[Primary graft dysfunction after lung transplantation]. / Disfunción primaria del injerto tras el trasplante pulmonar.

Lung transplantation is a therapeutic option for pulmonary diseases in which the other treatment options have failed or in cases of rapid disease progression. However, transplantation is not free from complications, and primary graft dysfunction is one of them. Primary graft dysfunction is a form of acute lung injury. It characteristically develops during the immediate postoperative period, being associated to high morbidity and mortality, and increased risk of bronchiolitis obliterans. Different terms have been used in reference to primary graft dysfunction, leading to a consensus document to clarify the definition in 2005. This consensus document regards primary graft dysfunction as non-cardiogenic pulmonary edema developing within 72 hours of reperfusion and intrinsically attributable to alteration of the lung parenchyma. A number of studies have attempted to identify risk factors and to establish the underlying physiopathology, with a view to developing potential therapeutic options. Such options include nitric oxide and pulmonary surfactant together with supportive measures such as mechanical ventilation or oxygenation bypass.

Pretransplant predictors of early mortality in adult recipients of liver transplantation in the MELD-Na Era. / Predictores pretrasplante de mortalidad precoz en receptores adultos de trasplante hepático en la era MELD-Na.

AIMS: To identify pretransplant predictors of early mortality (90 days after transplantation) and evaluate their discriminating capacity in adult liver transplant recipients (LTR). DESIGN: An observational, retrospective, nested cases-controls study from a consecutive cohort of LTRs was carried out. SETTING: University hospital. PATIENTS: All consecutive LTR between January 2003 and December 2016 were eligible for inclusion. Patients with acute liver failure, previous graft dysfunction, simultaneous multiple organ transplantation, non-heart beating donors, and those needing urgent retransplantation during the study period were excluded. The analysis comprised 471 patients. MAIN VARIABLES OF INTEREST: Pretransplant characteristics were the main variables of interest. The LTR were grouped according to the dependent variable (early mortality). Multivariate logistic regression analysis was conducted to identify predictors of early mortality. The discriminating capacity of the models obtained was evaluated by comparing ROC curves (models versus MELD-Na). RESULTS: The MELD-Na score (OR = 1.069, 95% CI = 1.014-1.127), age > 60 years (OR = 2.479, 95% CI = 1.226-5.015), and LTR height < 163cm (OR = 4.092, 95% CI = 2.115-7.917) were identified as independent predictors of early mortality. The cause of transplantation (hepatocellular carcinoma or decompensated cirrhosis) was identified as a confounding factor. CONCLUSIONS: In LTR due to decompensated cirrhosis, the MELD-Na score, age > 60 years, and height < 163cm are independent predictors of early mortality. These factors provide a better classification model than the MELD-Na score for early post-transplant mortality.

Rescue of Discarded Grafts for Liver Transplantation by Ex Vivo Subnormothermic and Normothermic Oxygenated Machine Perfusion: First Experience in Spain.

BACKGROUND: Ex vivo machine perfusion (MP) has been reported as a possibly method to rescue discarded organs. The main aim of this study was to report an initial experience in Spain using MP for the rescue of severely marginal discarded liver grafts, and to, secondarily, define markers of viability to test the potential applicability of these devices for the real increase in the organ donor pool. METHODS: The study began in January 2016. Discarded grafts were included in a research protocol that consisted of standard retrieval followed by 10 hours of cold ischemia. Next, either normothermic (NMP) or controlled subnormothermic (subNMP) rewarming was chosen randomly. Continuous measurements of portal-arterial pressure and resistance were screened. Lactate, pH, and bicarbonate were measured every 30 minutes. The perfusion period was 6 hours, after which the graft was discarded and evaluated as potentially usable, but never implanted. Biopsies of the donor and at 2, 4, and 6 hours after ex vivo MP were obtained. RESULTS: A total of 4 grafts were included in the protocol. The first 2 grafts were perfused by NMP and grafts 3 and 4 by subNMP. The second and third grafts showed a clear trend toward optimal recovery and may have been used. Lactate dropped to levels below 2.5 mmol/L with stable arterial and portal pressure and resistance. Clear biliary output started during MP. Biopsies showed an improvement of liver architecture with reduced inflammation at the end of the perfusion. CONCLUSION: This preliminary experience has demonstrated the potential of MP devices for the rescue of severely marginal liver grafts. Lactate and biliary output were useful for viability testing of the grafts. The utility of NMP or subNMP protocols requires further research.

