Mortality risk factors in critical post-surgical patients treated using continuous renal replacement techniques.

OBJECTIVE: To determine the influence of demographics, medical, and surgical variables on 30-day mortality in patients who need continuous renal replacement therapy (CRRT). MATERIALS AND METHODS: A retrospective-following study was conducted using the data of 112 patients admitted to the postoperative intensive care unit who required CRRT, between August 2006 and August 2011, and followed-up for 30 days. The following information was collected: age, gender, history of HBP, DM, cardiovascular disease, and CKD, urgent surgery, surgical speciality, organic dysfunction according to the SOFA scale, the number of organs with dysfunction, use of mechanical ventilation, diagnostic and origin of sepsis, type of CRRT, and 30-day mortality. General linear models were used for estimating the strength of association (relative risk [RR], and 95% confidence interval [CI] between variables and 30-day mortality. RESULTS: In the univariant analysis, the following variables were identified as risk factors for 30-day mortality: age (RR 1.04; 95% CI 1.01-1.06; P=.0005), and history of cardiovascular disease (RR 1.57; 95% CI 1.02-2.41; P=.039). Among the variables included in the multivariable analysis (age, history of cardiovascular disease, sepsis, and number of organs with dysfunction), only age was identified as an independent risk factor for 30-day mortality (RR 1.03; 95% CI 1.00-1.05; P=.007). CONCLUSION: Thirty-day mortality in postoperative, critically ill patients who require CRRT is high (41.07%). Age has been identified as an independent risk factor, with renal failure as the most common indication for the use of these therapies.

Analysis of patients referred to a lung transplantation unit.

This cross-sectional, concurrent and descriptive study presents the decisions regarding patients referred to our Lung Transplantation Unit (LTxU). Each patient is discussed in a multidisciplinary clinical session (phase I), rejecting some and accepting others for assessment in our LTxU (phase II) according to criteria of the National and International Guidelines for Transplantation. A protocol assessment in phase II, leads to a decision to reject, accept, or follow-up the candidate for LTx. Among 214 evaluation requests received in our unit from May 2008 to December 2011, 37 patients (17%) were rejected based on the information sent to our LTxU. Among the patients evaluated in phase II, 62 (28.9%) were put on the waiting list, 125 (58.4%) were rejected, and twenty-seven (12.6%) were postponed for future reconsideration, results that were similar to those described in the literature. The main disease referred for LTx was obstructive airflow (n = 98; 45.7%), followed by interstitial lung disease (ILD; n = 66; 30.8%), cystic fibrosis or bronchiectasis (n = 20; 9.3%), or primary pulmonary hypertension group 1 (n = 20; 9.3%). Ten patients (4.6%) were diagnosed with other respiratory diseases. Most patients (n = 165; 77.1%) lived in the region of our hospital (Madrid). The main reasons to reject patients for LTx were malnutrition, severe disease in other organs, toxic habits, and refusal of treatment. Finally, one out of four referred patients was accepted for LTx. In addition to serious comorbidities in various organs, a high percentage of patients who were not accepted for LTx because of these factors might have been of accepted had these conditions been corrected before patient referral.

[Spanish Society of Anaesthesia (SEDAR) guidelines for pre-anaesthesia checking procedures]. / Directrices de procedimientos de comprobación y validación («chequeo¼) previos a la anestesia de la Sociedad Española de Anestesiología.

