Graft Survival in Liver Transplantation: An Artificial Neuronal Network Assisted Analysis of the Importance of Comorbidities.

OBJECTIVES: Liver transplant represents a widespread therapeutic option for patients with end-stage liver failure. Up to now, most of the scores describing the probability of liver graft survival have shown poor predictive performance. With this in mind, the present study seeks to analyze the predictive value of recipient comorbidities on liver graft survival within the first year. MATERIALS AND METHODS: The study included prospectively collected data from patients who received a liver transplant at our center from 2010 to 2021. A predictive model was then developed through an Artificial Neural Network that included the parameters associated with graft loss as identified by the Spanish Liver Transplant Registry report and comorbidities with prevalence >2% present in our study cohort. RESULTS: Most patients in our study were men (75.5%); mean age was 54.8 ± 9.6 years. The main cause of transplant was cirrhosis (86.7%), and 67.4% of patients had some associated comorbidities. Graft loss due to retransplant or death with dysfunction occurred in 14% of cases. Of all the variables analyzed, we found 3 comorbidities associated with graft loss (as shown by informative value and normalized informative value, respectively): antiplatelet and/or anticoagulants treatments (0.124 and 78.4%), previous immunosuppression (0.110 and 69.6%), and portal thrombosis (0.105 and 66.3%). Remarkably, our model showed a C statistic of 0.745 (95% CI, 0.692-0.798; asymptotic P < .001), which was higher than others found in previous studies. CONCLUSIONS: Our model identified key parameters that may influence graft loss, including specific recipient comorbidities. The use of artificial intelligence methods could reveal connections that may be overlooked by conventional statistics.

Graft Risk Index After Liver Transplant: Internal and External Validation of a New Spanish Indicator.

OBJECTIVES: Scarcity of liver grafts has led to the use of marginal donors, consequently increasing the number of complications posttransplant. To prevent this situation, several indicators have been developed. However, important differences remain among countries. Here, we compared an early-risk liver transplant indicator based on the Spanish Liver Transplant Registry, called the Graft Risk Index, versus the US donor risk index and the Eurotransplant donor risk index. MATERIALS AND METHODS: The new indicator was based on prospectively collected data from 600 adult liver transplants performed in our center. We considered 2 events to compare the indexes: graft survival and rejection-free graft survival, with Cox proportional regression for analyses. Power to predict graft survival was evaluated by calculating the receiver operating characteristic area under the curve. RESULTS: We found no differences between the US and Eurotransplant donor risk indexes in prediction of patients with and without early graft failure. With regard to early survival, only the Graft Risk Index allowed better survival discrimination, in which survival progressively decreased with values ≥ 3 (with probability of graft survival at 1 month of 68%; 95% confidence interval, 46.2-82.5). This increase in risk was significant compared with the standard group (hazard ratio of 10.15; 95% confidence interval, C 3.91- 26.32; P < .001). We calculated powers of prediction of 0.52 (95% confidence interval, 0.43-0.62), 0.54 (95% confidence interval, 0.45-0.65), and 0.69 (95% confidence interval, 0.61-0.77) for donor risk index, Eurotransplant donor risk index, and early Graft Risk Index, respectively. CONCLUSIONS: Neither the US donor risk index nor the Eurotransplant donor risk index was valid for our Spanish liver donation and transplant program. Therefore, an indicator to predict posttransplant graft survival that is adapted to our environment is necessary. This national Graft Risk Index can be a useful tool to optimize donor-recipient matching.

Influence of gender on prognosis of acute coronary syndromes.

