Fast-Track Liver Transplantation: Six-year Prospective Cohort Study with an Enhanced Recovery After Surgery (ERAS) Protocol.

INTRODUCTION: Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs. We used this concept to design a comprehensive fast-track pathway (OR-to-discharge) before starting our liver transplant activity and then applied this protocol prospectively to every patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our first six years results. PATIENTS AND METHODS: Prospective cohort study of all the liver transplants performed at our institution for the first six years. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early. RESULTS: A total of 240 transplants were performed in 236 patients (191♂/45♀) over 74 months, mean age 56.3±9.6 years, raw MELD score 15.5±7.7. Predominant etiologies were alcohol (n = 136) and HCV (n = 82), with hepatocellular carcinoma present in 129 (54.7%). Nine patients received combined liver and kidney transplants. The mean operating time was 315±64 min with cold ischemia times of 279±88 min. Thirty-one patients (13.1%) were transfused in the OR (2.4±1.2 units of PRBC). Extubation was immediate (< 30 min) in all but four patients. Median ICU length of stay was 12.7 hours, and median post-transplant hospital stay was 4 days (2-76) with 30 patients (13.8%) going home by day 2, 87 (39.9%) by day 3, and 133 (61%) by day 4, defining our fast-track group. Thirty-day-readmission rate (34.9%) was significantly lower (28.6% vs. 44.7% p=0.015) in the fast-track group. Patient survival was 86.8% at 1 year and 78.6% at five years. CONCLUSION: Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care.

Presentación atípica de un caso de fiebre mediterránea familiar / Atypical presentation of a case of familial mediterranean fever

La fiebre mediterránea familiar (FMF) es un síndrome hereditario de fiebre periódica caracterizada por ataques cortos de fiebre e inflamación multisistémica (poliserositis y sinovitis, principalmente). El desarrollo de amiloidosis, sobre todo renal, es la principal complicación. Los síntomas aparecen, en la mayoría de casos, antes de la segunda década de vida. Se trata de una enfermedad hereditaria monogénica y el gen asociado se llama MEFV. El diagnóstico genético puede ser de gran ayuda, aunque existen aspectos que todavía no están claros. En un porcentaje muy pequeño de pacientes, la enfermedad aparece de una forma atípica, es decir, más tardía e iniciando con amiloidosis, sin existir antecedente de ataques previos inflamatorios o fiebres periódicas. Es el fenotipo II de la FMF. Presentamos el caso de un varón de 24 años con amiloidosis renal que cumple estas características, donde el estudio genético resultó clave para el diagnóstico (AU)

Familial Mediterranean Fever is a periodic hereditary fever syndrome characterised by short fever attacks and multisystemic inflammation (mainly polyserositis and synovitis). The main complication is development of amyloidosis, particularly renal. In the majority of cases, symptoms appear before the age of twenty. It is a monogenic hereditary disease that is related to the MEFV gene. A genetic diagnosis may be helpful, although there are some aspects that are still not clear enough. A small percentage of patients present an atypical form, appearing later and debuting with amyloidosis but without any previous inflammatory attacks or periodic fevers. This form is Familial Mediterranean Fever phenotype II. We present the case of a 24 year-old with renal amyloidosis that presents these characteristics and in whom the genetic study was fundamental for the diagnosis (AU)

Lupus eritematoso sistémico / Systemic lupus erythematosus

El lupus eritematoso sistémico es una enfermedad autoinmune, crónica,que afecta al tejido conectivo y cuya etiología es desconocida.Se caracteriza por la presencia de manifestaciones clínicas asociadasa la presencia de autoanticuerpos. Su prevalencia en España es de91 casos/100.000 habitantes. Es más frecuente en mujeres que enhombres en una relación 10:1.El propósito de este artículo, séptimo de una serie dirigida a los cuidadosenfermeros en reumatología, es presentar el lupus eritematososistémico, recorriendo generalidades de esta patología, sus manifestacionesclínicas, además del régimen terapéutico y la Educaciónpara la Salud dirigida a estos pacientes. Los cuidados enfermerosde las personas con esta patología tienen el objetivo de facilitar elautocuidado y el afrontamiento eficaz de la enfermedad, por lo quedeben incluir: recomendaciones higiénicas generales, recomendacionespara la reducción del riesgo cardiovascular y otras comorbilidades,enfatizar la importancia de la adherencia al tratamiento y elcumplimiento de las citas de revisión (AU)

Systemic lupus erythematosus is a chronic, autoimmune disease thataffects connective tissue and which aetiology is unknown. It is characterizedby clinical manifestations associated with the presence ofantibodies. Its prevalence in Spain is 91 cases/100,000 inhabitants.It is more frequent in women than men in a ratio of 10:1.The objective of this article, the seventh in a series aimed at nursingcare in rheumatology, is to present systemic lupus erythematosus,covering its general aspects, clinical manifestations, therapeuticregime and health education aimed at these patients. Nursing careof patients with this pathology aims to facilitate self-care and aneffective coping with the disease, thus making it necessary to include:general hygienic recommendations, recommendations forthe reduction of cardiovascular risk and other comorbidities, emphasison the importance of adherence to treatment and follow-upvisits (AU)