Retiro precoz de esteroides en la inmunosupresión del trasplante renal pediátrico / Early steroid withdrawal in pediatric renal transplantation

Background: Cardiovascular risk, growth failure and the new immunosuppressive drugs, have encouraged steroid withdrawal or total avoidance with promising results in renal transplant (Tx) immunosuppression. Aim: To evaluate a new immunosuppressor protocol with early withdrawal of steroids in pediatric kidney transplant. Patients and methods: Prospective study in pediatric patients older than 1 year and low immunological risk. Group A (n =28): steroids in decreasing doses until day 7 post Tx, tacrolimus (FK) and micophenolate mofetil (MMF). Group B (n =28) control: steroids, cyclosporine and azathioprine or steroids, FK and MMF. In both groups the induction therapy included basiliximab. Anthropometric and biochemical variables (renal function, lipid profile, hematological, blood glucose and acid-base equilibrium), acute rejection and CMV infection, were evaluated. Mean values and variations for continuous variables were calculated at months 1, 6, 12 and 18. Results: Two children were withdrawn before month 2, one had an untreatable diarrhea and the second died due to Aspergillus septicemia. Mean values at months 1, 6, 12 and 18 for groups A and B: Creatinine clearence (ml/min): 85.4 vs 89; 79.9 vs 83; 89 vs 80; 79.8 vs 80.6 (p: ns); hematocrit ( percent): 28.8 vs 30.4; 31.7 vs 34.4; 34.4; 32.4 vs 34.8; 34.4 vs 35.5 (p: ns). Total cholesterol (mg/dl): 151 vs 206; 139 vs 174; 138 vs 186; 140 vs 180 (p <0.05). Mean delta height/age Z score at the first year: 0.5 vs 0.15; 0.7 vs 0.22; 0.97 vs 0.25 (p <0.05). Mean systolic blood pressure Z score: 0.9 vs 1.5; 0.5 vs 0.9; -0.3 vs 0.8; 0.1 vs 1.0 (p <0.05). The height/age Z score was significantly superior in patients without steroids. A normalization of growth patterns at month 18 was observed (< 0.05). Both groups presented a negative variation of creatinine clearance during the follow-up, but it was minor in the study group (p <0.05). Two acute rejections were found in each group, and no difference in CMV infections...

[Early steroid withdrawal in pediatric renal transplantation]. / Retiro precoz de esteroides en la inmunosupresión del trasplante renal pediátrico.

BACKGROUND: Cardiovascular risk, growth failure and the new immunosuppressive drugs, have encouraged steroid withdrawal or total avoidance with promising results in renal transplant (Tx) immunosuppression. AIM: To evaluate a new immunosuppressor protocol with early withdrawal of steroids in pediatric kidney transplant. PATIENTS AND METHODS: Prospective study in pediatric patients older than 1 year and low immunological risk. Group A (n =28): steroids in decreasing doses until day 7 post Tx, tacrolimus (FK) and mycophenolate mofetil (MMF). Group B (n =28) control: steroids, cyclosporine and azathioprine or steroids, FK and MMF. In both groups the induction therapy included basiliximab. Anthropometric and biochemical variables (renal function, lipid profile, hematological, blood glucose and acid-base equilibrium), acute rejection and CMV infection, were evaluated. Mean values and variations for continuous variables were calculated at months 1, 6, 12 and 18. RESULTS: Two children were withdrawn before month 2, one had an untreatable diarrhea and the second died due to Aspergillus septicemia. Mean values at months 1, 6, 12 and 18 for groups A and B: Creatinine clearance (ml/min): 85.4 vs 89; 79.9 vs 83; 89 vs 80; 79.8 vs 80.6 (p: ns); hematocrit (%): 28.8 vs 30.4; 31.7 vs 34.4; 34.4; 32.4 vs 34.8; 34.4 vs 35.5 (p: ns). Total cholesterol (mg/dl): 151 vs 206; 139 vs 174; 138 vs 186; 140 vs 180 (p <0.05). Mean delta height/age Z score at the first year: 0.5 vs 0.15; 0.7 vs 0.22; 0.97 vs 0.25 (p <0.05). Mean systolic blood pressure Z score: 0.9 vs 1.5; 0.5 vs 0.9; -0.3 vs 0.8; 0.1 vs 1.0 (p <0.05). The height/age Z score was significantly superior in patients without steroids. A normalization of growth patterns at month 18 was observed (< 0.05). Both groups presented a negative variation of creatinine clearance during the follow-up, but it was minor in the study group (p <0.05). Two acute rejections were found in each group, and no difference in CMV infections was observed. CONCLUSIONS: Early steroid withdrawal in pediatric renal transplant recipients was effective and safe and did not increase the risk of rejection.

Changing trends in treatment of substance abuse: a look at some of the factors involved in third-party providers and treatment planning.

In order to better focus our care in providing patients with treatment that matched their needs, an inpatient study was done on patient discharges for 1990 involving 267 patients. Our study points out the influence of the changing drug scene in this country. In approximately 40% of the patients admitted, the drug of choice is other than alcohol. The importance of family and employer involvement in effective treatment stands out. Fewer patients are being admitted but those admitted are sicker and require more treatment. Chemical dependency programs in Louisiana and the United States are experiencing significant declines in the utilization of their service and many are closing. The patient census has been impaired primarily by the expense of or lack of insurance coverage by third-party payors. For patients with insurance coverage the criteria for inpatient treatment by third-party reviewers are so stringent that staff assessment recommendations are frequently over-ruled. Substance abuse is a chronic relapsing illness, yet many insurance companies limit coverage both in time and money. In no other field of medicine do patients leave treatment prematurely as they do in substance abuse.

Reconstrucción biliar experimental con asa interpuesta de yeyuno / Experimental biliar reconstruction with interposal jejunal segment

Se realiza en el perro ligadura del colédoco y derivación biliodigestiva con asa interpuesta de yeyuno. El objetivo central de la experiencia es lograr una dilatación significativa del colédoco, sin signos de colangitis. Este objetivo se logra con la observación de dilatación creciente del colédoco a los 3,6 y 9 meses, con ausencia de signos de colangitis. Esta técnica puede ser valedera para solucionar el grave problema del colédoco fino, lesionado por trauma y/o yatrogenia