INTRODUCTION: Ischemic heart disease presents different features in men and women. We analyzed the relation between gender and prognosis in patients who had suffered a high-risk acute coronary syndrome (ACS). METHODS: This was a prospective analytical cohort study performed at Lozano Blesa University Hospital, Zaragoza, Spain, of 559 patients diagnosed with high-risk ACS with and without ST-segment elevation according to the American College of Cardiology/American Heart Association guidelines. The sample was divided into two groups by gender and differences in epidemiologic, laboratory, electrocardiographic and echocardiographic variables and treatment were recorded. A Cox's proportional hazard model was applied and 6-month mortality was analyzed as the main variable. RESULTS: The median age was 65.2±12.7 years, and 21.8% were women. Baseline characteristics in women were more unfavorable, with higher GRACE scores, older age, higher prevalence of hypertension, diabetes and heart failure, lower ejection fraction and more renal dysfunction at admission. Women suffered more adverse cardiovascular events (27.9% vs. 15.8%, p=0.002). Sixty-four patients died, 18.9% of the women vs. 9.4% of the men (p=0.004). After multivariate analysis, female gender did not present an independent relation with mortality. Hemoglobin level, renal function, ejection fraction and Killip class >1 presented significant differences. CONCLUSIONS: Acute syndrome coronary in women has a worse prognosis than in men. Their adverse course is due to their baseline characteristics and not to their gender.

Pronóstico del síndrome cardiorrenal en pacientes con síndrome coronario agudo / Prognosis of cardiorenal syndrome in patients with acute coronary syndrome

Fundamento y objetivo: El síndrome cardiorrenal (SCR) incluye numerosas patologías que afectan al corazón y al riñón. El objetivo del estudio es conocer las características y el pronóstico del SCR en pacientes con un síndrome coronario agudo (SCA). Pacientes y método: Estudio prospectivo de 87 pacientes con SCA con y sin elevación del segmento ST de alto riesgo e insuficiencia cardíaca. Analizamos la presencia de SCR y su relación con variables epidemiológicas, clínicas, analíticas y de exploración complementaria. Mediante regresión de Cox investigamos su relación con la mortalidad en los siguientes 6 meses al evento. Resultados: Los pacientes que presentaban SCR (43,7%) eran con mayor frecuencia mujeres, de mayor edad, con más enfermedad cardiovascular previa y un perfil de riesgo mayor. El pronóstico era significativamente peor en este grupo y el SCR se comportó como predictor independiente de mortalidad (hazard ratio 3,08; intervalo de confianza del 95% 1,13-8,40; p=0,029). Conclusiones: La presencia de SCR influye en el pronóstico de los pacientes que sufren un SCA de alto riesgo y aumenta la probabilidad de fallecer en los siguientes 6 meses al evento (AU)

Background and objective: The cardiorenal syndrome (CRS) includes numerous pathologies affecting the heart and kidney. The objective of this study is to know the characteristics and prognosis of the CRS in patients with acute coronary syndrome (ACS). Patients and method: A prospective study of 87 patients with ACS with and without ST-segment elevation at high risk and heart failure. We analysed the presence of CRS and its relationship with epidemiological variables, clinical, analytical and complementary explorations. Through a Cox regression model we investigated its relationship with mortality in the subsequent 6 months of the event. Results: Patients with CRS (43.7%) were more frequently women, older, with more prior cardiovascular disease and a profile of higher risk. The prognosis was significantly worse in this group and the CRS was an independent predictor of mortality (hazard ratio 3.08; 95% confidence interval 1.13-8,40; P=.029). Conclusions: The presence of CRS has an influence in the prognosis of patients who suffer an ACS high-risk and increases the likelihood of dying during 6 months after the event (AU)

Subacute combined spinal cord degeneration and pancytopenia secondary to severe vitamin B12 deficiency.

CONTEXT: Decreased vitamin B12 concentration does not usually result in clinical or hematological abnormalities. Subacute combined spinal cord degeneration and pancytopenia are two serious and rarely displayed consequences that appear in severe deficits. CASE REPORT: We present the case of a patient with subacute combined spinal cord degeneration and pancytopenia secondary to severe and sustained vitamin B12 deficiency. Such cases are rare nowadays and have potentially fatal consequences. CONCLUSIONS: Vitamin B12 deficiency should be taken into consideration in the differential diagnosis in cases of blood disorders or severe neurological symptoms. Early diagnosis and treatment can avoid irreversible consequences.

