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2.
Clin Transplant ; 35(8): e14311, 2021 08.
Artículo en Inglés | MEDLINE | ID: mdl-33829561

RESUMEN

Postoperative pain is a significant source of morbidity in patients undergoing living donor nephrectomy (LDN) and a deterrent for candidates. We implemented a standardized multimodal analgesic regimen, which consists of pharmacist-led pre-procedure pain management education, a combination transversus abdominis plane and rectus sheath block performed by the regional anesthesia team, scheduled acetaminophen and gabapentin, and as-needed opioids. This single-center retrospective study evaluated outcomes between patients undergoing LDN who received a multimodal analgesic regimen and a historical cohort. The multimodal cohort had a significantly shorter length of stay (LOS) (days, mean ± SD: 1.8 ± 0.7 vs. 2.6 ± 0.8; p < .001) and a greater proportion who were discharged on postoperative day (POD) 1 (38.6% vs. 1.5%; p < .001). The total morphine milligram equivalents (MME) that patients received during hospitalization were significantly less in the multimodal cohort on POD 0-2. The outpatient MME prescribed through POD 60 was also significantly less in the multimodal cohort (median [IQR]; 180 [150-188] vs. 225 [150-300]; p < .001). The mean patient-reported pain score (PRPS) was significantly lower in the multimodal cohort on POD 0-2. The maximum PRPS was significantly lower on POD 0 (mean ± SD: 7 ± 2 vs. 8 ± 1, respectively; p = .02). This study suggests that our multimodal regimen significantly reduces LOS, PRPS, and opioid requirements and has the potential to improve the donation experience.


Asunto(s)
Laparoscopía , Donadores Vivos , Analgésicos/uso terapéutico , Humanos , Nefrectomía , Estudios Retrospectivos
3.
Transplant Proc ; 53(4): 1360-1364, 2021 May.
Artículo en Inglés | MEDLINE | ID: mdl-33888344

RESUMEN

Acute myeloid leukemia (AML) is a rare malignancy with increased incidence in the kidney transplantation (KT) population for which immunosuppression has been implicated as a putative cause. The average time interval from KT to AML development is 5 years. We present the case of a 61-year-old man who was found to have peripheral blood blasts on a postoperative day 20 routine blood draw after an uneventful unrelated living donor kidney transplant. He subsequently had a bone marrow biopsy and next-generation sequencing (NGS)-based molecular testing, which demonstrated AML characterized by SMC1A and TET2 mutations. He received induction chemotherapy followed by hematopoietic cell transplantation (HCT) from the kidney donor, who happened to be matched at one haplotype. At 12 months after his HCT and 15 months after his KT, his AML remained in remission, normal renal function was preserved, no active graft-versus-host disease was present, and immunosuppression was tapering. With full donor-derived hematopoietic chimerism, we expect to be able to discontinue immunosuppression shortly, thereby achieving tolerance. The short time interval between KT and development of AML suggests the malignancy was likely present before KT. Modern NGS-based analysis offers a promising method of identifying transplant candidates with unexplained hematologic abnormalities on pre-KT testing who may benefit from formal hematologic evaluation.


Asunto(s)
Trasplante de Riñón/efectos adversos , Leucemia Mieloide Aguda/diagnóstico , Médula Ósea/patología , Proteínas de Ciclo Celular/genética , Quimerismo , Proteínas Cromosómicas no Histona/genética , Proteínas de Unión al ADN/genética , Dioxigenasas , Enfermedad Injerto contra Huésped/etiología , Haplotipos , Trasplante de Células Madre Hematopoyéticas , Humanos , Leucemia Mieloide Aguda/etiología , Leucemia Mieloide Aguda/genética , Leucemia Mieloide Aguda/terapia , Donadores Vivos , Masculino , Persona de Mediana Edad , Mutación , Proteínas Proto-Oncogénicas/genética , Inducción de Remisión
4.
Transpl Infect Dis ; 23(4): e13573, 2021 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-33527728

