Echocardiographic Pulmonary Hypertension Predicts Post-transplantation Renal Allograft Failure.

BACKGROUND: Pulmonary hypertension in the setting of renal transplantation has been associated with early allograft dysfunction and increased mortality, but this relationship has not been extensively studied. METHODS: We performed a retrospective cohort study of adult patients who underwent their first renal transplantation in the years 2003-2009 and had pre-transplantation echocardiograms. Pulmonary hypertension was defined as right ventricular systolic pressure ≥40 mm Hg in the absence of left-sided valvular disease and/or left ventricular ejection fraction ≤50%. Eighty-two of 205 patients (40%) met the inclusion criteria. The relationship between pulmonary hypertension and death-censored allograft failure (hemodialysis dependence or retransplantation) and serum creatinine was assessed with the use of Cox hazard regression and generalized mixed models. RESULTS: The presence of pulmonary hypertension was associated with a 3-fold increase in the risk of death-censored allograft failure (95% confidence interval, 1.20-7.32; P = .02). Failure rates were 19% at 24 months and 51% at 96 months for those with pulmonary hypertension versus 7% at 24 months and 20% at 86 months for those without pulmonary hypertension (P = .01). Among those without graft failure, there was an increase in creatinine levels after transplantation (P = .01). Effect estimates were unchanged by adjustment for multiple covariates and when pulmonary hypertension was defined as right ventricular systolic pressure ≥36 mm Hg. CONCLUSIONS: Pulmonary hypertension before renal transplantation carries a 3-fold increased risk of death-censored allograft failure. The relationship between the pulmonary circulation and renal allograft failure warrants further study.

Extracorporeal membrane oxygenation for diffuse alveolar hemorrhage and severe hypoxemic respiratory failure from silicone embolism.

Liquid silicone is an inert material that may be used for cosmetic procedures by physicians as well as illegally by non-medical personnel. The use of silicone may result in severe complications, disfigurement, and even death. In addition, the indications for extracorporeal membrane oxygenation (ECMO) support have been increasing as a salvage therapy for a variety of life-threatening conditions. The patient is a 27-year-old woman with no significant medical conditions who developed silicone emboli, and subsequent diffuse alveolar hemorrhage after being injected with silicone in her gluteal region without medical supervision. She became profoundly hypoxemic and suffered a brief asystolic cardiac arrest in this setting. The patient was placed on veno-venous ECMO support for 14 days. Medical care during ECMO was complicated by pulmonary hemorrhage, hemothorax, pneumothorax, and blood clot, resulting in oxygenator change-out. A modified adult ECMO circuit (Jostra QuadroxD, Maquet Cardiopulmonary, Rastatt, Germany) was used to transport the patient from a nearby community affiliate hospital and then reconfigured for the medical intensive care unit on a standard HL-20 heart-lung console. Although the use of ECMO for severe hypoxemic respiratory failure has been widely reported, to our knowledge, this is the first reported successful use of ECMO for silicone embolism syndrome associated with diffuse alveolar hemorrhage and severe hypoxemic respiratory failure.