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PURPOSE: In the modern era of robotic renal procedures and diagnostics, an even more detailed anatomical understanding than hitherto is necessary. Valves of the renal veins (RVV) have been underemphasized and have been disputed by some authors, and few textbooks describe them. The current anatomical study was performed to address such shortcomings in the literature. METHODS: One hundred renal veins were studied in fifty adult formalin-fixed cadavers. Renal veins were removed from the abdomen after sectioning them flush with their entrance to the renal hilum. The inferior vena cava was then incised longitudinally and opened, and RVV were examined grossly and histologically. A classification scheme was developed and applied to our findings. RESULTS: Nineteen RVVs were observed in the fifty cadavers (38%). Four (8%) valves were found on right sides and fifteen (30%) on left sides. The valves were seen as cord/band-like, folds, and single and double leaflets. Histologically, they were all extensions of the tunica intima. CONCLUSION: On the basis of our study, RVV are not uncommon. They were more common on left sides, and on both sides, they were found within approximately one centimeter of the junction of the inferior vena cava and renal vein. Although the function of such valves cannot be inferred from this anatomical study, the structures of the Single leaflet valve (TS2) and Double leaflet valve (TS3) valves suggest they could prevent venous reflux from the IVC into the kidney.
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Veias Renais , Veia Cava Inferior , Adulto , Humanos , Prevalência , Abdome , CadáverRESUMO
BACKGROUND: Coronavirus disease-2019 (COVID-19) has a deleterious effect on several systems, including the cardiovascular system. We aim to systematically explore the association of COVID-19 severity and mortality rate with the history of cardiovascular diseases and/or other comorbidities and cardiac injury laboratory markers. METHODS: The standardized mean difference (SMD) or odds ratio (OR) and 95% confidence intervals (CIs) were applied to estimate pooled results from the 56 studies. The prognostic performance of cardiac markers for predicting adverse outcomes and to select the best cutoff threshold was estimated by receiver operating characteristic curve analysis. Decision tree analysis by combining cardiac markers with demographic and clinical features was applied to predict mortality and severity in patients with COVID-19. RESULTS: A meta-analysis of 17 794 patients showed patients with high cardiac troponin I (OR = 5.22, 95% CI = 3.73-7.31, P < .001) and aspartate aminotransferase (AST) levels (OR = 3.64, 95% CI = 2.84-4.66, P < .001) were more likely to develop adverse outcomes. High troponin I more than 13.75 ng/L combined with either advanced age more than 60 years or elevated AST level more than 27.72 U/L was the best model to predict poor outcomes. CONCLUSIONS: COVID-19 severity and mortality are complicated by myocardial injury. Assessment of cardiac injury biomarkers may improve the identification of those patients at the highest risk and potentially lead to improved therapeutic approaches.
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COVID-19/complicações , COVID-19/mortalidade , Doenças Cardiovasculares/virologia , Traumatismos Cardíacos/virologia , Miocárdio/patologia , Biomarcadores/análise , COVID-19/fisiopatologia , Doenças Cardiovasculares/fisiopatologia , Comorbidade , Árvores de Decisões , Humanos , Prognóstico , Análise de Regressão , Índice de Gravidade de DoençaRESUMO
BACKGROUND: An elevated BMI is a major cause of transplant preclusion for patients with end-stage renal disease (ESRD). This phenomenon exacerbates existing socioeconomic and racial disparities and increases the economic burden of maintaining patients on dialysis. Metabolic bariatric surgery (MBS) in such patients is not widely available. Our center created a collaborative program to undergo weight loss surgery before obtaining a kidney transplant. STUDY DESIGN: We studied the outcomes of these patients after MBS and transplant surgery. One hundred eighty-three patients with ESRD were referred to the bariatric team by the transplant team between January 2019 and June 2023. Of these, 36 patients underwent MBS (20 underwent Roux-en-Y gastric bypass and 16 underwent sleeve gastrectomy), and 10 underwent subsequent transplantation, with another 15 currently waitlisted. Both surgical teams shared resources, including dieticians, social workers, and a common database, for easy transition between teams. RESULTS: The mean starting BMI for all referrals was 46.4 kg/m 2 and was 33.9 kg/m 2 at the time of transplant. The average number of hypertension medications decreased from 2 (range 2 to 4) presurgery to 1 (range 1 to 3) postsurgery. Similarly, hemoglobin A1C levels improved, with preoperative averages at 6.2 (range 5.4 to 7.6) and postoperative levels at 5.2 (range 4.6 to 5.8) All transplants are currently functioning, with a median creatinine of 1.5 (1.2 to 1.6) mg/dL (glomerular filtration rate 46 [36.3 to 71]). CONCLUSIONS: A collaborative approach between bariatric and transplant surgery teams offers a pathway toward transplant for obese ESRD patients and potentially alleviates existing healthcare disparities. ESRD patients who undergo MBS have unique complications to be aware of. The improvement in comorbidities may lead to superior posttransplant outcomes.