[Prognosis of cardiorenal syndrome in patients with acute coronary syndrome]. / Pronóstico del síndrome cardiorrenal en pacientes con síndrome coronario agudo.

BACKGROUND AND OBJECTIVE: The cardiorenal syndrome (CRS) includes numerous pathologies affecting the heart and kidney. The objective of this study is to know the characteristics and prognosis of the CRS in patients with acute coronary syndrome (ACS). PATIENTS AND METHOD: A prospective study of 87 patients with ACS with and without ST-segment elevation at high risk and heart failure. We analysed the presence of CRS and its relationship with epidemiological variables, clinical, analytical and complementary explorations. Through a Cox regression model we investigated its relationship with mortality in the subsequent 6 months of the event. RESULTS: Patients with CRS (43.7%) were more frequently women, older, with more prior cardiovascular disease and a profile of higher risk. The prognosis was significantly worse in this group and the CRS was an independent predictor of mortality (hazard ratio 3.08; 95% confidence interval 1.13-8,40; P=.029). CONCLUSIONS: The presence of CRS has an influence in the prognosis of patients who suffer an ACS high-risk and increases the likelihood of dying during 6 months after the event.

Características del síndrome coronario agudo en pacientes ancianos españoles / Features regardingacute coronary syndrome in elderly Spanish patients

Objetivos: Los pacientes ancianos que sufren un síndrome coronario agudo (SCA) de alto riesgo están escasamente representados en trabajos de investigación y guías de práctica clínica. El objetivo del trabajo es conocer las características del SCA de alto riesgo en pacientes de >75 años. Métodos: Estudio prospectivo descriptivo de 161 pacientes de >75 años con SCA con y sin elevación del segmento ST de alto riesgo según criterios de la ACA/AHA. Se recogieron variables analíticas, electrocardiográficas, ecocardiográficas y epidemiológicas. Tras seis meses de seguimiento observamos el pronóstico en relación con mortalidad y eventos cardiovasculares adversos (ECVA) de tipo de angorpostinfarto, reinfarto o insuficiencia cardíaca. Resultados: La edad media de edad era de 79,4+3,4 años. El 59,6 % eran varones, La hipertensión arterial era el factor de riesgo cardiovascular más frecuente (65,2 %) y el angor el antecedente más común (33,5 %). El 57,8 % presentaban elevación del segmento ST y predominaba la fracción de eyección conservada (>50 %): 44,7 %. La mayoría presentaban algún grado de disfunción renal con media de: 61,4+21,8 ml/min/1,73m2(MDRD-4). El 23,6 % sufrían arritmias durante el ingreso. El tratamiento de reperfusión precoz con trombolíticos y/o intervencionismo coronario percutáneo en el SCACEST fue de un 48,4 %. El pronóstico era adverso, 20,5 % sufrían algún ECVA y fallecían el 24,2 %. Conclusión: El perfil del SCA en pacientes de 75 años y más es un varón hipertenso, con angor previo, fracción de eyección conservada, deterioro de la función renal, alta morbimortalidad y tratamiento inicial conservador.

Objective: Elderly patients suffering from acute coronary syndrome (ACS) are poorly represented in research and practice clinical guides. This study was aimed at ascertaining characteristics in patients aged older than seventy years having a high risk of ACS. Methods: This was a prospective and descriptive study of 161 patients aged older than seventy years suffering ACS with and without ST segment elevation and high risk according to ACC/AHA guidelines. Analytic, electrocardiographic, echocardiography and epidemiological variables were included. Mortality and adverse cardiovascular events like post-infarct angina, re-infarct or heart failure were observe dafter six months. Results: Average age was 79.4+3.4 years old; 59.6 % of the sample was male. Arterial hypertension was the most common background (33.5 %). 57.8 % of the patients had an elevated ST segment, 44.7 % having a preserved ejection fraction (>50 %). Most patients had kidney failure (average 61.4+21.8 ml/min/1.73m2 (MDRD-4) and 23.6 % suffered arrhythmia on admission to hospital. 48.4 % of ACS having ST elevation received early reperfusion treatment with fibrinolytic therapy or percutaneous coronary intervention. They had an adverse prognosis as 20.5 % of them suffered stroke and 24.2 % died. Conclusion: The ACS profile for people aged older than seventy years consisted of a hypertensive male having suffered previous angina, maintained ejection fraction, kidney failure, high morbimortality and conservative treatment at the time of initial healthcare.