RESUMEN

Cytomegalovirus (CMV) is a significant cause of morbidity in kidney transplant recipients (KTR). Historically at our institution, KTR with low and intermediate CMV risk received 6 months of valganciclovir if they received lymphocyte depleting induction therapy. This study evaluates choice and duration of CMV prophylaxis based on donor (D) and recipient (R) CMV serostatus and the incidence of post-transplant CMV viremia in low (D-/R-) and intermediate (R+) risk KTR receiving lymphocyte-depleting induction therapy. A protocol utilizing valacyclovir for 3 months for D-/R- and valganciclovir for 3 months for R+ was evaluated. Adult D-/R- and R+ KTR receiving anti-thymocyte globulin, rabbit or alemtuzumab induction from 8/20/2016 to 9/30/2018 were evaluated through 1 year post-transplant. Patients were excluded if their CMV serostatus was D+/R-, received a multi-organ transplant, or received basiliximab. Seventy-seven subjects met the inclusion criteria: 25 D-/R- (4 historic group, 21 experimental group) and 52 R+ (31 historic, 21 experimental). No D-/R- patients experienced CMV viremia. Among the R+ historic and experimental groups, there was no significant difference in viremia incidence (35.5% vs 52.4%; P = .573). Of these cases, the peak viral load was similar between the groups (median [IQR], 67 [<200-444] vs <50 [<50-217]; P = .711), and there was no difference in the incidence of CMV syndrome (16.1% vs 14.3%; P = 1.000) or CMV related hospitalization (12.9% vs 14.3%; P = 1.000). No patient experienced tissue invasive disease. These results suggest limiting valganciclovir exposure may be possible in low and intermediate risk KTR receiving lymphocyte-depleting induction therapy with no apparent impact on CMV-related outcomes.


Asunto(s)
Citomegalovirus , Trasplante de Riñón , Animales , Antivirales/uso terapéutico , Ganciclovir/uso terapéutico , Humanos , Trasplante de Riñón/efectos adversos , Linfocitos , Conejos , Estudios Retrospectivos
6.
Transplant Proc ; 53(3): 865-871, 2021 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-33358526

RESUMEN

BACKGROUND: In December 2014, the Kidney Donor Profile Index (KDPI) was developed to give more precise information on donor kidney quality. Kidneys with KDPI scores ≥ 85 (K ≥ 85) have been reported to have inferior outcomes to kidneys with KDPI scores < 85. METHODS: After the implementation of the new Kidney Allocation System, we developed a protocol to evaluate K ≥ 85 use. We analyzed the safety and efficacy of our institutional criteria and evaluated post-transplant outcomes. K ≥ 85 recipients were stratified based on their 1-year creatinine and estimated glomerular filtration rates to elucidate characteristics associated with serum creatinine < 1.7 mg/dL or estimated glomerular filtration rates ≤ 45 mL/min/1.73 m2. RESULTS: From December 2014 to December 2019, 304 deceased donor kidney transplants were performed at Hartford Hospital; 58 (19%) were K ≥ 85 with an average KDPI of 91%. There were 4 graft losses; 2 were death censored. Prolonged cold ischemia time and black recipient race were associated with inferior recipient graft function at 1 year. CONCLUSIONS: High KDPI kidney use requires a multifaceted evaluation that takes into account donor and recipient characteristics for an ideal match. We have identified several characteristics that may predict optimal post-transplant kidney function.


Asunto(s)
Fallo Renal Crónico/cirugía , Trasplante de Riñón/mortalidad , Selección de Paciente , Donantes de Tejidos/estadística & datos numéricos , Obtención de Tejidos y Órganos/métodos , Adulto , Isquemia Fría/mortalidad , Creatinina/sangre , Femenino , Tasa de Filtración Glomerular , Supervivencia de Injerto , Humanos , Riñón/fisiopatología , Fallo Renal Crónico/mortalidad , Fallo Renal Crónico/fisiopatología , Trasplante de Riñón/métodos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Trasplantes/fisiopatología
7.
Liver Transpl ; 26(10): 1254-1262, 2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-32657478

