-term steroid-related complications.

Prospective Controlled Protocol for Three Months Steroid Withdrawal with Tacrolimus, Basiliximab, and Mycophenolate Mofetil in Renal Transplant Recipients

During the past few years, new immunosuppressants, such as tacrolimus, mycophenolate mofetil (MMF) and basiliximab, have been shown to successfully decrease the incidence of acute rejection, possibly acting as potent substrates for safe steroid withdrawal. Therefore, clinical outcome of 3 months steroid withdrawal, while using the above immunosuppressants, was analyzed. Clinical trial registry No. was NCT 01550445. Thirty de novo renal transplant recipients were enrolled, and prednisolone was slowly withdrawn 3 months post-transplantation by 2.5 mg at every two weeks, until 8 weeks. During steroid withdrawal, 10 patients (30.0%) discontinued the protocol and they were maintained on steroid treatment. Among 20 steroid free patients, 8 patients (40.0%) re-started the steroid within 12 months post-transplantation. By the study endpoint, 12 (40%) recipients did not take steroid and survival of patients and grafts was 100%. In conclusion, in kidney transplant patients, 3 months steroid withdrawal while taking tacrolimus, basiliximab and mycophenolate mofetil was not associated with increased mortality or graft loss. Despite various causes of failure of steroid withdrawal during the follow-up period, it is a strategy well advised for kidney transplant recipients with regard to long-term steroid-related complications.

Small bowel transplantation in outbred rats / Transplante de intestino delgado em ratos não-isogênicos

PURPOSE: To investigate the clinical evolution of orthotopic small bowel transplantation in outbred rats. METHODS: Seventy-two outbred Wistar rats weighting from 250 to 300g were used as donor and recipient in 36 consecutives ortothopic small intestine transplantation without immunosuppression. The graft was transplanted into the recipient using end-to-side aortic and portacaval microvascular anastomosis. Procedure duration, animal clinical course and survival were evaluated. Survival shorter than four days was considered technical failure. Recipients were sacrificed with signs of severe graft rejection or survival longer than 120 days. Necropsies were performed in all recipients to access histopathological changes in the graft. RESULTS: Median time for the procedure was 107 minutes. Six recipients (16.7 percent) presented technical failure. Twenty-seven recipients were sacrificed due to rejection, being nineteen (52.7 percent) between 7th and 15th postoperative day and eight (22.2 percent) between 34th and 47th postoperative day. Graft histology confirmed severe acute cellular rejection in those recipients. Uneventful evolution and survival longer than 120 days without rejection were observed in three recipients (8.3 percent). CONCLUSION: Intestinal transplantation in outbred rats without immunosuppressant regiment accomplishes variable clinical evolution.

OBJETIVO: Investigar a evolução clínica do transplante de intestino delgado ortotópico em ratos não-isogênicos. MÉTODOS: Setenta e dois ratos Wistar não-isogênicos, com peso variando entre 250 e 300g, foram utilizados como doadores e receptores em 36 transplantes ortotópicos de intestino delgado sem regime de imunossupressão. Os enxertos foram implantados nos receptores por meio de anastomose microvascular término-lateral aorta-aorta e porto-cava. A duração do procedimento, evolução clínica dos animais e sobrevida foram avaliados. Sobrevida menor que quatro dias foi considerada falha técnica. Os receptores foram sacrificados quando apresentaram sinais de rejeição grave do enxerto ou sobrevida maior que 120 dias. Necropsias foram realizadas em todos os receptores para avaliar alterações histopatológicas no enxerto. RESULTADOS: O tempo médio para o procedimento foi de 107 minutos. Seis receptores (16,7 por cento) apresentaram falha técnica Vinte e sete receptores (75 por cento) foram sacrificados por rejeição sendo dezenove (52,7 por cento) entre o 7º e 15º dia de pós-operatório e oito (22,2 por cento) entre o 34º e 47º. Análise histopatológica confirmou rejeição celular aguda severa nesses recipientes. Evolução sem complicações e sobrevida maior que 120 dias sem sinais de rejeição foi observada em três receptores (8,3 por cento). CONCLUSÃO: O transplante de intestino delgado ortotópico em ratos Wistar não-isogênicos sem regime de imunossupressão apresenta evolução clínica variada.