La paradoja del tabaquismo: fumar o no fumar / Smoking paradox: smoking or not smoking

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[Features regarding acute coronary syndrome in elderly Spanish patients]. / Características del síndrome coronario agudo en pacientes ancianos españoles.

OBJECTIVE: Elderly patients suffering from acute coronary syndrome (ACS) are poorly represented in research and practice clinical guides. This study was aimed at ascertaining characteristics in patients aged older than seventy years having a high risk of ACS. METHODS: This was a prospective and descriptive study of 161 patients aged older than seventy years suffering ACS with and without ST segment elevation and high risk according to ACC/AHA guidelines. Analytic, electrocardiographic, echocardiography and epidemiological variables were included. Mortality and adverse cardiovascular events like post-infarct angina, re-infarct or heart failure were observe dafter six months. RESULTS: Average age was 79.4+3.4 years old; 59.6 % of the sample was male. Arterial hypertension was the most common background (33.5 %). 57.8 % of the patients had an elevated ST segment, 44.7 % having a preserved ejection fraction (>50 %). Most patients had kidney failure (average 61.4+21.8 ml/min/1.73m2 (MDRD-4) and 23.6 % suffered arrhythmia on admission to hospital. 48.4 % of ACS having ST elevation received early reperfusion treatment with fibrinolytic therapy or percutaneous coronary intervention. They had an adverse prognosis as 20.5 % of them suffered stroke and 24.2 % died. CONCLUSION: The ACS profile for people aged older than seventy years consisted of a hypertensive male having suffered previous angina, maintained ejection fraction, kidney failure, high morbimortality and conservative treatment at the time of initial healthcare.

Subacute combined spinal cord degeneration and pancytopenia secondary to severe vitamin B12 deficiency / Degenarión combinada subaguda medular y pancitopenia secundaria a déficit severo de vitamina B12

CONTEXT: Decreased vitamin B12 concentration does not usually result in clinical or hematological abnormalities. Subacute combined spinal cord degeneration and pancytopenia are two serious and rarely displayed consequences that appear in severe deficits. CASE REPORT: We present the case of a patient with subacute combined spinal cord degeneration and pancytopenia secondary to severe and sustained vitamin B12 deficiency. Such cases are rare nowadays and have potentially fatal consequences. CONCLUSIONS: Vitamin B12 deficiency should be taken into consideration in the differential diagnosis in cases of blood disorders or severe neurological symptoms. Early diagnosis and treatment can avoid irreversible consequences.

CONTEXTO: El descenso de la concentración de vitamina B12 no suele derivar en alteraciones clínicas o hematológicas. La degeneración combinada subaguda medular y la pancitopenia son dos consecuencias graves y poco frecuentes que aparecen en los déficit severos. CASO CLÍNICO: Presentamos el caso de un paciente con una degeneración combinada subaguda medular y pancitopenia secundarios a un déficit severo y mantenido de vitamina B12. Un caso poco común en nuestros días y con consecuencias potencialmente fatales. CONCLUSIONES: Debemos considerar el déficit de vitamina B12 dentro del diagnóstico diferencial en caso de alteraciones hematológicas o síntomas neurológicos graves. Su diagnóstico y tratamento precoz pueden evitar secuelas irreversibles.

