Donor structural and functional parameters are independent predictors of renal function at 3 months.

INTRODUCTION: Epidemiological studies have shown that demographic, clinical, and histological donor characteristics influence renal function after transplantation, but whether these variables are independent predictors has not been established. The aim of this study was to evaluate the relative contribution of different donor variables on glomerular filtration rates (GFRs) at 3 months. PATIENTS AND METHODS: We analyzed single renal transplants performed at our center from January 2000 to July 2004. Donor variables included age, gender, weight and height, cause of death, duration of brain death, serum creatinine at admission and preprocurement, history of arterial hypertension or diabetes mellitus, and smoking habit. Donor chronic damage score was calculated in preimplantation biopsies as was the addition of interstitial fibrosis, fibrous intimal thickening, and glomerulosclerosis (<10% = 0, >10% = 1). Donor and recipient GFRs were calculated according to the Cockroft-Gault formula. RESULTS: We analyzed 202 transplants obtained from 113 deceased donors. A renal biopsy was available in 111 transplants. Recipient GFR at 3 months correlated negatively with donor age (R = -0.32, P < .01) and donor chronic damage score (R = 0.32, P < .01). GFR was lower among recipients of female versus male donors (50 +/- 15 vs 60 +/- 20 mL/min; P < .01). Donor cerebrovascular accident death (53 +/- 19 vs 63 +/- 19 mL/min; P < .01) and hypertension (48 +/- 16 vs 59 +/- 20 mL/min; P < .01) were also associated with lower GFR at 3 months. There was a positive correlation between GFR at admission, GFR preprocurement, and GFR at 3 months (R = 0.32 and R = 0.18 respectively; P < .01). Stepwise regression analysis included chronic damage score, GFR at admission, and donor gender but not donor age as independent predictors of GFR at 3 months (R = 0.50; P < .01). CONCLUSION: Donor structural and functional parameters are independent predictors of renal function at 3 months.

Donors with positive blood culture: could they transmit infections to the recipients?

A retrospective analysis of data from January 1996 to June 2004 was performed to evaluate the transmission of bacterial infections from organ donors to recipients. Donors were classified according to blood culture results: group 1 with negative blood culture (n = 216), and group 2 with positive blood cultures (n = 52). The age, cause of death, temperature, leukocytes, and number of organs procured were similar in both groups. Donors of group 2 had significantly more days in the intensive care unit (ICU): group 1 (3.14 +/- 3) versus group 2 (4.39 +/- 3.38 days P = .038). Fifty-one percent of group 1 and 52% of group 2 received antibiotic treatment, in most cases because of the suspected presence of a respiratory infection. In 22 donors the organisms that yielded in the blood culture were considered potentially pathogenic/contaminants (subgroup 2A) and in 30 donors the organisms were considered pathogenic (subgroup 2B). The demographic profiles of these two subgroups were similar. During the first month after transplantation, kidney and liver recipients were closely monitored. Recipients received wide-spectrum antimicrobial prophylaxis. Ten of 61 renal recipients developed infectious diseases. In nine cases (four in subgroup 2A and five in subgroup 2B) there were urinary infections. One recipient of subgroup 2B developed prostatitis. Six of 34 hepatic recipients developed infectious diseases. Four of the six cases (four in group 2A and five in group 2B) developed catheter infections and two cases of peritoneal infections. We could not find any case where a bacterial blood isolate from a donor matched a positive culture in the corresponding recipient. A longer stay of a donor in the ICU resulted in the more pronounced growth of organisms in blood cultures, as expected. In our experience, organs obtained from a donor with a positive blood culture may be transplanted safely, probably due to the low virulence of the organisms as well as the polymicrobial therapy routinely given to the recipients.

Importance of tumoral markers in donors: study of prostate-specific antigen.

UNLABELLED: We established a protocol to determine the serum prostate-specific antigen (PSA) in male donors of 50 years or older, and to histologically examine the prostate glands. From January 1997 to December 2002 we analysed serum PSA in 51 cases, of which it was normal in 34 and high in 17. Prostate glands were examined histologically in 13 of the high PSA cases. Donors were classified according to the PSA level and histology: donors with high PSA values and adenocarcinoma or high-grade PIN (group A, n=6); donors with elevated PSA but no malignancy (group B, n=7); and donors with normal PSA (group C, n=34). The ages, days in hospital, and causes of death were similar among the 3 groups. The levels of PSA were significantly higher among group A than group B or group C, but were similar between group B and C. The list of transplanted organs is as follows: 5 organs of group A; 8 organs of group B; and 59 organs of group C. CONCLUSIONS: High PSA levels seem show 2 patterns: (1) small increases of PSA related to donors with no prostate cancer, and (2) high levels of PSA related to the presence of prostate cancer, as is the case in the general population. The incidence of prostate cancer in overall male donors was 3.1%. Due to this high incidence, we believe it is important to determine PSA levels to diagnose prostate cancer in older donors. A separate consideration is what to do with the organs of those donors.

Tranexamic acid reduces red cell transfusion better than epsilon-aminocaproic acid or placebo in liver transplantation.