RESUMEN

The prevalence of substance use disorder in the liver transplantation (LT) population makes postoperative pain management challenging. We report our initial experience with a novel, comprehensive, multidisciplinary opioid avoidance pathway in 13 LT recipients between January 2018 and September 2019. Patients received comprehensive pre-LT education on postoperative opioid avoidance by the surgeon, pharmacist, and psychologist at the time of listing. Immediately after LT, patients received a continuous incisional ropivacaine infusion, ketamine, acetaminophen, and gabapentin as standard nonopioid medications; rescue opioids were used as needed. We compared outcomes with a historical cohort of 27 LT recipients transplanted between August 2016 and January 2018 managed primarily with opioids. On average, opioid avoidance patients used 92% fewer median (interquartile range [IQR]) morphine milligram equivalents (MMEs) versus the historical cohort (7 [1-11] versus 87 [60-130] MME; P < 0.001) per postoperative day over a similar length of stay (8 [7-10] versus 6 [6-10] days; P = 0.14). Fewer outpatient MMEs were prescribed within the first 60 days after LT in the opioid avoidance group versus the historical cohort: 125 (25-150) versus 270 (0-463) MME (P = 0.05). This proof-of-concept study outlines the potential to profoundly reduce opioid utilization in the LT population using a comprehensive multidisciplinary approach.


Asunto(s)
Analgésicos no Narcóticos , Trasplante de Hígado , Trastornos Relacionados con Opioides , Analgésicos Opioides/efectos adversos , Humanos , Trasplante de Hígado/efectos adversos , Trastornos Relacionados con Opioides/tratamiento farmacológico , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/prevención & control , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & control
8.
Transpl Infect Dis ; 22(6): e13367, 2020 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-32533615

RESUMEN

The clinical course and outcomes of immunocompromised patients, such as transplant recipients, with COVID-19 remain unclear. It has been postulated that a substantial portion of the disease burden seems to be mediated by the host immune activation to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Herein, we present a simultaneous heart-kidney transplant (SHKT) recipient who was hospitalized for the management of respiratory failure from volume overload complicated by failure to thrive, multiple opportunistic infections, and open non-healing wounds in the setting of worsening renal dysfunction weeks prior to the first case of SARS-CoV-2 being detected in the state of Connecticut. After his third endotracheal intubation, routine nucleic acid testing (NAT) for SARS-CoV-2, in anticipation of a planned tracheostomy, was positive. His hemodynamics, respiratory status, and ventilator requirements remained stable without any worsening for 4 weeks until he had a negative NAT test. It is possible that the immunocompromised status of our patient may have prevented significant immune activation leading up to clinically significant cytokine storm that could have resulted in acute respiratory distress syndrome and multisystem organ failure.


Asunto(s)
COVID-19/inmunología , Cardiomiopatía Dilatada/cirugía , Trasplante de Corazón , Huésped Inmunocomprometido/inmunología , Inmunosupresores/uso terapéutico , Fallo Renal Crónico/cirugía , Trasplante de Riñón , Desnutrición/inmunología , Infecciones Oportunistas/inmunología , Antibióticos Antineoplásicos/efectos adversos , Virus BK , Bacteriemia/complicaciones , Bacteriemia/inmunología , COVID-19/complicaciones , Prueba de Ácido Nucleico para COVID-19 , Cardiomiopatía Dilatada/inducido químicamente , Cardiomiopatía Dilatada/complicaciones , Cardiotoxicidad , Doxorrubicina/efectos adversos , Rechazo de Injerto/prevención & control , Infecciones por Bacterias Grampositivas/complicaciones , Infecciones por Bacterias Grampositivas/inmunología , Humanos , Hallazgos Incidentales , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/terapia , Masculino , Desnutrición/complicaciones , Staphylococcus aureus Resistente a Meticilina , Persona de Mediana Edad , Ácido Micofenólico/uso terapéutico , Infecciones Oportunistas/complicaciones , Infecciones por Polyomavirus/complicaciones , Infecciones por Polyomavirus/inmunología , Complicaciones Posoperatorias/terapia , Prednisona/uso terapéutico , Diálisis Renal , SARS-CoV-2 , Infecciones Estafilocócicas/complicaciones , Infecciones Estafilocócicas/inmunología , Infección de la Herida Quirúrgica/complicaciones , Infección de la Herida Quirúrgica/inmunología , Tacrolimus/uso terapéutico , Traqueostomía , Infecciones Tumorales por Virus/complicaciones , Infecciones Tumorales por Virus/inmunología , Enterococos Resistentes a la Vancomicina , Viremia/complicaciones , Viremia/inmunología , Desequilibrio Hidroelectrolítico/complicaciones , Desequilibrio Hidroelectrolítico/terapia
9.
Transpl Infect Dis ; 22(5): e13332, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-32428334