We present this document as a guide to preparing a specific institutional pre-anaesthesia checklist, as recommended in the Helsinki declaration on patient safety in anaesthesiology. Also, the recently recommended WHO "safe surgery check-list" includes a check-list for anaesthesia. A working group was established in accordance with the charter of the Spanish Society of Anaesthesiology and Resuscitation (Sociedad Española de Anestesiología y Reanimación [SEDAR]). The new patient safety culture introduced into medicine, and the recommendations of European anaesthesia societies has led us to design and update protocols in order to improve results in this important part of our speciality. We have prepared these recommendations or guidelines using, as examples, updates of pre-anaesthesia check-lists by other American (ASA), British, or Canadian societies of anaesthesia. With that aim, we enlisted the help of anaesthesia ventilator experts and the participation and advice of experienced anaesthesiologists from all parts of Spain. After various corrections and modifications, the document was available at www.sedar.es, so that any anaesthesiologist could propose any correction, or give their opinion. Finally, these guidelines have been approved by the SEDAR Board of Directors, before it was sent for publication in this journal. The aims of this document are to provide: a guideline applicable to all anaesthesia machines, a descriptive pre-anaesthesia check-list that include everything necessary for the anaesthesia procedure, and a resumed check-list to be available in all the anaesthesia machines or other equivalent, but prepared for each institution, which should include anaesthetic equipment and drugs. So, in order to ensure the aims and requirements of the European Board of Anaesthesiology, the European Society of Anaesthesiology, and the WHO are met, each institution should have a protocol for checking equipment and drugs. These guidelines are applicable to any anaesthesia equipment, enabling every institution to develop their own checking protocols, adapted to their anaesthesia machines and their procedures. With the consent of the SEDAR, this group will collaborate with anaesthesia machines providers in order to develop specific checklists for each of their models that will be available at www.sedar.es.

Anesthetic management of a combined heart and liver transplantation in an amyloidotic patient: a case report.

Few cases of combined heart and liver transplantation (CHLT) have been reported for familial amyloidosis. Our first CHLT was performed on a female patient with familial amyloidosis due to a genetic defect in transthyretin, characterized by deposition of amyloid in various organs and tissues. This disease produced autonomic heart dysfunction that preceded the development of clinical manifestations and may be an important factor in determining the optimal timing for liver transplantation. CHLT can be performed successfully, even in patients with advanced disease. However, the most compromised patients are more exposed to intraoperative risks, postoperative complications, and worsening of extracardiac and extrahepatic symptoms. Our patient presented severe cardiac dysfunction requiring CHLT. The operative technique is far from being consolidated, despite this, both organs were transplanted in the same day with 2 hours in the intensive care unit (ICU) between surgeries. The outcome of both organs has been favorable. The amyloidotic liver was transplanted to another patient, a sequential (domino) transplantation.

First Spanish series of intestinal transplantation in adult recipients.

BACKGROUND: short-bowel transplantation has experienced a substantial growth worldwide following improved results from the late 1990's on, and its coverage by Medicare. According to the International Registry (1985-2005), a total of 1,292 intestinal transplants for 1,210 patients in 65 hospitals across 20 countries have been carried out thus far. OBJECTIVE: to know short-term (6 months) results regarding patient and graft survival from the first Spanish series of intestinal transplants in adult recipients. MATERIAL AND METHODS: we present our experience in the assessment of 20 potential candidates to short-bowel transplantation between June 2004 and October 2005. Of these, 10 patients were rejected and 4 were transplanted, which makes up the sample of our study. RESULTS: to this date 5 transplants have been carried out in 4 patients (2 retransplants, 2 desmoid tumors, 1 short bowel syndrome after excision as a result of mesenteric ischemia). Upon study completion and after a mean follow-up of 180 days (range 90-190 days) all recipients are alive, and all grafts but one (75%) are fully operational, with complete digestive autonomy. All patients received induction with alemtuzumab except one, who received thymoglobulin; in all induction was initiated with no steroids. CONCLUSIONS: intestinal transplantation represents a therapeutic option that is applicable in our setting and valid for recipients with an indication who have no other feasible alternative to keep their intestinal failure under control.

[Patient with right ventricular arrhythmogenic dysplasia, ascites and ulcerative colitis: anesthetic management during major abdominal surgery]. / Manejo anestésico de un paciente con displasia arritmogénica de ventrículo derecho, ascitis y colitis ulcerosa para una cirugía abdominal mayor.

A 43-year-old man with ulcerative colitis was scheduled for pancolectomy owing to adenomatous transformation of polyps. The patient had right ventricular arrhythmogenic dysplasia, with deteriorating ventricular function, and carried an automatic implantable defibrillator. We discuss the general features of arrhythmogenic right ventricular dysplasia and its implications for management and monitoring during major abdominal surgery. Perioperative management of a patient with an implantable defibrillator is also discussed, with special attention to the influence of electromagnetic interference that can affect how the device functions during surgery. Finally, we list signs that should lead to suspicion of arrhythmogenic right ventricular dysplasia in an asymptomatic patient.