Short-term evolution of renal transplant with grafts from donation after cardiac death: Type III Maastricht category.

BACKGROUND: Kidney transplantation from donors after cardiac death (Type III Maastricht category) is a therapeutic option for patients with terminal renal failure. MATERIALS AND METHODS: We present a cohort of 8 patients who received a kidney transplant from donors after cardiac death (DCD). We analyzed the analytical results for the first 6 months after transplantation. RESULTS: We included 8 cases of kidney transplants with organs from DCD (Type III Maastricht category). The mean age of donors was 58.40 ± 4.39 years and 3 (60%) were male. The mean creatinine (Cr) level prior to death was 1.10 ± 0.36 mg/dL. The mean age of recipients was 59.88 ± 10.58 years and 7 (87.5%) were male. Seven patients (87.5%) were on hemodialysis, whereas only 1 (12.5%) was on peritoneal dialysis. The median time on renal replacement therapy was 18 months (range, 2-76). Mean total warm ischemia time (WIT) was 24.88 ± 6.72 minutes, whereas the mean real WIT was 20.13 ± 4.51 minutes. The mean cold ischemia time (CIT) was 6 hours and 12 minutes ± 2 hours. Preimplantation biopsy showed acute tubular necrosis (extensive 40%). Tubular atrophy was mild in 100% of cases. After transplantation, 6 patients (75%) had delayed graft function requiring dialysis sessions whereas 2 patients (25%) did not require renal replacement therapy. Mean Cr level at 1, 3, and 6 months after transplantation was 2.37, 1.75, and 1.17 mg/dL, respectively. CONCLUSION: Kidney transplantation with grafts from donors after cardiac arrest Maastricht Type III evolves favorably in the short term. According to preliminary results, controlled asystole donation could be an effective alternative to transplantation.

[Nodular lymphoid hyperplasia of the intestine. Clinico-pathologic characteristics in 11 cases]. / Hiperplasia linfoide nodular intestinal. Características clínico-patológicas en 11 casos.

The clinical-pathological characteristics of 11 patients with intestinal nodular lymphoid hyperplasia (INLH) are described. Five fulfilled the criteria for Herman's syndrome and presented all or several of the following alterations: dysgammaglobulinemia, recurrent respiratory tract infections, sinusitis, pneumonia and giardiasis; of the remaining six cases, in five gammaglobulin levels were not quantified and in one they were normal. All the patients in this group suffered from recurrent pharyngotonsillitis, and Giardia lamblia was isolated in four. In both groups the INLH occurred in young patients with an average age of 21 years. Eight of the 11 were men. The most frequent symptoms included diarrhea, steatorrhea and weight loss. Radiologically, INLH usually was a finding affecting the jejunum and/or the ileum. Prominent lymph nodes in mucosa and submucosa were documented histologically in all cases, and a large decrease or absence of plasma cells in the lamina propria was seen in 7 of the 11. In spite of the diversity in the treatment schemes instituted, symptoms persisted for months or years after diagnosis. In two cases (one with dysgammaglobulinemia and one without) associated intestinal lymphoma existed. Other associated diseases included non-deforming joint arthritis, erythema nodosum, and intestinal infection by E. coli and Entamoeba histolytica.

Meningioma-like intracranial granulocytic sarcoma (chloroma). Radiologic and surgical findings.

We present the case of a 23 years old female with chronic granulocytic leukemia and two intracranial tumors with all the radiological characteristics of intracranial meningiomas. Successful removal of the largest tumor was accomplished using the technique described for meningiomas. The recovery was very good and the histopathologic diagnosis was of granulocytic sarcoma. Radiotherapy of the second tumor reduced the tumor mass within one month leaving the patient neurologically intact. We recommended surgery in the future treatment of large chloromas.

[Metaplastic carcinoma of the breast as a second neoplasm. Report of a case]. / Carcinoma metaplásico de mama como segunda neoplasia. Informe de un caso.