RESUMEN

Noncirrhotic hyperammonemia (NCH) is a rare but often fatal complication of solid organ transplantation. We present a case wherein an infectious cause of NCH was suspected following kidney transplantation (KT) and the patient was promptly started on empirical antibiotic treatment which proved to be lifesaving. A 56-year-old Chinese woman with a past medical history of end-stage renal disease secondary to ischemic nephropathy and cerebrovascular accident received a kidney from a 52-year-old brain-dead donor with a Kidney Donor Profile Index score of 70%. She experienced immediate graft function and was discharged on post-operative day (POD) 4. On POD 10, she presented with a fever, acute onset of confusion, and abdominal pain. Her mental status deteriorated and required emergent intubation. Empiric broad-spectrum antibiotics were initiated. On hospital day 3, a serum ammonia was 889 µmol/L (normal <53 µmol/L). A urine sample was sent for Ureaplasma polymerase chain reaction (PCR) testing, and moxifloxacin and doxycycline were empirically started. Her ammonia rapidly normalized, and her mental status improved 48 hours after antibiotic initiation. She was extubated 5 days into treatment and was discharged after an 11-day hospitalization. Following discharge, her urine test resulted positive for Ureaplasma parvum or Ureaplasma urealyticum DNA detection with the 16S rRNA gene amplification probe. Mental status changes and hyperammonemia in the first 30 days post-KT should raise suspicion for NCH, and prompt empiric treatment with antimicrobials covering Ureaplasma and Mycoplasma should be considered.


Asunto(s)
Hiperamonemia , Trasplante de Riñón , Infecciones por Ureaplasma , Femenino , Humanos , Persona de Mediana Edad , ARN Ribosómico 16S , Ureaplasma
10.
CEN Case Rep ; 9(2): 182-185, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-31989454

RESUMEN

Spontaneous native kidney rupture (SNKR) is a rare occurrence, commonly associated with underlying renal tumors or acquired renal cystic disease in both the kidney transplant (KT) and non-KT populations. Herein, we present a 65-year-old African American man who experienced a non-malignant SNKR 6 days after a deceased donor KT and underwent emergent native nephrectomy. The patient's hospital course was complicated by thrombocytopenia and refractory hypertension. He experienced delayed graft function and was maintained on hemodialysis until post-operative day 30. This case demonstrates an unusual presentation of SNKR in the immediate post-KT setting and illustrates the clinical decision-making algorithm.


Asunto(s)
Infecciones por VIH/complicaciones , Trasplante de Riñón/efectos adversos , Riñón/patología , Complicaciones Posoperatorias/fisiopatología , Negro o Afroamericano/etnología , Anciano , Cadáver , Funcionamiento Retardado del Injerto/etiología , Funcionamiento Retardado del Injerto/terapia , Humanos , Hipertensión/tratamiento farmacológico , Masculino , Nefrectomía/métodos , Diálisis Renal/métodos , Rotura Espontánea/complicaciones , Rotura Espontánea/diagnóstico , Rotura Espontánea/cirugía , Trombocitopenia/terapia , Donantes de Tejidos , Tomografía Computarizada por Rayos X/métodos , Resultado del Tratamiento
11.
Transplant Proc ; 51(10): 3244-3251, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31753420