Simultaneous liver-kidney transplantation for adult recipients with irreversible end-stage renal disease.

HYPOTHESIS: Combined liver-kidney transplantation is safe (low morbidity and acceptable mortality) and effective in patients with end-stage liver disease. Although refinements in surgical technique have resulted in better patient and allograft outcomes, the negative impact of renal insufficiency on survival in patients undergoing liver transplantation has been widely reported, although some aspects are controversial. DESIGN: Analysis of the clinical characteristics and outcome in the management of patients undergoing combined liver-kidney transplantation. The end points were operative mortality, morbidity, and long-term survival. SETTING: University Hospital 12 de Octubre. PATIENTS: Between May 1986 and December 2001, 820 liver transplantations were performed. There were 16 cases (1.96%) of combined liver-kidney transplantations, which represent the sample of this study. RESULTS: Mean +/- SD follow-up of 42.2 +/- 29 months: 6 patients died (37.5% mortality rate). There were 4 (25%) hospital deaths within 6 months following surgery and 2 after 6 months (4 sepsis, 1 refractory heart failure, and 1 recurrent hepatitis C virus disease). Univariate analysis related to mortality included age, sex, etiology, preoperative creatinine level, United Network for Organ Sharing status, Child-Pugh score, type of hepatectomy (piggyback), intraoperative blood product administration, and the presence of postoperative complications. The only 2 significant factors were the presence of postoperative complications (P = .01) and the United Network for Organ Sharing status (P = .02). Crude survival rate was 62.5%. Actuarial survival rates were 80%, 71%, and 60% at 1, 3, and 5 years, respectively. CONCLUSION: Because end-stage renal disease is not a formal contraindication for liver transplantation, a combined liver-kidney transplantation for adults with end-stage renal disease can be done safely and effectively.

Simultaneous liver-kidney transplant for combined renal and hepatic end-stage disease.

INTRODUCTION: After the first combined liver-kidney transplantation (CLKT) reported by Margreiter in 1984, it became clear that renal failure was no longer an absolute contraindication. OBJECTIVE: Our goal was to assess our results with combined liver-kidney transplant. Among 875 liver transplants performed between May 1986 and October 2002, there were 17 cases (1.96%) of combined liver-kidney transplant. RESULTS: With a mean follow-up of 42.2+/-29 months (range, 1-90), six patients had died (mortality: 37.5%). There were four (25%) operative in-hospital deaths, and two late mortality cases (beyond the month 6 after hospital discharge). The causes were sepsis (four cases, three postoperative and one in later follow-up), refractory heart failure (one postoperative), and recurrent liver disease (HCV-induced severe recurrence) during follow-up one). Actuarial survival (calculated for those who survived the postoperative period) was 80%, 71%, and 60% at 12, 36, and 60 months. Actuarial mean survival time was 60 months (95%IC:47-78). Neither the sex, the UNOS status, the etiology of liver disease, the etiology of renal failure, the type of hepatectomy (piggy back vs others) or the type of immunosuppression (P=.83) were related to long-term survival according to the log-rank test. A control group of 48 patients was constructed with subjects who underwent liver transplantation immediately before or after the combined transplant. A total (two cases after the CLKT and one case prior to). There were no differences in survival. CONCLUSION: Combined liver-kidney transplant represents a proper therapeutic option for patients with simultaneously failing organs based on long- and short-term outcomes.

The link between excitotoxic oligodendroglial death and demyelinating diseases.

Oligodendrocytes, the myelinating cells of CNS axons, are highly vulnerable to excitotoxic signals mediated by glutamate receptors of the AMPA and kainate classes. Receptors in these cells are commonly activated by glutamate that is released from axons and glial cells. In addition, oligodendrocytes contribute to the control of extracellular glutamate levels by means of their own transporters. However, acute and chronic alterations in glutamate homeostasis can result in overactivation of AMPA and kainate receptors and subsequent excitotoxic oligodendroglial death. Furthermore, demyelinating lesions caused by excitotoxins can be similar to those observed in multiple sclerosis. This, together with the effect of AMPA and kainate receptor antagonists in ameliorating the neurological score of animals with experimental autoimmune encephalomyelitis (an animal model of multiple sclerosis), indicates that oligodendrocyte excitotoxicity could be involved in the pathogenesis of demyelinating disorders.