Heart Transplantation in Pediatric Patients: Twelve-Year Experience of the Asan Medical Center

Heart transplantation is a standard treatment for end-stage heart disease. Pediatric heart transplantation, however, is not frequently performed due to the shortage of pediatric heart donors. This is the first report of pediatric heart transplantation in Korea. Our retrospective study included 37 patients younger than 18 yr of age who underwent heart transplantation at Asan Medical Center between August 1997 and April 2009. Preoperative diagnosis was either cardiomyopathy (n = 29, 78.3%) or congenital heart disease (n = 8, 22.7%). Mean follow up period was 56.9 +/- 44.6 months. There were no early death, but 7 late deaths (7/37, 18.9%) due to rejection after 11, 15, 41 months (n = 3), infection after 5, 8, 10 months (n = 3), suspicious ventricular arrhythmia after 50 months (n = 1). There was no significant risk factor for survival. There were 25 rejections (25/37, 67.6%); less than grade II occurred in 17 patients (17/25, 68%) and more than grade II occurred in 8 patients (8/25, 32%). Actuarial 1, 5, and 10 yr survival was 88.6%, 76.8%, and 76.8%. Our midterm survival of pediatric heart transplantation showed excellent results. We hope this result could be an encouraging message to do more pediatric heart transplantation in Korean society.

Long-term Mortality in Adult Orthotopic Heart Transplant Recipients

Heart transplantation is now regarded as the treatment of choice for end-stage heart failure. To improve long-term results of the heart transplantation, we analyzed causes of death relative to time after transplantation. A total of 201 consecutive patients, 154 (76.6%) males, aged > or = 17 yr underwent heart transplantation between November 1992 and December 2008. Mean ages of recipients and donors were 42.8 +/- 12.4 and 29.8 +/- 9.6 yr, respectively. The bicaval anastomosis technique was used since 1999. Mean follow up duration was 6.5 +/- 4.4 yr. Two patients (1%) died in-hospital due to sepsis caused by infection. Late death occurred in 39 patients (19.4%) with the most common cause being sepsis due to infection. The 1-, 5-, and 10-yr survival rates in these patients were 95.5% +/- 1.5%, 86.9% +/- 2.6%, and 73.5% +/- 4.1%, respectively. The surgical results of heart transplantation in adults were excellent, with late mortality due primarily to infection, malignancy, and rejection. Cardiac deaths related to cardiac allograft vasculopathy were very rare.

HBsAg as predictor of outcome in renal transplant patients

Las hepatitis virales crónicas causadas por los virus B y C son un problema común en los pacientes trasplantados renales. No hay un consenso en cuanto a su influencia en la evolucíon del injerto y la sobrevida de los pacientes trasplantados renales. Evaluamos en forma retrospectiva la influencia de la positividad de antiHBc, antiHCV y HBsAg; sexo; edad mayor de 50 años al momento del trasplante; elevación de la alaninaminotransferasa en el período pre y postrasplante; rechazo agudo; tipo de injerto; número de trasplantes; y tratamiento inmunosupresor en la sobrevida del injerto renal y del paciente en los pacientes trasplantados en nuestro centro entre 1991 y 1998. El análisis univariado mostró que la presencia de antiHBc, anti HCV y HBsAg, más de un trasplante renal y uno o más episodios de rechazo agudo se asociaron con una disminución en la sobrevida de los pacientes. El análisis multivariado mostró que la presencia de positividad para HBsAg y uno o más episodios de rechazo agudo se asociaron con una disminución en la sobrevida del injerto, y ninguna de las variables se asoció con una disminución en la sobrevida de los pacientes. En conclusión: la presencia de antiHCV y HBsAg se asoció con un mayor riesgo de muerte, aunque esto no fue estadísticamente significativo.