Valor pronóstico del filtrado glomerular en el síndrome coronario agudo: ¿índice de Cockcroft o ecuación MDRD? / Prognostic value of glomerular filtrate in acute coronary syndrome: Cockcroft's index or MDRD equation?

Fundamento y objetivo: La tercera parte de los pacientes con un episodio coronario agudo presenta insuficiencia renal. El objetivo es determinar la relación entre la insuficiencia renal y la mortalidad en pacientes que tienen un síndrome coronario agudo (SCA) mediante el índice de Cockcroft y la ecuación modification of diet in renal disease study group 4 (MDRD-4), y analizar cuál de las 2 es preferible como estratificación pronóstica. Pacientes y método: Estudio prospectivo de 455 pacientes ingresados de forma consecutiva entre 2006 y 2007 con SCA de alto riesgo mediante división de la muestra según su función renal al ingreso en <60ml/min/1,73m2 y ≥60ml/min/1,73m2 y mediante el índice de Cockcroft-Gault y la ecuación MDRD-4, junto con otras variables. Se realizó un análisis de regresión logística multivariante para cada uno de éstos y se analizó su relación con la mortalidad en los siguientes 6 meses al ingreso. Resultados: La insuficiencia renal (creatinina<1,1mg/dl) estaba presente en el 27,9%, en un 30,5% según el índice de Cockcroft-Gault y en un 22,6% según la ecuación MDRD-4. La media (desviación estándar) del filtrado glomerular (FG) fue de 81,6 (35,2)ml/min según el índice de Cockcroft-Gault y de 77,2 (26,1)ml/min/1,73m2 según la ecuación MDRD-4. Los pacientes con FG <60ml/min presentaron mayor mortalidad, con una odds ratio de 2,652 (intervalo de confianza [IC] del 95%: 1,140–6,166) (p=0,024) según el índice de Cockcroft-Gault y de 3,372 (IC del 95%: 1,637–6,954) (p=0,001) según la ecuación MDRD-4.Conclusión: La insuficiencia renal incrementa el riesgo de fallecer en los siguientes 6 meses tras un SCA. El cálculo del FG mediante el índice de Cockcroft-Gault o la ecuación MDRD-4 depende de las características de la población y es indiferente con filtrados entre 60 y 80ml/min (AU)

Background and objectives: One third of patients with a coronary event show kidney failure. Our aim is to establish the relationship between kidney failure and mortality in patients diagnosed of acute coronary syndrome (ACS) through Cockcroft Index (C-G) and MDRD-4 equation, analyzing which of them is better for prognostic stratification. Patients and method: Prospective study of 445 patients admitted consecutively between 2006 and 2007 with a high risk of ACS, dividing the sample depending on his kidney function at admission in <60mL/min/1,73m2 and ≥60mL/min/1,73m2 through C-G and modification of diet in renal disease study gruop 4 (MDRD-4) and other variables. We performed a multivariate logistic regression for both of them, analysing the relationship with mortality in the following six months after admission. Results: Renal failure was present in 27.9% (creatinine<1,1mg/dl); 30,5% (C-G) and 22,6% (MDRD-4). Glomerular filtration (GF) was 81,6±35,2mL/min (C-G) and 77,2±26,1mL/min/1,73m2 (MDRD-4). Patients with GF<60mL/min showed high mortality, Odds ratio 2,652; p=0,024 (IC 95%, 1,140–6,166) for C-G and 3,372; p=0,001 (IC 95%, 1,637–6,954) for MDRD-4. Conclusion: Renal failure increases the risk to die in the following six months after an ACS. The estimation through Cockcroft Index and/or MDRD-4 equation depends on the population characteristics and is indifferent with GF between 60 and 80mL/min (AU)

[Prognostic value of glomerular filtrate in acute coronary syndrome: Cockcroft's index or MDRD equation?]. / Valor pronóstico del filtrado glomerular en el síndrome coronario agudo: ¿índice de Cockcroft o ecuación MDRD?