KA1-like kainate receptor subunit immunoreactivity in neurons and glia using a novel anti-peptide antibody.

Functional kainate receptors can be formed by various combinations of subunits with low (GluR5, GluR6 and GluR7) or high affinity (KA1 and KA2) for kainate. The precise contribution of each subunit to native receptors, as well as their distribution within the central nervous system (CNS) is still unclear. Here, we describe the presence of KA1-like immunoreactivity in both neurons and glial cells of the CNS, using a newly developed antiserum to a specific carboxy terminus epitope of the KA1 subunit. Intense immunoreactivity was observed in the CA3 area of the rat hippocampus. Electron microscopy revealed that immunostaining was present in dendritic structures postsynaptic to commissural-associational fibers, rather than in those contacted by mossy fiber terminals. We also observed immunostaining of CA1 pyramidal cell apical dendrites. In the cerebral cortex, KA1-like immunostaining was observed in many pyramidal neuron somata, mainly in layer V, and along their apical dendrites. A subset of gamma-amino-butyric acidic cells were also intensely stained. In the cerebellum, the antiserum selectively stained Purkinje cell somata and their dendrites as well as Bergmann glial processes. Other types of macroglia were also labeled by the KA1 antiserum. Thus, optic nerve oligodendrocytes both in vitro and in situ and cultured astrocytes were densely stained. Our results indicate that KA1-type subunits are more widely distributed throughout the CNS than previously thought. This newly developed antiserum may help to clarify the properties of kainate receptors containing KA1 or KA1-type subunits within the normal and pathological brain.

Postnatal development of perisomatic GABAergic axon terminals on neurons projecting from area 17 to area 18 of the cat visual cortex.

We have studied the postnatal development of presumptive axon terminals (puncta) which were recognized by antibodies to the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) and were located on the somata of area 17 neurons projecting to the ipsilateral area 18 of the visual cortex in cats ranging from 7 days of age to adulthood. Projection neurons were retrogradely labeled by injection of horseradish peroxidase conjugated to wheat germ agglutinin into the ipsilateral area 18. These neurons were mainly pyramidal in shape at all the developmental stages examined and the adult distribution of labeled cells was reached by 21 days. Subsequent GABA postembedding immunohistochemistry using high-resolution light microscopy was carried out to study the development of GABAergic terminals on cell bodies of identified projecting neurons in layers II-III. At all ages examined, we found perisomatic GABAergic puncta on these cells. Their density showed a significant increase from postnatal days 7 to 45, and then remained largely constant through adulthood. Since GABAergic puncta are considered the light-microscopic correlate of GABAergic synaptic terminals, our results support the idea of a developmentally regulated increase in the inhibitory activity of local interneurons on area 17 pyramidal neurons projecting to area 18 in the cat visual cortex which occurs within the same time frame as that of the acquisition of the mature operation of these cells.

Anesthetic support in synchronous liver and kidney transplantation.

BACKGROUND/AIMS: We performed a retrospective evaluation of 11 patients in the final stages of hepatic disease with chronic kidney failure, in whom simultaneous double liver-kidney transplantation was performed. METHODOLOGY: In the immediate pre-, intra- and postoperative periods, we assessed metabolic, hemodynamic and coagulation parameters; bicarbonate, calcium and inotropic drug requirements; the incidences during reperfusion of the graft; the surgical technique employed; the need for hemodialysis and/or ultrafiltration; and the survival rate of the patients. RESULTS: Of the 11 cases studied, four patients needed hemodialysis, while only one patient needed ultrafiltration; three patients required both techniques, and no dialysis or ultrafiltration was performed in three patients. The following surgical techniques were employed: Total clamping of the inferior vena cava using an external venovenous bypass in two cases; total clamping of the inferior vena cava without an external venovenous bypass in three cases; and partial clamping of the inferior vena cava with preservation of the retrohepatic cava in six cases. The results showed one death in the first postoperative month and two deaths in the course of subsequent follow-up. The survival rate was 72.7%. CONCLUSIONS: The use of conventional intraoperative hemodialysis and/or ultrafiltration is feasible, useful and achieves good results in patients undergoing double liver-kidney transplantation. Partial clamping of the inferior vena cava at the anhepatic stage appears to reduce the need for ultrafiltration. There is no increase in perioperative mortality in patients who underwent liver transplantation while conserving their renal function.

