Severe rhabdomyolysis after allogeneic transplantation of facial structures: a case report.

We present a patient with panfacial neurofibromatosis type 1 who underwent allogeneic transplantation of facial structures, which was complicated by severe rhabdomyolysis and temporary oligoanuria. Because of his underlying disease, this 35 year-old man, weighing 68 kg and with a body mass index (BMI) of 27, had undergone 17 operations for resection modeling of hypertrophied tissues, either alone or combined with static suspension techniques. He finally underwent allogeneic transplantation of facial structures. In the early hours of the postoperative period, in the context of a systemic inflammatory response syndrome, he experienced severe rhabdomyolysis, with elevation of the muscle enzyme creatine kinase producing a minor impact on kidney function. The patient was discharged home at 12 weeks after the transplantation.

Kidney failure after heart transplantation.

BACKGROUND AND PURPOSE: Heart transplantation is a procedure with a high mortality rate. Altered kidney function (AKF) after a heart transplant is common. The purpose of this study was to determine the incidence of and associated factors for renal dysfunction among patients who underwent heart transplantation in our hospital between January 2006 and November 2008. PATIENTS AND METHODS: This retrospective observational study was performed on all patients receiving a heart transplant between January 1, 2006 and November 15, 2008. The following variables were recorded: patient comorbidities, indication, presurgical urea and creatinine levels, donor variables, surgical procedure, and postoperative features. RESULTS: A total of 54 heart transplantations were performed with 68.5% of patients being male. The average age at transplant was 49.52 years (±13.45 y) and the mean weight 72.5 kg (±14.8 kg). Overall mortality was 28.30%. Of the 54 patients, 70.4% showed AKF during the first week after transplantation; 30.61% were in stage III according to the Acute Kidney Injury classification. There were no statistically significant differences between the group of patients with versus without renal failure, except for the extracorporeal surgery time, which was significantly longer among those patients who had AKF, and glycemia, which was also higher in the immediate postoperative period. Analysis of patient mortality showed no significant differences for the patients with AKF (80% vs 68.4%; P=31). CONCLUSIONS: The rate of acute kidney failure was high (70.4%), as was the use of chronic renal replacement therapy (28.85%), but it decreased considerably when followed over time.

Considerations regarding major bleeding after cardiac transplantation.

Postoperative bleeding is one of the most frequent complications after cardiac surgery, leading to longer stays in the intensive care unit (ICU) and the hospital as well as increased morbidity and mortality. We designed an observational prospective study to evaluate early complications after cardiac transplantation, focusing on major bleeding and transfusion requirements. We also evaluated whether massive transfusion was related to increased morbidity and mortality. In patients who received ≥6 blood units, we observed significant differences regarding the need for continuous renal replacement techniques (50% vs 12.5%; P=.01) and ICU mortality (33.3% vs 4%; P=.01). This difference in mortality was also observed when comparing plasma transfusion requirements (35.3% vs 9.4%; P=.04). The overall mortality rate was 24.50%, showing significant differences in patients with massive transfusion (83.3% vs 37.8%; P=.008). In conclusion, perioperative bleeding and massive transfusion were associated with increased morbidity and mortality in this group of patients, which may prompt a review of surgical procedures and the introduction of new techniques, such as thromboelastography.

[Evaluation and maintenance of heart donors]. / Evaluación y mantenimiento del donante cardíaco.

Heart transplantation is currently the best treatment option to improve hope and quality of life in patients with terminal heart failure that is refractory to conventional treatment. The scarcity of donors remains a difficult problem and is the main factor limiting the number of transplants that can be performed. Given the current situation of stagnation and disparity between the number of potential organ donors, actual donors, and patients requiring transplants, we need effective strategies to reduce the differences between supply and demand and to ensure the best possible prognosis in organ recipients. These strategies should aim to ensure optimal donor selection. Likewise, it is essential to increase the number of potential donors by widening the criteria for donation and to improve our ability to take advantage of suboptimal donors. Moreover, we need to achieve acceptable physiological maintenance of donated organs. All these actions, together with the standardization of future treatments like hormone replacement therapy and genomic evaluation, will undoubtedly lead to an increase in the rate of transplants in the short and mid term, because the option of heart transplantation continues to have only slight repercussions in the high prevalence of terminal heart failure in our environment.

Evaluación y mantenimiento del donante cardíaco / Evaluation and maintenance of heart donors

Actualmente el trasplante de corazón es la mejor opción terapéutica para aumentar la esperanza y la calidad de vida en los pacientes con insuficiencia cardíaca terminal refractaria al tratamiento convencional. La escasez de donantes es un problema difícil y pendiente de resolver, y constituye el principal factor limitante en el incremento de las cifras de trasplante. En la actual situación de estancamiento y disparidad entre el número de donantes de órganos potenciales, donantes reales y las necesidades clínicas de implantación se requieren estrategias efectivas para reducir esta diferencia y para mantener las mejores posibilidades de éxito en el pronóstico de los receptores. Estas estrategias deben ir dirigidas hacia una óptima selección del donante, así como hacia un incremento del número de potenciales donantes mediante la ampliación de los criterios de aceptación de éstos y hacia una mejora en el aprovechamiento de los donantes subóptimos. Además, debemos lograr un mantenimiento fisiológico adecuado del órgano. Todo este tipo de actuaciones, junto con la estandarización de tratamientos futuros (tratamiento hormonal de reemplazamiento o valoración genómica), nos tiene que llevar, sin duda, a un aumento en las cifras de transplantes a corto y a medio plazo, ya que la opción del transplante cardíaco sigue teniendo escasa repercusión en el gran alto grado de prevalencia de la insuficiencia cardíaca terminal en nuestro medio (AU)