RESUMEN

OBJECTIVE: Kidney Donor Profile Index (KDPI) and cold ischemic time (CIT) independently influence recipient outcomes after kidney transplantation; however, the compound effect of these variables on posttransplant outcomes is unknown. DESIGN: The Scientific Registry of Transplant Recipients database of deceased-donor kidney transplant recipients between January 2012 and December 2016 was reviewed. Recipients were stratified based on their KDPI (0%-20%, 21%-85%, 86%-100%) and then based on CIT (0-12, 13-24, 25-30, 31-36, ≥ 37 hours). The primary outcome is 1-year allograft loss. Secondary outcomes include primary nonfunction, delayed graft function, biopsy-proven rejection, and 1-year recipient mortality. RESULTS: Allograft loss was not affected by CIT for KDPI 0% to 20% (P = .898) or KDPI 86% to 100% (P = .731), but was significantly different for KDPI 21% to 85% (P < .001). The KDPI 21% to 85% group was the only group with a significant difference in primary nonfunction, demonstrating a linear rise with increasing CIT (P < .001). CIT did not affect recipient mortality for any KDPI group (KDPI 0%-20%, P = .306; KDPI 21%-85%, P = .098; KDPI 86%-100%, P = .774). Incidence of delayed graft function was greater for each KDPI group (P < .001) with increased CIT. Biopsy-proven rejection was not affected by CIT for KDPI 21% to 85% (P = .244) or KDPI 86% to 100% (P = .946). For KDPI 0% to 20%, there was a significant difference (P = .024); however, the incidence was not linear with increasing CIT. For the KDPI 86% to 100% group, incidence of mortality, allograft loss, primary nonfunction, and biopsy-proven rejection did not differ between CIT groups. CONCLUSIONS: Extended CIT alone should not hinder utilization of higher KDPI organs.


Asunto(s)
Isquemia Fría/efectos adversos , Funcionamiento Retardado del Injerto/etiología , Supervivencia de Injerto , Fallo Renal Crónico/cirugía , Trasplante de Riñón/mortalidad , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Donantes de Tejidos , Receptores de Trasplantes , Trasplante Homólogo
12.
Transpl Infect Dis ; 21(5): e13144, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31291501

RESUMEN

Post-transplant lymphoproliferative disorder (PTLD) is an uncommon, but well-described complication after liver transplantation. Most recently, Hepatitis C virus (HCV) has been implicated in the development of PTLD. A HCV-negative 62-year-old man with autoimmune hepatitis received a HCV nucleic acid amplification test-positive liver graft from a 73-year-old brain-dead donor (D+/R-). After his recovery from the operation, the patient was treated for HCV and achieved an undetectable viral load. He was readmitted 6 months after transplant with a spontaneous perisplenic hematoma, weight loss, failure to thrive, low-grade fevers, and abnormal liver function tests. He had a rapid clinical deterioration and expired shortly after admission. His liver biopsy demonstrated EBV-negative monomorphic B-cell PTLD. Our case is the first to report an aggressive early-onset EBV-negative monomorphic B-cell PTLD in a HCV D+/R- liver transplant. This case illustrates the paucity of knowledge on HCV seroconversion and its involvement in EBV-negative monomorphic B-cell PTLD development.


Asunto(s)
Linfocitos B/patología , Hepatitis C/transmisión , Trasplante de Hígado/efectos adversos , Trastornos Linfoproliferativos/diagnóstico , Seroconversión , Trasplantes/virología , Infecciones por Virus de Epstein-Barr , Herpesvirus Humano 4 , Humanos , Trastornos Linfoproliferativos/virología , Masculino , Persona de Mediana Edad , Donantes de Tejidos , Carga Viral
13.
World J Hepatol ; 10(3): 388-395, 2018 Mar 27.
Artículo en Inglés | MEDLINE | ID: mdl-29599902

RESUMEN

We report the first case of a healthy 23-year-old female who underwent an interventional radiology-guided embolization of a hepatic adenoma, which resulted in a gas forming hepatic liver abscess and septicemia by Clostridium paraputrificum. A retrospective review of Clostridial liver abscesses was performed using a PubMed literature search, and we found 57 clostridial hepatic abscess cases. The two most commonly reported clostridial species are C. perfringens and C. septicum (64.9% and 17.5% respectively). C. perfringens cases carried a mortality of 67.6% with median survival of 11 h, and 70.2% of the C. perfringens cases experienced hemolysis. All C. septicum cases were found to have underlying liver malignancy at the time of the presentation with a mortality of only 30%. The remaining cases were caused by various Clostridium species, and this cohort's clinical course was significantly milder when compared to the above C. perfringens and C. septicum cohorts.

