Subject(s)
Glomerulosclerosis, Focal Segmental/blood , Glomerulosclerosis, Focal Segmental/etiology , Kidney Transplantation/adverse effects , Nitric Oxide/blood , Adult , Disease Progression , Female , Glomerulosclerosis, Focal Segmental/complications , Humans , Immunosuppressive Agents/therapeutic use , Plasmapheresis , Proteinuria/etiology , Proteinuria/physiopathology , RecurrenceABSTRACT
BACKGROUND: Management of patients with co-existent coronary and carotid disease is a controversial and challenging issue. The risk for stroke after coronary artery bypass grafting (CABG) in patients with hemodynamically significant carotid stenosis is up to 30%. In these patients a common practice is to proceed first with the restoration of cerebral perfusion and then perform the coronary revascularization. The rationale is that this strategy will reduce perioperative neurological morbidity and mortality. However, what happens when the carotid procedure is acutely complicated by cardiac instability which necessitates the interruption of the carotid procedure? CASE REPORT: We describe a case of a patient with unstable angina and high grade asymptomatic bilateral carotid stenosis who underwent emergency combined CABG and carotid endarterectomy (CEA). Due to hemodynamic instability, ST-T changes, hypotension and bradycardia, upon completion of endarterectomy we placed a carotid shunt and the patient was put on cardiopulmonary bypass through median sternotomy. After triple CABG (duration of 90 minutes) we concluded the interrupted CEA procedure with primary closure of the carotid arteriotomy with the shunt in place. The postoperative course was uneventful and the patient was discharged after a week. In extreme cases with bilateral severe carotid stenosis and coronary artery disease where the carotid procedure should be interrupted, we suggest the use of carotid shunt which can provide adequate cerebral perfusion giving time to cardiac surgeon to perform the life saving cardiac procedure first.
Subject(s)
Carotid Artery, Internal/surgery , Carotid Stenosis/surgery , Coronary Artery Bypass/methods , Coronary Artery Disease/surgery , Endarterectomy, Carotid/methods , Extracorporeal Circulation/methods , Stroke/prevention & control , Aged, 80 and over , Carotid Stenosis/complications , Carotid Stenosis/diagnosis , Coronary Angiography , Coronary Artery Disease/complications , Coronary Artery Disease/diagnostic imaging , Electrocardiography , Follow-Up Studies , Humans , Male , Stroke/etiology , Ultrasonography, Doppler, DuplexABSTRACT
BACKGROUND: The objective of this study was to examine whether there was an association between acute rejection (AR) and nitric oxide (NO) levels and also to evaluate the clinical impact of NO measurement as a noninvasive marker for early detection of AR. METHODS: Fifty consecutive patients aged 17-62 years old received a living-related kidney graft. Serum levels of total nitrite and nitrate (NOx) were measured 30 min after graft reperfusion (NOx 1) and on days 1 (NOx 2), 5 (NOx 3), and 10 (NOx 4) post-transplantation (Tx). If clinically indicated, graft biopsy was performed. RESULTS: Acute humoral rejection was diagnosed by biopsy on 3rd post-Tx day in one patient. His serum NOx 2 levels were remarkably higher (380%) compared with his NOx 1 measurement. At the same time, NOx 1-2 measurements in uncomplicated group showed lower levels (-12%). Additionally, during the first month post-Tx, 5 cases of acute cellular rejection (ACR) were diagnosed. The mean percent change of NOx 3-4 levels in ACR group was 180.7 versus 16.1 in uncomplicated patients (P < 0.01). In addition, >70 µmol/L change in NOx levels in consecutive samples had a sensitivity of 100% and a specificity of 97.7% in predicting AR episodes. CONCLUSION: Our study reports significant increase in serum NOx levels in episodes of AR. NOx might be an useful noninvasive marker for early diagnosis of AR.