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Cirurgia Bariátrica , Derivação Gástrica , Falência Renal Crônica , Laparoscopia , Obesidade Mórbida , Humanos , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Obesidade/complicações , Obesidade/cirurgia , Cirurgia Bariátrica/efeitos adversos , Falência Renal Crônica/complicações , Falência Renal Crônica/cirurgia , Gastrectomia/efeitos adversos , Laparoscopia/efeitos adversos , Resultado do Tratamento , Estudos RetrospectivosRESUMO
Angiosarcoma is a rare, almost universally fatal malignant neoplasm in kidney transplant recipients. No evidence-based guidelines are available for disseminated disease. Here, we report a case of a 66-year-old woman who developed disseminated angiosarcoma 4 months after living nonrelated kidney transplant. She underwent only 2 rounds of chemotherapy because of intolerable adverse effects. Her mycophenolic acid and tacrolimus were withdrawn and sirolimus use was started. In addition to its immunosuppressant effects, sirolimus has been shown to have antineoplastic properties. Remarkably, at almost 2 years post-transplant, the patient has had complete resolution of all gross metastatic disease with only immunosuppressant medication changes. This case highlights the interesting possibility that sirolimus is an effective adjunct treatment for disseminated angiosarcoma in kidney transplant recipients.
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Hemangiossarcoma , Transplante de Rim , Humanos , Feminino , Idoso , Sirolimo/efeitos adversos , Transplante de Rim/efeitos adversos , Hemangiossarcoma/tratamento farmacológico , Imunossupressores/efeitos adversos , Tacrolimo/efeitos adversos , Ácido Micofenólico/efeitos adversos , Rejeição de EnxertoRESUMO
Although living donation is the preferred method of kidney transplant, many donors are not a match with their intended recipient. One unique way of overcoming this is by performing a donor paired exchange. By swapping donors, transplant centers may be able to bring about multiple transplants that would not have otherwise been possible. This manuscript describes the first three way domino paired donor exchange transplant in Louisiana. Because of a single altruistic donor, we were able to facilitate three recipients getting transplanted. We discuss the formulation of this unique program, the choosing of potential donor/recipient pairs and outcomes. A review of the controversies of paired kidney donation is also presented.