14.
Ann Pharmacother ; 51(1): 21-26, 2017 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-27609941

RESUMEN

BACKGROUND: Postoperative pain is a common complication of laparoscopic living-donor nephrectomies (LLDNs). OBJECTIVE: To determine whether intravenous (IV) acetaminophen administration post-LLDN influenced length of stay (LOS) when used for pain management. METHODS: This single-center, retrospective study compared patients undergoing LLDN who had received IV acetaminophen for pain control versus those who did not between June 1, 2011, and November 30, 2015. Patient LOS, 30-day readmissions, frequency of pain assessments, patient-reported pain scores, and opioid administration were assessed. RESULTS: A total of 90 patients were included in the analysis (IV acetaminophen, n = 48; non-IV acetaminophen, n = 42). Patients who did not receive IV acetaminophen were more often older (48.8 ± 12.1 vs 39.3 ± 12.1 years; P = 0.012) and female (71.4% vs 47.9%; P < 0.001). The average LOS was similar between the 2 groups (median = 3.0; interquartile range = [3, 4] vs 3.5 [3, 4]; P = 0.737). The 30-day readmissions were higher in the IV acetaminophen group (16.7%) compared with the group not receiving IV acetaminophen (2.4%; P = 0.033). After the first postoperative day, the frequencies of pain assessments performed were similar among the 2 groups. There was no difference in average pain scores between the groups at any time after LLDN. CONCLUSIONS: Patients receiving IV acetaminophen were found to have no improvements in hospital LOS, average pain score, or opioid requirements compared with patients not receiving IV acetaminophen. Patients who received IV acetaminophen were also found to have a higher 30-day readmission rate.


Asunto(s)
Acetaminofén/administración & dosificación , Analgésicos no Narcóticos/administración & dosificación , Trasplante de Riñón , Donadores Vivos , Nefrectomía/métodos , Manejo del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Acetaminofén/uso terapéutico , Administración Intravenosa , Adulto , Anciano , Analgésicos no Narcóticos/uso terapéutico , Analgésicos Opioides/administración & dosificación , Femenino , Humanos , Infusiones Intravenosas , Laparoscopía , Tiempo de Internación , Trasplante de Hígado , Masculino , Persona de Mediana Edad , Dimensión del Dolor/enfermería , Readmisión del Paciente , Estudios Retrospectivos
15.
Ann Pharmacother ; 50(5): 369-75, 2016 May.
Artículo en Inglés | MEDLINE | ID: mdl-26847860

RESUMEN

BACKGROUND: Impaired glucose regulation posttransplantation can affect allograft survival and may lead to the development of posttransplant diabetes mellitus (PTDM). OBJECTIVES: The primary purpose of this study is to assess the difference in insulin burden between liver transplant patients who develop PTDM and patients who do not. METHODS: This was a single-center, retrospective study. Adult liver transplant recipients transplanted between January 1, 2005, and August 1, 2013, were included. PTDM was defined as: (1) use of an oral antihyperglycemic agent for ≥30 consecutive days after transplant, (2) use of insulin ≥30 consecutive days after transplant, or (3) hemoglobin A1C≥6.5 any time after transplant. RESULTS: Of the 114 patients included, 48 (42%) developed PTDM. The average 24-hour insulin requirement on the medical floors was 17.2 ± 14.5 units in the PTDM group and 11.3 ± 12.2 units in the PTDM-free group;P= 0.02. The average blood glucose level on the medical floor was 184.7 ± 31.5 mg/dL in the PTDM group and 169.3 ± 31.4 mg/dL in the PTDM-free group;P= 0.013. Multivariate analysis revealed that experiencing rejection was positively associated with the development of PTDM: adjusted odds ratio (AOR) = 3.237; 95% CI = 1.214-8.633. Basiliximab was negatively associated with the development of PTDM: AOR = 0.182; 95% CI = 0.040-0.836. CONCLUSION: Univariate analyses suggest that insulin burden is a positive risk factor for the development of PTDM; this association is lost in multivariate analyses. Rejection was a positive predictor, and use of basiliximab was a negative predictor for the development of PTDM.