Heart transplantation is currently the best treatment option to improve hope and quality of life in patients with terminal heart failure that is refractory to conventional treatment. The scarcity of donors remains a difficult problem and is the main factor limiting the number of transplants that can be performed. Given the current situation of stagnation and disparity between the number of potential organ donors, actual donors, and patients requiring transplants, we need effective strategies to reduce the differences between supply and demand and to ensure the best possible prognosis in organ recipients. These strategies should aim to ensure optimal donor selection. Likewise, it is essential to increase the number of potential donors by widening the criteria for donation and to improve our ability to take advantage of suboptimal donors. Moreover, we need to achieve acceptable physiological maintenance of donated organs. All these actions, together with the standardization of future treatments like hormone replacement therapy and genomic evaluation, will undoubtedly lead to an increase in the rate of transplants in the short and mid term, because the option of heart transplantation continues to have only slight repercussions in the high prevalence of terminal heart failure in our environment (AU)

Application of the McCluskey Index to predict blood product requirements during liver transplantation.

BACKGROUND: A recent study proposed a risk index (McCluskey index) based on 7 parameters to identify the transfusion needs of patients during surgery and in the first 24 hours postoperation. The initial objective of our study was to validate this predictor for blood product transfusions. PATIENTS AND METHODS: We undertook a retrospective, observational study of all liver transplant patients between January 1, 2005 and December 31, 2006. The following variables were recorded for each patient: age, gender, patient comorbidity, biochemical values prior to liver transplantation, and transfusion needs. RESULTS: Comparing the transfusion needs of those patients with scores <5 with those of scores >/=5, we observed significant differences in terms of the use of red blood cell concentrates, plasma, and platelets, both during the first 24 hours and in the total number. The index sensitivity was 80% (95% confidence interval [CI]: 71.23-88.76), with a specificity of 84.21% (95% CI: 67.81-100), where the positive predictive value was 95.52% (95% CI: 90.57-100.4) and the negative predictive value was 50% (95% CI: 32.67-67.32). CONCLUSION: The McCluskey index showed sufficient sensitivity and specificity to predict which patients will require a massive transfusion.

Comparison between two drugs on the hemodynamic evaluation of pulmonary hypertension prior to heart transplantation.

INTRODUCTION: Invasive estimation of pulmonary pressure is part of the usual protocol prior to heart transplantation. The aim of this study was to compare the results of 2 different vasodilators, nitric oxide (NO) and prostacyclin, in an acute vasodilator test (AVT) for patients with pulmonary venous hypertension. MATERIALS AND METHODS: From January 2000 to December 2006, 94 right-sided heart catheterizations were performed in our center within pretransplantation evaluations. AVT was performed if the mean pulmonary artery pressure (mPAP) >35 mm Hg or if the pulmonary vascular resistance (PVR) was >4 Wood units (WU). Epoprostenol was administered to 40 patients, NO to 6 patients, and both agents to 8 patients. RESULTS: A significant decrease in both mPAP and PVR was shown with maximum doses of epoprostenol, with an average variation of 8.96 mm Hg in mPAP (P < .001) and 3.26 WU in PVR (P < .001). An increased cardiac output (CO) was observed with epoprostenol, with a mean difference of 1.9 L/min (P < .001) at maximum compared with baseline doses. A tendency for the mPAP and PVR to decrease was also observed with maximum NO doses, with mean decreases of mPAP and PVR of 5.62 mm Hg and 1.14 WU, respectively. A tendency for CO to decrease was observed with NO (0.75 L/min; P = .039). CONCLUSIONS: In our experience, NO is the best drug for AVT due to its pulmonary tree selectivity. A study with epoprostenol was complementary; both drugs can be used in these patients prior to heart transplantation.

Correlation of echocardiographic and hemodynamic parameters in pulmonary hypertension assessment prior to heart transplantation.

INTRODUCTION: Invasive assessment of pulmonary artery pressure (PAP), via right heart catheterization, is part of the usual protocol prior to heart transplantation. Echocardiography is considered a valuable technique to evaluate PAP. We sought to determine the reliability of measurements of PAP via a noninvasive technique, echocardiography, in relation to the estimated PAP via right catheterization. We also determined its safety when invasive procedures are restricted to just patients with pulmonary hypertension (PHT) according to echocardiographic parameters. MATERIALS AND METHODS: We performed a retrospective study of 67 right catheterizations performed in our hospital, within the heart transplant study protocol, from January 2000 to December 2006. PAP parameters were estimated by echocardiography and right catheterization. RESULTS: Hemodynamically, 57.1% of the patients had severe PHT (more than 45 mm Hg mean PAP); 13.2% moderate PHT (between 35 and 45 mm Hg mean PAP); 12.1% had mild PHT (between 25 and 35 mm Hg mean PAP); and 17.6% of patients showed no PHT. Pearson correlation index with systolic PAP (estimated via echocardiography) and mean PAP (calculated via invasive method) was 0.69 (P < .001). PHT was considered significant when systolic PAP estimated via echocardiography reached more than 40 mm Hg and mean PAP estimated via right catheterization reached more than 35 mm Hg, the value from which the vasodilator test was carried out. According to these parameters, echocardiography showed a sensitivity of 89% to diagnose significant PHT and 46% specificity, with positive and negative predictive values of 70% and 76%, respectively.