A patient with a metaplastic breast carcinoma as a second primary carcinoma after a renal pelvis neoplasm, an association not described before, is reported. Her first admission in October 1983 was due to a silent hematuria secondary to a mass in the right kidney. The histopathologic diagnosis was a grade II transitional cell carcinoma of the renal pelvis without distant or regional lymph nodes metastasis. Four years later, a right upper and outer quadrant breast mass was detected. Malignant disease was diagnosed by needle biopsy, and a simple mastectomy (Madden type) was performed. The histologic evaluation showed a metaplastic carcinoma with a pseudosarcomatous appearance: fifteen axillary lymph nodes showed only lymphoreticular hyperplasia. After surgery, the patient received locoregional radiotherapy. At present, eight years and five months after the first malignant neoplasia and four years and four months after the second malignancy, the patient is asymptomatic and free of disease. We comment the prevalence of multiple primary malignant neoplasms, the risk of developing a second tumor after a renal pelvis carcinoma, and the histologic findings and prognostic factors in metaplastic breast carcinoma.

[Non-alcoholic fatty liver: 10 years' experience at the Insituto Nacional de la Nutrición Salvador Zubirán]. / Esteatohepatitis no alcohólica: Experiencia de 10 años en el Instituto Nacional de la Nutrición Salvador Zubirán.

AIM: To describe the characteristics of non-alcoholic steatohepatitis (NASH) at the Instituto Nacional de la Nutricion Salvador Zubiran. MATERIAL AND METHODS: We reviewed all liver biopsy reports from January 1982 to December 1991. From patient records we obtained the following data: clinical, biochemical, imaging studies and we reviewed the histological material. We correlated clinical, biochemical and histological data. RESULTS: From 2963 biopsies reviewed we obtained 16 cases of NASH. We found a 7:1 female/male ratio. Median age was 30 years and six patients were obese. Eleven patients had concomitant disease (diabetes in seven) and nine were using drugs. All had been studied for biochemical abnormalities and were asymptomatic. Ten patients had hepatomegaly and six splenomegaly. Ultrasound suggested the diagnosis in 50% of the cases. All had steatosis, inflammatory infiltrate, necrosis, fibrosis and Mallory bodies at different stages. One case had cirrhosis on initial biopsy and two developed cirrhosis on follow-up (one and eight years later). We did not find any correlation between clinical, biochemical or imaging characteristics and histological findings. When we compared these findings between obese and non obese patients and primary and secondary NASH we did not find any differences between groups. CONCLUSIONS: NASH is infrequent in our institution. The underlying pathogenesis seems to be multifactorial. There is no biochemical-histological correlation. Cirrhosis can develop in some cases.

[Frequency of gastric lymphoma at 6 hospitals in Mexico City]. / Frecuencia de linfoma gástrico en seis hospitales de la Ciudad de México.

BACKGROUND: Gastric lymphoma has been traditionally considered a rare neoplasm that constitutes 1-5% of malignant gastric tumors. Two studies performed in Mexico in 1960 and 1966 found that only 1.9% and 1% of gastric neoplasms were lymphomas. Nevertheless, some studies made in the U.S. and in some European countries in recept decades have revealed an increase in the frequency of this neoplasm. A recent study made at two National Health Institutes in Mexico City (Instituto Nacional de Cancerología and Instituto Nacional de la Nutrición) revealed a remarkable increase in the frequency of gastric lymphoma (9.3% and 10.3%, respectively) in recent years. AIM: To define whether there is an actual increase of lymphoma in our population and whether it includes other hospitals in Mexico City that provides attention to populations different from those who attend referral centers. MATERIALS AND METHODS: Six hospitals in Mexico City were selected, including two National Health Institutes (Instituto Nacional de la Nutrición and Instituto Nacional de Cancerología), two private general hospitals used by patient with a high socioeconomic level (Hospital Español and Hospital Inglés), and two public general hospitals frequented by low-income patients (hospital Juárez and Hospital General de México). In each case, the gastric lymphomas diagnosed in each participant hospitals in the last 5 years were registered. For comparative purpose, diagnosed cases of gastric adenocarcinoma during the same period were also registered. Other types of gastric neoplasms were excluded from the study because they formed a very heterogeneous group and represented a minimal proportion of malignant gastric tumors. Age and sex of each patient were included for all lymphomas. RESULTS: A total of 879 malignant gastric neoplasms were included in our study. The relative percentage for gastric lymphoma by institution in descendent order was Hospital Español 25.4%; Instituto Nacional de la Nutrición 13.7%, Hospital Inglés 11.5%, Hospital General de México 8.5%, Instituto Nacional de Cancerología 6%, and Hospital Juárez 6%. Mean general frequency taking into account the six hospitals was 9.1%. CONCLUSIONS: Frequency of gastric lymphomas in all analyzed institutions was higher than that reported in most series in the medical literature (1-5%) and that reported for the Mexican population in 1960 and 1966. The increase was most remarkable in hospitals attended by patients with high incomes (Hospital Español, Hospital Inglés), although the total number of neoplasms reported by these institutions was smaller than that reported by hospitals were by patients with lower incomes (Hospital Juárez, Instituto Nacional de Cancerología). The reason for this increase is unknown, but one might speculate that some strains of Helicobacter pylori, nutritional factors, and ethnic differences could be involved. Both gastroenterologists and pathologists must recognize the increase of this neoplasm because unlike gastric adenocarcinoma, gastric lymphoma is a curable disease in a high percentage of cases.