Asunto(s)
Diabetes Mellitus/tratamiento farmacológico , Hipoglucemiantes/efectos adversos , Insulina/efectos adversos , Trasplante de Hígado , Complicaciones Posoperatorias/tratamiento farmacológico , Adulto , Diabetes Mellitus/etiología , Femenino , Rechazo de Injerto/etiología , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Retrospectivos , Factores de Riesgo
16.
Pharmacotherapy ; 36(4): e18-22, 2016 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-26892892

RESUMEN

Pregnancy in solid organ transplant recipients carries numerous risks to the mother such as increased risk of rejection, gestational diabetes mellitus, and preeclampsia. The developing fetus is subjected to risks such as birth defects, preterm delivery, and low birth weight. Typically, these risks can be managed through intensive, multidisciplinary prenatal care and a proper immunosuppressive regimen. In the setting of rejection, however, little data are available to suggest safe and effective treatment of acute cellular rejection, antibody-mediated rejection, or mixed rejection episodes in the pregnant solid organ transplant recipient. We describe the first case, to our knowledge, in which antithymocyte globulin (rabbit) was used to successfully treat a pregnant renal transplant recipient who experienced a mixed rejection episode. A 22-year-old, African American woman with stage 6 chronic kidney disease received a deceased donor renal transplant after undergoing hemodialysis for 3 years. Her maintenance immunosuppressive regimen at the time of transplantation consisted of tacrolimus, prednisone, and mycophenolate mofetil. Despite counseling efforts on the importance of having a planned pregnancy after kidney transplantation so that her immunosuppressive medications could be optimized, the patient became pregnant 12 months later; her mycophenolate mofetil was changed to azathioprine to reduce the risk of fetal deformities or death. Three months later, the patient was admitted for biopsy of her transplanted kidney and was evaluated for possible kidney rejection. After confirmation of a mixed 1B acute cellular rejection and antibody-mediated rejection episode, the patient decided to pursue resolution of her rejection episode and continue the pregnancy despite the potential risks to the fetus. She was treated with high-dose corticosteroids, intravenous immunoglobulin, plasmapheresis, and antithymocyte globulin (rabbit). Twenty-nine months after transplantation, the patient was induced and gave birth to a healthy baby boy. Our patient's case offers unique insight into the potential management of a rejection episode requiring aggressive immunosuppressive therapy. Although potent immunosuppressive therapies were successfully used in our patient, further studies are needed to make definitive recommendations regarding the use of such therapies for treatment of rejection episodes in pregnant solid organ transplant recipients. The risks and uncertainties of treating rejection episodes should always be discussed with and understood by the patient before an informed decision is made.


Asunto(s)
Suero Antilinfocítico/uso terapéutico , Rechazo de Injerto/tratamiento farmacológico , Inmunosupresores/uso terapéutico , Trasplante de Riñón/efectos adversos , Complicaciones del Embarazo/tratamiento farmacológico , Embarazo de Alto Riesgo , Adulto , Animales , Suero Antilinfocítico/efectos adversos , Terapia Combinada , Femenino , Retardo del Crecimiento Fetal/etiología , Rechazo de Injerto/patología , Rechazo de Injerto/fisiopatología , Rechazo de Injerto/terapia , Humanos , Inmunosupresores/efectos adversos , Recién Nacido , Fallo Renal Crónico/cirugía , Trabajo de Parto Inducido , Masculino , Embarazo , Complicaciones del Embarazo/patología , Complicaciones del Embarazo/fisiopatología , Complicaciones del Embarazo/terapia , Conejos , Índice de Severidad de la Enfermedad , Nacimiento a Término , Resultado del Tratamiento , Adulto Joven
17.
J Vasc Access ; 17(1): 47-54, 2016.
Artículo en Inglés | MEDLINE | ID: mdl-26165814