BACKGROUND AND OBJECTIVES: One third of patients with a coronary event show kidney failure. Our aim is to establish the relationship between kidney failure and mortality in patients diagnosed of acute coronary syndrome (ACS) through Cockcroft Index (C-G) and MDRD-4 equation, analyzing which of them is better for prognostic stratification. PATIENTS AND METHOD: Prospective study of 445 patients admitted consecutively between 2006 and 2007 with a high risk of ACS, dividing the sample depending on his kidney function at admission in < 60 mL/min/1.73 m(2) and > or =60 mL/min/1.73 m(2) through C-G and Modification of Diet in Renal Disease study group 4 (MDRD-4) and other variables. We performed a multivariate logistic regression for both of them, analysing the relationship with mortality in the following six months after admission. RESULTS: Renal failure was present in 27.9% (creatinine < 1.1mg/dl); 30.5% (C-G) and 22.6% (MDRD-4). Glomerular filtration (GF) was 81.6+/-35.2 mL/min (C-G) and 77.2+/-26.1 mL/min/1.73 m(2) (MDRD-4). Patients with GF < 60 mL/min showed high mortality, Odds ratio 2.652; p=0.024 (IC 95%, 1.140-6.166) for C-G and 3.372; p=0.001 (IC 95%, 1.637-6.954) for MDRD-4. CONCLUSION: Renal failure increases the risk to die in the following six months after an ACS. The estimation through Cockcroft Index and/or MDRD-4 equation depends on the population characteristics and is indifferent with GF between 60 and 80 mL/min.

Importancia de un estudio protocolizando en pacientes con hipertensión pulmonar / Importance of protocolized study in patients with pulmonary hypertension

La hypertension pulmonary (HTP) es una enfermedad relativamente desconocida pero con elevada morbi-mortalidad. Presenta etiologías y comorbilidades diversas por lo que es valorada por múltiples especialidades, lo que dificulta que existan expertos en el tema y la realización de estudios sistemáticos que lleven al origen de la patología. Planteamos un estudio sistemático, siguiendo las guías de práctica clínica actuales, de pacientes menores de 75 años diagnosticados de HPT severa (PAPs>60mmHg) mediante ecocardiografía desde enero 1995 a agosto 2007 en el área 3 del Servicio Aragonés de Salud. Recogemos 58 casos de http severa a los que en una primera entrevista se les atribuye un diagnóstico de sospecha en base a los datos clínicos hasta ese momento. Posteriormente se les realizan las pruebas diagnósticas recomendadas por las guías y en una segunda entrevista se informa de los resultados y se da un diagnóstico definitivo de su http si se ha conseguido. Se obtuvo diagnóstico final en 54 pacientes (93,1%) y no fue posible en 4 (6,9%). En 41 ocasiones (70,7%) se confirmó la sospecha inicial, mientras que en 17 casos (29,3%) el diagnóstico final fue diferente al inicial. La etiología más frecuente fue la asociada a enfermedades de corazón izquierdo sobre todo valvulopatías con el 50% de los casos (AU)

Pulmonary hypertension (PHT) is an unusual and unknown illness byt with high morbi-mortality. It shown different etiology and comorbidity so its studied by many specialities, this is a reason for existing experts about this pathology and a lot of following the actual practical clinical guidelines, about patients less than 75 years old with severe PHT (PBPS>60 mmHg) with echocardiography from January 1995 through august 2007 in area 3 of Aragones Health Service. We compiled 58 cases of severe PHT with suspected diagnosis based only in clinical details. Later we realize test recommended in guidelines and in a second interview we report the results and give them a definitive diagnosis if we would have achieved it. In 54 patients we had a final diagnosis (93.1%) and it wasn´t possible in 4 (6,9%). Un 42 cases (70,7%) was confirmed the initial suspect, but in 17 patients (29,3%) the final diagnosis was different than the initial. The more frequent etiology was PHT associated to left heart illness, mainly valve disease in 50% of them (AU)