[Intestinal lymphoid nodular hyperplasia in a patient with acquired dysgammaglobulinemia, chronic diarrhea, and bacterial overgrowth syndrome]. / Hiperplasia nodular linfoide intestinal en un paciente con disgamaglobulinemia adquirida, diarrea crónica y síndrome de sobrepoblación bacteriana.

The association between intestinal nodular lymphoid hyperplasia (INLH) and acquired dysgammaglobulinemia was first described by Hermans et al in 1966. One of the largest series reported in the literature is mexican. We described the clinical out come of a young man with diarrhea, steatorrhea and history of upper respiratory tract infections in whom INLH was established by clinical, radiological, endoscopic and histopathologic studies. Jejunal fluid showed infection by E. coli, C. freundii and Candida albicans as well as cysts of Giardia lamblia. Serum concentration of Ig A and Ig M were decreased. As well as B lymphocytes count in peripheral blood. The patient received treatment with itraconazole, ciprofloxacin and furazolidone with an excellent response. At present he is asymptomatic with cyclic doses of antibiotics and parenteral administration of gammaglobulins.

[Diarrhea as clinical expression of gastrinoma. A case report]. / Diarrea como expresión clínica de gastrinoma. Informe de un caso.

We present a case of Zollinger Ellison Syndrome (ZES), that manifested itself as chronic diarrhea, without the presence of peptic ulcer disease. The purpose of this work in to report a case of ZES with and unusual clinical manifestation and to review the diagnostic methods (gastrin, secretin stimulation and angiotomography) and surgical therapeutic treatment (tumor resection).

[Primary biliary cirrhosis: clinical features and survival of a Mexican population]. / Cirrosis biliar primaria: características clínicas y supervivencia en la población Mexicana.

BACKGROUND: PBC progresses to cirrhosis and results in death due to liver failure or bleeding portal hypertension. Data of the clinical characteristics and survival of PBC patients allows the assessment of therapeutical alternatives as well as the establishment of inclusion criteria for liver transplantation. AIMS: One hundred and twenty patients with histological diagnosis of PBC, admitted from 1972 to 1992, were selected with the purpose of studying the clinical and biochemical characteristics and survival. METHODS: Patients who underwent liver transplant or those who had an incomplete follow-up were excluded. RESULTS: Therefore only 80 patients were included: these were seventy five women and five men, with mean age 46 +/- 11 years (X +/- SD) to whom demographic data, biochemical analysis, liver function (Child-Pugh) and liver damage (Ludwig) were recorded at the time of histological diagnosis, which was considered zero for calculating the survival (Kaplan Meier). The most common symptoms at diagnosis were pruritus in 63 patients, jaundice in 48, asthenia and adynamia in 55 patients. Eight cases were asymptomatic. According to Child-Pugh's classification, patients were grouped as follows: forty in stage A, 29 in B, and three in C; and according to liver damage (Ludwig), 8 in grade I, 28 in grade II, 22 in grade III and 14 in grade IV. The most frequent clinical associations were Sjögren's syndrome, in 30% of patients, although one case was associated to progressive muscular dystrophy and another one to multiple myeloma and hypothyroidism; in 58.7% of the cases, antimitochondrial antibodies were negative. One year survival was 75%, five years 44%, and seven years 13%. CONCLUSIONS: The most important characteristics of the studied patients were elevated percentage of negative antimitochondrial antibodies and short survival. it is important to impel the development of liver transplantation as the only mean to improve survival.

Outcomes in renal transplantation with expanded-criteria donors.