Steroid withdrawal is safe and beneficial in stable cyclosporine-treated liver transplant patients.

BACKGROUND: In the immunosuppression of orthotopic liver transplant recipients, steroids are used despite their unspecific action and long-term side effects. Few studies have been carried out on steroid withdrawal and many aspects remain to be elucidated. METHODS: A prospective study was performed to analyse the effect of steroid withdrawal on 86 patients with stable graft function, more than 1 year after orthotopic liver transplant. Thirty patients had chronic hepatitis in the graft. Seventy-two continued with cyclosporine (CsA) and 14 with CsA-azathioprine (AZA) therapy. The follow-up was 23.2 +/- 8.1 months (range 12-52 months). A paired t-test was used for statistical analysis. RESULTS: No acute or chronic rejection occurred, and steroids were not reinstituted. There were no changes in serum transaminase levels, but bilirubin levels decreased (p < 0.01). At the end of the follow-up, we found improvements in blood pressure in hypertensive patients (systolic 156.1 +/- 8.4 mmHg vs. 139.4 +/- 8.7 mmHg, p < 0.001); body weight (72 +/- 13.5 kg vs. 70.8 +/- 13 kg, p < 0.05); serum cholesterol (211.3 +/- 42 mg/dl vs. 191.6 +/- 43.5 mg/dl, p < 0.001) and bone mineral density in lumbar spine (0.823 +/- 0.13 g/cm2 vs. 0.893 +/- 0.135 g/cm2, p < 0.001). Four of ten diabetic patients were no longer insulin-dependent and insulin requirements decreased in the remaining six. No significant biochemical changes were found in patients with hepatitis in the graft, and we found an improvement in inflammatory activity in the nine biopsied patients. CONCLUSIONS: Steroid withdrawal with CsA monotherapy is feasible, safe and beneficial in patients who have stable liver graft function 1 year after orthotopic liver transplant. We consider that AZA therapy is not necessary unless drastic reduction of CsA levels is required because of renal dysfunction.

[Intraoperative anesthetic management of kidney failure in adult liver transplantation. Conventional hemodialysis]. / Manejo anestésico intraoperatorio del fallo renal en el trasplante hepático del adulto. Hemodiálisis convencional.

OBJECTIVE: To evaluate our application of indications, use and benefits of conventional hemodialysis during surgery in patients with advanced liver disease and acute or chronic renal failure undergoing liver transplantation (LP), liver retransplantation (LRT) or combined hepatorenal transplantation (CHRT). PATIENTS AND METHODS: We retrospectively reviewed the cases of 22 patients with advanced liver disease, 11 with acute renal failure and 11 with chronic renal failure. We performed 6 LT, 5 LRT and 11 CHRT. The following data were recorded in the periods before, during and immediately after surgery: metabolic, hemodynamic and coagulation parameters; bicarbonate, calcium and inotropic drug requirements; incidences during reperfusion of the graft; surgical technique used; and survival. RESULTS: Seven patients (32%) needed hemodialysis, 4 (18%) needed ultrafiltration, 7 (32%) needed both and 4 (18%) required neither. For 6 patients total clamping of the inferior vena cava (ICV) was required with external venovenous bypass. For 8 patients total clamping of the IVC was performed without venovenous bypass. For 8 others IVC clamping was partial with retrohepatic preservation (piggy-back). There were 2 deaths during surgery, 4 more within the first month after surgery and 4 more in the second month. Overall survival was 36.4% among acute patients and 72.7% among CHRT patients. CONCLUSIONS: 1) Conventional hemodialysis during surgery is feasible and gives good results; 2) conventional "high efficiency" hemodialysis is more effective and useful in these patients than is either slow, continuous hemodialysis or filtration; 3) the survival rate of CHRT patients is similar to that of patients undergoing LT with normal kidney function, and 4) partial IVC clamping in the anhepatic phase may decrease the need for ultrafiltration.