RESUMEN

INTRODUCTION: Cryopreserved vein allografts (cadaveric vein) have emerged as an option for arteriovenous graft reconstruction; however, indications for their use in hemodialysis access remains to be clearly defined. Observations from our own experience have suggested that cadaveric vein grafts (CVGs) provide good outcomes, particularly in patients with a history of infection, recurrent access failure and advanced age. METHODS: This is a 10-year retrospective study. Primary outcomes were (1) to identify characteristics specific to this patient population and (2) to better define indications for use of cadaveric vein in hemodialysis access creation. RESULTS: Indications for creation of CVGs included patient history of either active or recent infection (41.5%), recurrent access failure (43.4%) or surgeon preference secondary to patients' advanced age (9.4%). Observed primary patency rates were 84.9% (30 days), 22.6% (1 year) and 16.0% (2 years). Secondary patency was 93.4% (30 days), 66.0% (1 year) and 52.8% (2 years). Patient death was the highest cause of graft abandonment (52.9%) followed by thrombosis (19.1%), infection (11.7%) and rupture (11.7%). CVG patency at the time of patient death was 83.7%. CONCLUSIONS: The rates of both primary and secondary patency in CVGs are highly comparable to the reported patency rates of polytetrafluoroethylene (PTFE) grafts and allow for lifelong maintenance of dialysis access. Our observed outcome suggests that CVGs should be considered for patients needing vascular access in the presence of infection. CVGs may likewise be viable alternatives to PTFE grafts in the elderly and patients with limited access options.


Asunto(s)
Derivación Arteriovenosa Quirúrgica/instrumentación , Bioprótesis , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Criopreservación , Diálisis Renal , Venas/trasplante , Adulto , Anciano , Aloinjertos , Derivación Arteriovenosa Quirúrgica/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Femenino , Oclusión de Injerto Vascular/etiología , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular
20.
Surg Innov ; 20(2): 126-33, 2013 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-22696028

RESUMEN

BACKGROUND: The authors recently published their experience of recanalizing umbilical veins in deceased liver donors, with recanalized umbilical veins as vascular conduits for meso-Rex bypass procedures. They have since found recanalized umbilical veins to be an excellent, easy to harvest vascular conduit that can be used for multiple vascular procedures and repair. Here, they report their experience using this vessel for bypass and vascular reconstruction. METHODS: They have recanalized umbilical veins and used them in a total of 5 Meso-Rex bypasses; 5 pancreaticoduodenectomies; 1 left hepatic trisegmentectomy with right portal vein (PV) resection and reconstruction; 1 right hepatectomy and 1 adrenalectomy, both with partial inferior vena cava (IVC) resection and reconstruction; 1 coronary-Rex bypass shunt for extrahepatic PV thrombosis; and 1 orthotopic liver transplantation with infrahepatic IVC anastomotic dehiscence patched with umbilical vein graft. Umbilical veins were dilated mechanically and used in situ for the meso-Rex bypass surgery; they were ligated in the space of Rex and then dilated ex vivo otherwise to be used as interposition grafts or a vein patch. RESULTS: A total of 15 hepato-pancreato-biliary procedures were done using the recanalized umbilical vein as graft; 2 patients required thrombectomy postoperatively with reexploration, venotomy, thrombectomy with fogarty catheter, and venotomy closure. CONCLUSION: The umbilical vein graft is a fine vascular conduit and can serve many purposes in hepatobiliary surgery.


Asunto(s)
Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/métodos , Prótesis Vascular , Procedimientos Quirúrgicos del Sistema Digestivo/instrumentación , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Vena Porta/cirugía , Venas Umbilicales/cirugía , Adolescente , Adrenalectomía , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Hepatectomía , Humanos , Hígado/irrigación sanguínea , Hígado/cirugía , Trasplante de Hígado , Masculino , Persona de Mediana Edad , Páncreas/irrigación sanguínea , Páncreas/cirugía , Pancreaticoduodenectomía , Complicaciones Posoperatorias , Estudios Retrospectivos , Resultado del Tratamiento
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