UNLABELLED: We evaluated the efficacy of the prophylactic administration of epsilon-aminocaproic acid and tranexamic acid for reducing blood product requirements in orthotopic liver transplantation (OLT) in a prospective, double-blinded study performed in 132 consecutive patients. Patients were randomized to three groups and given one of three drugs prophylactically: tranexamic acid, 10 mg. kg(-1). h(-1); epsilon-aminocaproic acid, 16 mg. kg(-1). h(-1), and placebo (isotonic saline). Perioperative management was standardized. Coagulation tests, thromboelastogram, and blood requirements were recorded during OLT and in the first 24 h. There were no differences in diagnosis, Child score, or preoperative coagulation tests among groups. Administration of packed red blood cells was significantly reduced (P = 0.023) during OLT in the tranexamic acid group, but not in the epsilon-aminocaproic acid group. There were no differences in transfusion requirements after OLT. Thromboembolic events, reoperations, and mortality were similar in the three groups. Prophylactic administration of tranexamic acid, but not epsilon-aminocaproic acid, significantly reduces total packed red blood cell usage during OLT. IMPLICATIONS: In a randomized study of 132 consecutive patients undergoing liver transplantation, we found that tranexamic acid, but not epsilon-aminocaproic acid, reduced intraoperative total packed red blood cell transfusion.

The prophylactic effect of aprotinin on intraoperative bleeding in liver transplantation: a randomized clinical study.

Fibrinolysis has been recognized as an important cause of intraoperative bleeding during orthotopic liver transplantation (OLT). Several investigators have used prophylactic administration of aprotinin in patients to inhibit fibrinolysis and to decrease transfusion requirements, morbidity, and mortality. Nevertheless, the role of aprotinin in this situation is not yet clear. The goal of this study was to determine the effects of prophylactic administration of aprotinin on intraoperative bleeding and blood requirements, and on hemostatic changes during OLT. Eighty consecutive patients were included in a double-blind, prospective study and were randomized in two groups. In group A (n = 39), an initial dose of 2 x 10(6) kallikrein inactivator units (KIU) of aprotinin was administered in the induction of anesthesia followed by infusion of 5 x 10(5) KIU/h until the end of the procedure. The control group (n = 41) received an identical volume of saline solution. The majority of the operations were performed with vena cava preservation (piggy-back technique) without venovenous bypass. During the anhepatic phase, a significant increase in levels of tissue plasminogen activator, thrombin-antithrombin complexes (TAT) and D-dimers (DD) was noted in both groups. A significant increment of TAT was observed in group A during reperfusion. The remaining hemostatic parameters were similar in both groups. Intraoperative requirements of packed red cells, fresh-frozen plasma (FFP), platelets, and cryoprecipitate were similar in the two groups. Our results suggest that prophylactic administration of aprotinin is not useful in reducing bleeding and blood product requirements during OLT.

[Chylothorax. An infrequent complication in surgical exeresis of the esophagus]. / Quilotórax. Una complicación poco frecuente en la cirugía exerética de esófago.

We report a case of massive bilateral chylothorax occurring after surgical resection of the esophagus in a patient with esophageal neoplasm. The surgical approach consisted of a thoracotomy and a cervicostomy. The relevance of this case is based on the low incidence of chylothorax after esophageal surgery. The literature indicates an incidence of about 0.9 to 3%. In our series of 200 patients operated on during the last 10 years we found and incidence of 2%. The patient herein reported presented an immediate postoperative clinical picture of respiratory insufficiency associated with the presence of milky fluid in the pleural drainage. Hematologic and biochemical examination of the pleural fluid confirmed the diagnosis of chylothorax. During the first 24 hours we collected a total volume of 2,500 ml of chyle. The patient was treated with conservative procedures including parenteral nutrition and intravenous reposition of fluids. After 48 hours the total volume of chyle reached 8,500 ml and the patient died.

[Traumatic tear of the diaphragm]. / Rotura traumática del diafragma.

We have carried out a 9-month retrospective study in the Emergency Resuscitation Unit; 21 patients with abdominal trauma, 42 patients with chest trauma and 895 patients with multiple injuries were treated; 197 (22%) of the latter had also chest and/or abdomen involvement. Of the 260 patients with chest and/or abdomen involvement, six (2.3%) patients had traumatic tear of the diaphragm and four of them, presented thoracic herniation of abdominal content. Diagnostic suspicion was entertained in five patients by means of x-ray plain chest film; diagnosis was confirmed by a barium meal in two patients. In one patient, the diagnosis was established perioperatively. All patients had associated lesions. Four patients required mechanical ventilation after the operation. One patient died of cardiogenic shock on the fourth postoperative day. We emphasize the importance of the suspicion of such condition in patients with multiple injuries with chest and/or abdomen involvement.

[Use of axillary perivascular blockage of the brachial plexus with a catheter as treatment in accidental intra-arterial injection of drugs]. / Utilización del bloqueo perivascular axilar del plexo braquial mediante catéter como tratamiento de la inyección accidental intraarterial de fármacos.

We report the intraarterial injection of a flunitrazepam tablet dissolved in water in a patient with intravenous drugs addiction. Several ecchymotic lesions were present at different sites of the arm. In order to achieve analgesia and the sympathetic blockade of the arm, we performed an axillary perivascular block of the brachial plexus by means of the intermittent injection through a catheter of 0.25% bupivacaine with a 1:200,000 epinephrine solution. In addition, an anticoagulant treatment with heparin was started as prophylaxis of the thrombosis of the vessel. There was a satisfactory clinical course even though a distal phalange had to be amputated on the 18th day. We propose the continuous perivascular block as the method of choice of this type of medical problem.