Anatomical evidence for glutamate and/or aspartate as neurotransmitters in the geniculo-, claustro-, and cortico-cortical pathways to the cat striate cortex.

Data obtained by using various experimental approaches suggest that in the mammalian brain, most neurons within the visual system projecting to the striate cortex employ excitatory amino acids as transmitters. In order to investigate further the neurotransmitter phenotype of the ipsilateral afferents to area 17 of the cat, we have injected D-[3H]-aspartate, a retrograde tracer which selectively reveals putative glutamatergic and/or aspartatergic pathways, into this area. Retrogradely labelled neurons were observed in the dorsal lateral geniculate nucleus, visual claustrum, cortical areas 18, 19, 21a, and in both posteromedial and posterolateral parts of the suprasylvian areas but not in other known thalamic afferents such as the lateral posterior-pulvinar complex and the intralaminar nuclei. The distribution and localization of the labelled cells in all these regions were similar to that observed by using the non-selective tracer horseradish peroxidase conjugated to wheat germ agglutinin, though the number of cells was higher with the latter. Our findings provide additional evidence for the presence of excitatory amino acids as neurotransmitters in the major afferents to the cat striate cortex.

[Anesthesia in 3 cases of Marfan's syndrome]. / Anestesia en tres casos de síndrome de Marfan.

We report the cases of 3 patients with Marfan's syndrome with a wide range of clinical signs and severe cardiovascular involvement. The first case was an 18-year-old man who received general anesthesia during laparotomy for acute abdomen. Surgery was uneventful, even though emergency conditions precluded a full preoperative workup. In the second case (herniorrhaphy in a 36-year-old man) and the third (total hip replacement in a 23-year-old woman), surgery was scheduled, permitting heart function testing, assessment of previous treatment, premedication and adjustment of length of the surgical table. Surgery was likewise uneventful in the second and third cases.

Localization of AMPA-selective glutamate receptor subunits in the adult cat visual cortex.

We have studied the presence and distribution of alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA)-selective glutamate receptor subunits (GluR1, 2, 3, and 4) in the adult cat visual cortical areas 17, 18, 19, and the lateral suprasylvian areas (LSA). Reverse transcription-polymerase chain reaction (RT-PCR) amplification indicated that the genes encoding GluR1, 2, 3, and 4 are expressed in these areas and Western blot analysis revealed that the size of the corresponding peptides is similar to those described in the rat brain. In situ hybridization (ISH) using digoxigenin-labeled riboprobes showed that mRNAs coding for GluR1 and GluR3 were located in cells in all layers of the areas examined and also in the underlying white matter. GluR1 mRNA was relatively abundant throughout layers II-VI while GluR3 mRNA revealed a more laminated pattern of expression, preferentially labeling cells in layers II, III, V, and VI. The distribution of AMPA-selective receptor subunit peptides was studied by immunohistochemistry using subunit specific antibodies and found to be consistent with ISH results. In addition, we observed that most of the cells strongly labeled by the anti-GluR1 antibody were non-pyramidal neurons and that intense GluR2/3 immunoreactivity was seen preferentially in pyramidal neurons. Interestingly, double-labeling experiments indicated that neurons expressing gamma-aminobutyric acid (GABA) as well as the GluR1 subunit were particularly abundant in deeper layers. The GluR4 peptide was predominantly found in a relatively low number of layer III and layer V neurons with either pyramidal or non-pyramidal morphology. Finally, the distribution of neurons expressing the various receptor subunits was similar in all the visual cortical areas studied. These findings indicate a high expression of GluR1-3 subunits in the cat visual cortex and that GluR1 and GluR2/3 subunits are particularly abundant in non-pyramidal and pyramidal neurons, respectively. In addition, the results described here provide a reference for future studies dealing with the effect of visual deprivation on the expression of this receptor type.