Transplante cardíaco ortotópico: experiência na Universidade Federal de Säo Paulo / Orthotopic heart transplants: experience of the Universidade de Säo Paulo

From November, 1986 to April, 1997; 92 orthotopic heart transplants were performed, with recipient mean age of 44,9 years (range 3 to 63 years). Recipient diagnoses included dilated cardiomyopathy in 42 (44.6 per cent) ischemic cardiomyopathy in 23 (25 per cent), Chagas disease in 21 (22.8 per cent), valve disease in 3 (3.2 per cent) patients. The surgical technique used (described by Lower e Shumway, in 1960, with minor modification) was satisfactory and without complication. Graft ischemic time - Longer in heart transported from other institutions compared to side-by-side transplantation - was always less than 4 hours. The most common chronic complications of immunosuppressive therapy were: arterial hyperthension (84.6 per cent), hyperuricemia (75.4 per cent) and hypercholesterolemia (63 per cent). Regarding infections, viral were the most common ones with 92 (45.6 per cent) followed by bacterial with 35 (38.0 per cent), and protozoal with 15 (16.3 per cent) cases. Among bacterial infections, 7 occurred in the surgical wound, with good evolution. Among those infections caused by protozoal, 7 (46.6 per cent) were due to Trypanossoma cruzi. The overall mortality rate within 30 days of transplantation was 17.3 per cent, with infection, neurologic complications and rejection as major causes. From 30 days to 1 year of transplantation, the mortality rate was 10.3 per cent, with infection and rejection as primary causes. And after one year post-transplantation, the mortality rate was 14 per cent, with several different causes: sudden death, infection, rejection and others. The actuarial survival estimates at 1, 2, 3, 4, 5, and 6 years were 71.6 per cent, 66.5 per cent, 60.5 per cent, 54.4 per cent, 54.4 per cent and 54.4 per cent, respectively. There were no follow-up losses, and all the surviving patients are in functional type I of the NYHA. Cardiac transplantation procedure is possible in our community with accetable survival and post-operative complication rates acceptable, even though different from international statistics.

Anestesia general para el paciente transplantado / General anesthesia in transplanted patients

Con el incremento del número de transplantes cardíacos y cardiopulmonares y la mayor supervivencia de los mismos, se han comenzado a ver pacientes transplantados a los que es necesario realizarle algún otro tipo de procedimiento quirúrgico. Las cirugías que son necesario efectuarles pueden o no estar relacionadas con el transplante a que fueron sometidos (broncoscopías para detectar rechazo, reemplazo de cadera por osteoporosis por corticoides, etc.). En general los pacientes transplantados reciben una gama de drogas que debemos relacionar con el tipo de anestesia por las posibles interacciones medicamentosas. Además es importante tener en cuenta que los órganos transplantados, por la denervación, responden a las drogas en forma diferente a los pacientes comunes.

Informe del primer trasplante de bloque cardiopulmonar realizado en México / Report of the first cardiopulmonar block transplantation performed in Mexico

Objetivo: Informar sobre el primer trasplante cardiopulmonar que se realiza en México. Diseño: Informe de caso clínico. Se trató de paciente femenino de 47 años de edad, con hipertensión pulmonar severa y defecto septal auricular en clase funcional III. El día 4 de junio de 1995, en el Hospital de Cardiología del Centro Médico Nacional Siglo XXI se obtuvo bloque cardiopulmonar a partir de donación múltiple y se traspantó a la paciente. Resultados: El tiempo de hipotermia isquémica fue de 3 horas. La actividad cardíaca reinició a los 14 segundos de reperfusión. El destete de la derivación cardiopulmonar se efectuó sin problemas. A las 36 horas presentó abdomen agudo por hemoperitoneo, se requirió laparotomía por hemostasia, además de detectarse pancreatitis. El bloque cardiopulmonar funcionó adecuadamente por 5 días al cabo de los cuales presentó aumento de cortocorcuitos, hipoxemia, bajo gasto cardíaco y falleció al sexto día. El informe de la autopsia fue: pancreatitis edematosa, rechazo de corazón y pulmón, cambios isquémicos del miocardio y edema pulmonar. Conclusión: Es factible realizar trasplante cardiopulmonar en nuestro país. Las complicaciones coinciden con las descritas en la literatura mundial