BACKGROUND: Kidney transplantation is the treatment of choice for patients with end-stage renal disease. In recent years donor criteria have changed to increase the percentage of expanded-criteria donors (ECDs). The aim of this study was to analyze transplants from ECDs obtained at our institution from. 2010 to 2012. We studied the comorbidity of ECD, preimplantation histologic study, renal function, and survival of transplanted grafts. PATIENTS AND METHODS: Eighty ECDs (160 kidneys) were analyzed. Forty-nine grafts were not implanted owing to macroscopic lesions (37 kidneys) or histologic findings on preimplantation biopsy (12 kidneys). Finally, 60 grafts from ECDs were implanted in our center. We analyzed the characteristics of the grafts (kidney function, creatinine clearance) and compared the data with a control group of allografts from standard-criteria donors (n = 14). RESULTS: The median age of the ECD group was 72 years (range 65-77). No differences were found in certain characteristics between the ECDs whose kidneys were or were not implanted (hypertension, diabetes, creatinine at the time of the donation or proteinuria). However, there were differences in donor age (75 vs 67; P = .043), increased preimplantation biopsy score (6.8 ± 1.3 vs 4.8 ± 1.1; P = .041), and a higher percentage of cardiovascular disease (62.5% vs 43%; P = .038). Comparison of ECD and non-ECD grafts showed a lower creatinine clearance at 1 year (50 ± 05 mL/min vs 69 ± 96 mL/min, respectively; P < .001) and 2 years (50 ± 07 mL/min vs 67 ± 74 mL/min; P < .001) after transplantation. There were no differences in delayed graft function or graft survival between the 2 groups at 2 years after transplantation (95% vs 100%; P = .38). CONCLUSIONS: We found no differences in graft survival from ECD compared with the control group of standard-criteria donors. The evaluation of grafts from ECD may be a strategy to increase the number of kidney transplants.

Postoperative complications in the intensive care unit following lung transplantation in adults: results in University Hospital Reina Sofia.

The postoperative period following lung transplantation remains critical because of several complications. Infection, primary graft failure, acute rejection, and surgical complications are risk factors for mortality and morbidity. The recognition and early treatment of these complications is important to optimize outcomes. This article provides an overview of postoperative complications observed in our center during the last year. We were particularly interested in the influence of variables, such as inotrope usage and Acute Physiology and Chronic Health Evaluation (APACHE II) score, a well-known, and validated mortality prediction model for general intensive care unit (ICU) patients only infrequently reported in the transplantation literature. High APACHE II scores were significantly associated with prolonged mechanical ventilation (P = 0.041) and a tracheostomy requirement (P = .035). The factors significantly associated with an early postoperative death were older donor age (P = .005), prolonged donor ICU period (P = .004), need for cardiopulmonary bypass (CB; P = .005), and high inotrope requirements in the ICU (P = .034). CB data were biased because we selected the worst case patients. Donor age and high inotrope requirements in the ICU have been reported previously to be prognostic factors for poor graft function. We believe that control of these variables may improve outcomes.

Carcinoma bronquioloalveolar. Consideraciones sobre 23 casos. / Bronchioloalveolar carcinoma. Study of 23 cases

Se estudiaron las principales caracteristicas clinicas e histopatologicas de 23 casos de carcinoma bronquioloalveolar que correspondieron al 4.8% de 466 tumores bronquiogeneticos. Este tumor es de diagnostico clinico dificil. Fue mas frecuente en la sexta decada de la vida; la localizacion multicentrica bilateral fue la mas comun, 78.2%. El habito de fumar no tuvo relacion con este tipo de tumor. El tipo histologico mas frecuente fue el secretor, 10 casos. Se discuten algunos aspectos de su histogenesis y se consideran las bases para el diagostico histologico de sus tres variedades: secretor, no secretor y poco diferenciado. Se senala la importancia de la microscopia electronica que permite determinar la presencia de moco y de otros marcadores histologicos como granulos electrodensos semejantes a los que hay en las celulas de Clara y otros elementos celulares como los que existen en los neumocitos tipo II. El muestreo extenso de cada especimen es indispensable en virtude de que puede haber en una misma lesion diferentes aspectos histopatologicos. Se senala la utilidad de los metodos citologicos y del estudio de especimenes de tejido pulmonar para el diagnostico de esta entidad oncologica pulmonar. Aunque la distribucion de las lesiones puede ser multicentrica bilateral o nodular solitaria, el diagnostico histologico puede corresponder a cualquiera de las variedades senaladas