Deciphering the True Immunologic Risk in Renal Transplantation in Patients With HIV.

Since 1995, rates of end-stage renal disease have risen dramatically in patients living with HIV infection. However, given the concern for higher rates of acute rejection in this patient population, the immunologic threat posed by HIV infection is a specter clinicians must continually confront. Living donor transplantation may negate this risk; this study aims to assess the benefit of living donor transplantation in this population and to ascertain the immunologic risk faced by patients who are HIV-infected. The 2021 UNOS database was queried, and all HIV-infected kidney transplant recipients since 1987 were identified. Recipients were stratified based on deceased (DDKT) vs living (LDKT) donor status. Overall survival, allograft survival, acute rejection, panel reactive antibody (PRA) percentage, and crossmatch positivity were compared between groups. One thousand two hundred twenty-six patients underwent DDKT, and 304 patients underwent LDKT. Living donor kidney transplantation demonstrated greater overall survival (P = .045) and graft survival (P < .001). However, no difference in acute rejection was noted between the cohorts, and no difference in overall or graft survival was evident based on PRA percentage. Crossmatch positive status did not negatively affect graft survival. Patients with HIV undergoing LDKT fared better than those undergoing DDKT. Nevertheless, patients at higher immunologic risk-elevated PRA% and crossmatch positivity-did not experience graft loss at a higher rate than patients at lower immunologic risk. These results were valid in both DDKT and LDKT cohorts. These findings suggest that infection with HIV does not overtly increase patients' immunologic risk, and concerns surrounding transplantation in this population may be overestimated.

Fatty liver: The metabolic syndrome increases major hepatectomy mortality.

BACKGROUND: As the obesity epidemic worsens, the prevalence of fatty liver disease has increased. However, minimal data exist on the impact of combined fatty liver and metabolic syndrome on hepatectomy outcomes. Therefore, the aim of this analysis is to measure the outcomes of patients who do and do not have a fatty liver undergoing hepatectomy in the presence and absence of the metabolic syndrome. METHODS: Patients with fatty and normal livers undergoing major hepatectomy (≥3 segments) were identified in the 2014 to 2018 American College of Surgeon National Surgical Quality Improvement Program database. Patients undergoing partial hepatectomy and those with missing liver texture data were excluded. Propensity matching was used and adjusted for multiple variables. A subgroup analysis stratified by the metabolic syndrome (body mass index ≥30 kg/m2, hypertension and diabetes) was performed. Demographics and outcomes were compared by χ2 and Mann-Whitney tests. RESULTS: Of 2,927 hepatectomies, 30% of patients (N = 863) had a fatty liver. The median body mass index was 28.6, and the metabolic syndrome was present in 6.3% of patients (N = 184). After propensity matching, 863 patients with fatty and 863 with normal livers were compared. Multiple outcomes were significantly worse in patients with fatty livers (P <.05), including serious morbidity (32% vs 24%), postoperative invasive biliary procedures (15% vs 10%), organ space infections (11% vs 7.8%), and pulmonary complications. Patients with fatty livers and the metabolic syndrome had significantly increased postoperative cardiac arrests, pulmonary embolisms, and mortality (P < .05). CONCLUSION: Fatty liver disease is associated with significantly worse outcomes after major hepatectomy. The metabolic syndrome confers an increased risk of postoperative mortality.

Marca-passo permanente após implante percutâneo valvular aórtico: a necessidade é maior que imaginávamos? / Permanent pacemaker after percutaneous aortic valve implantation: is the need greater than we had anticipated?

O implante percutâneo valvular aórtico é uma alternativa promissora no tratamento da estenose aórtica grave de pacientes com elevado risco cirúrgico. No entanto, parte desses pacientes pode desenvolver distúrbios do sistema de condução elétrico do coração e necessidade de implante de marca-passo permanente. O mecanismo das alterações do sistema de condução não está completamente elucidado. Nosso objetivo é avaliar a frequênia e os fatores relacionados à necessidade de marca-passo permanente em nosso meio. Método: Série de casos com descrição das variáveis absolutas e relativas associadas à necessidade de marca-passo permanente em pacientes submetidos a implante percutâneo valvular aórtico no Instituto de Cardiologia do Rio Grande do Sul. Resultados: Entre novembro de 2008 e novembro de 2009, 10 pacientes foram submetidos a implante percutâneo valvular...

BACKGROUND: Percutaneous aortic valve implantation (PAVI) is a promising alternative treatment for severe aortic stenosis in high surgical risk patients. However, part of these patients may develop electrical conduction system disturbances and require permanent pacemaker implantation. The mechanism of such electrical conduction system disturbances has not been totally elucidated. Our objective is to assess the frequency and factors related to the need of a permanent pacemaker (PPM) in this scenario. METHOD: A series of cases describing absolute and relative variables associated to PPM implantation in patients submitted to PAVI at Instituto de Cardiologia do Rio Grande do Sul. RESULTS: Between November 2008 and November 2009, ten patients were submitted to PAVI using the CoreValveTM prosthesis. Two patients who died due to complications not associated to the conduction system disturbances were excluded. The procedure was successfully carried out in the eight remaining patients, with gradient reduction between the left ventricle and aorta and symptomatic relief. Most of the patients were women (75%) and mean age was 86 years. PPM was required in six patients (75%) after PAVI. The single procedure related event was the development of left bundle branch block (LBBB). During clinical follow-up, one patient resumed sinus rhythm, two alternated their own rhythm with the pacemaker rhythm and three remain totally dependent of artificial stimulus. CONCLUSIONS: We observed an increased need of PPM after PAVI and the development of LBBB seems to be associated to it. Additional and powered studies, comparing other techniques, are required to define the exact incidence of rhythm disturbances caused by PAVI.

[Use of prostheses in the treatment of laparocele]. / L'utilizzo di protesi nel trattamento dei laparoceli.

Effective solutions to the problem of surgery for bulk laparoceles began to emerge with the introduction of synthesis materials that can be used to reinforce or replace the abdominal wall. The ideal prosthesis has yet to be found, though today a large number of laparoceles are treated with the use of polypropylene (Marlex) and PTFE (Goretex), which are considered the best materials for alloplasty with only a very limited number of recurrences and complications. The authors describe their experience over two distinct periods: in the first of these, from 1985 to 1994, 49 of 126 patients were treated with prostheses (39 using the Rives technique and 10 simple alloplasty); in the second period, from 1995 to 2000, 39 of 79 patients were treated with prostheses (12 using the Rives technique and 27 simple alloplasty). This prosthesis was used only to reinforce the abdominal wall with a modified technique. The mortality rate was nil. In the first period the complications presented by the 49 patients were 6 seromas and 3 infections; in the second period (39 patients) the complications observed were 3 seromas, resolved with conservative therapy, and one relapse due to the use of a Vycril prosthesis. One case of haematoma and one of subcuticular infection occurred, but neither of these required removal of the prosthesis.