Five year review of open radical nephrectomies at a regional hospital in South Africa: room for improvement

Background:To review the presentation and outcomes of patients undergoing open radical nephrectomy (ORN) for renal cell carcinoma (RCC) at a regional hospital in KwaZulu-Natal, South Africa.Methods:A retrospective chart review was performed of patients having undergone nephrectomy at St Aidan's hospital between 2010 and 2015, focusing on those with RCC. Demographic, operative, histopathology and outcomes data were collected.Results:Fifty-two patients (51%) had ORN for suspected malignant disease. Forty-one RCCs were found including one incidental finding at simple nephrectomy. Data was insufficient to assess risk factors for RCC. HIV positive patients tended to present earlier (45 vs. 53 years). The mean tumour size was 10 cm and organ confined disease was present in 73.2% of patients. Only 11 patients (26.8%) had pT1 disease. The high-grade complication rate was 9.8%, in-hospital mortality rate 4.9% and transfusion rate 51.2%. The median operating time was 1h 50min and length of hospital stay 13 days.Conclusions:Open radical nephrectomy is the standard surgical treatment for RCC at regional level in South Africa. Patients tend to present at a younger age, particularly if HIV positive, and with large tumours. Further research into risk factors for RCC in the South African population is needed. There are high complication and transfusion rates in patients undergoing ORN. Review of accessibility of blood at St Aidan's hospital and revision of the transfusion protocol is suggested. A follow-up study to assess the feasibility and cost-effectiveness of laparoscopic nephrectomy in the resource-constrained South African environment is necessary

TRALI, una amenaza enmascarada: biología y fisiopatología / TRALI, a masked menace: biology and pathophysiology

El daño pulmonar agudo ocasionado por la transfusión o TRALI (por sus siglas en inglés), definido como la aparición de un distrés respiratorio agudo en un paciente recién transfundido, pasó de ser considerado una complicación infrecuente de la terapia transfusional a ser actualmente la principal causa de mortalidad por transfusión, según sistemas de hemovigilancia de Europa y Norteamérica. Su desarrollo en forma clínicamente reconocible se atribuye a la interacción entre factores dependientes de la unidad transfundida (tipo de componente, presencia de sustancias biológicamente activas, etc.) y el estado de las respuestas celulares en el receptor. La heterogeneidad en cuanto al cuadro clínico de los pacientes afectados,la variación en el volumen infundido, el tipo de componente implicado y el tiempo desde el inicio de la transfusión hasta la aparición de los síntomas, ha hecho evolucionar la explicación a la génesis de este evento adverso, en el afán de incluir los casos sin explicación mediante las distintas hipótesis. Dos interesantes acercamientos patogénicos resultan la teoría de dos golpes y el modelo basado en el umbral que impone la relación entre los distintos factores de riesgo. La naturaleza multicausal del TRALI y el sinnúmero de variables que pueden influir en su aparición y reconocimiento, continúan haciendo de este un reto médico importante en el contexto de la medicina transfusional, donde su mejor enfoque terapéutico sigue siendo el preventivo(AU)

Transfusion-related acute lung injury (TRALI) defined as the onset of an acute respiratory distress in a recently transfused patient, has passed from been considered a rare complication of transfusion therapy to be the leading cause of transfusion-associated death, as reported by hemovigilance systems in Europe and America. In a previous paper definition, epidemiology and some clinical aspects of TRALI are reviewed. Now we focused our efforts in reviewing the incompletely understood world of its pathogenesis. Clinically recognizable TRALI´s development depends on the interaction between risk factors from both the transfused component unit (as the kind of component and substances within it) and receiver patient´s cellular response. Heterogeneity of clinical features, transfused volumes, component type and time elapsed from the beginning of transfusion to the onset of symptoms have pushed the explanations for its genesis to evolve in an effort to include as much cases as the different hypotheses allowed. Two interesting approaches to TRALI´s pathogenesis are the two hit; theory and the threshold; model imposed by risk factors interactions. The large diversity of variables and causes which can influence its onset and clinical recognition continue to make it a real challenge for clinicians, mainly within transfusion medicine, where the best therapeutic approach available is prevention(AU)