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Altruísmo , Transplante de Rim/psicologia , Doadores de Tecidos/psicologia , Adulto , Idoso , Incompatibilidade de Grupos Sanguíneos , Seleção do Doador , Feminino , Humanos , Transplante de Rim/imunologia , Louisiana , Masculino , Seleção de Pacientes , Resultado do TratamentoRESUMO
INTRODUCTION: We examined the effects of increasing human leukocyte antigen (HLA) mismatches (MM) on long-term graft outcomes in patients transplanted with a panel reactive antibody (PRA) >80% over a 10-yr period. METHODS: A total of 142 recipients were divided into three groups based on the number of HLA MM with their allograft (0-2, 3-4 and 5-6 MM; Groups I, II and III). All patients received the same immunosuppression protocol. RESULTS: The higher MM groups had a higher incidence of rejection (4.4% vs. 11.4% vs. 31.3%, p < 0.01). A multivariate analysis showed that rejection was the only significant variable affecting graft loss (OR = 7.45, p = 0.01). There was a trend toward more CMV infection and worse graft function with higher MM. Kaplan-Meier five-yr graft survival estimates were 100% vs. 81% vs. 74% for Groups I, II and III, respectively (p = 0.14). CONCLUSIONS: In patients with PRA levels >80%, a higher HLA MM is associated with higher incidence of acute rejection. Acute rejection was the only significant variable affecting graft loss. We found a trend toward more CMV infections and worse graft outcomes with higher MM. Closer HLA matching and immunologic monitoring needs to be considered to improve graft outcomes among sensitized recipients.
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Rejeição de Enxerto/imunologia , Antígenos HLA/imunologia , Isoanticorpos/sangue , Transplante de Rim/imunologia , Transplante Homólogo/imunologia , Adulto , Feminino , Seguimentos , Sobrevivência de Enxerto , Teste de Histocompatibilidade , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Taxa de SobrevidaRESUMO
Background: Necrotizing fasciitis (NF) is a fulminant, life-threating infection of fascia and subcutaneous tissue. Because of the low incidence, previous studies were statistically underpowered to assess factors associated with the risk of mortality. The aim of this study is to identify the risk factors associated with mortality in this select group of patients. Methods: A retrospective cross-sectional study was performed utilizing the Nationwide Readmissions Database, 2010-2014. The database captures 56.6% of all U.S. annual hospitalizations. Study population included inpatients admitted emergently with NF. Results: A total of 4,178 cases were included, of which 2,061(48.9%) patients had a history of diabetes mellitus (DM). The most common presentation was septicemia (39.5%) and 9.2% were admitted initially as cellulitis/abscess. Overall mortality risk was 12.6% with no substantial change in the annual trend. Mortality in patients with diabetes was substantially lower (8.5% vs. 16.5%, odds ratio [OR]: 0.44, 95% confidence interval [CI] = [0.34, 0.56], p < 0.001). Factors associated with a higher mortality risk included: older age, chronic liver diseases, disseminated intravascular coagulopathy, septic shock, pulmonary complications, acute renal failure, and not undergoing surgical intervention (p < 0.05 each). Patients who did not undergo surgical debridement were more likely to be ≥65 years of age and have multiple comorbidities. Hyperbaric oxygen therapy and intravenous immunoglobulin were used in 1.3% and 0.3% of the sample, respectively, with no reported use among patients who died. Conclusions: This study provides a new and updated perspective on the prevalence, trend, and outcomes of NF in the United States. Necrotizing fasciitis is associated with septicemia and lack of surgical intervention is associated with a higher mortality.
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Fasciite Necrosante , Idoso , Comorbidade , Estudos Transversais , Desbridamento , Fasciite Necrosante/epidemiologia , Fasciite Necrosante/terapia , Humanos , Prevalência , Estudos RetrospectivosRESUMO
OBJECTIVE: Evidence-based characterization of the diagnostic and prognostic value of the hematological and immunological markers related to the epidemic of Coronavirus Disease 2019 (COVID-19) is critical to understand the clinical course of the infection and to assess in development and validation of biomarkers. METHODS: Based on systematic search in Web of Science, PubMed, Scopus, and Science Direct up to April 22, 2020, a total of 52 eligible articles with 6,320 laboratory-confirmed COVID-19 cohorts were included. Pairwise comparison between severe versus mild disease, Intensive Care Unit (ICU) versus general ward admission and expired versus survivors were performed for 36 laboratory parameters. The pooled standardized mean difference (SMD) and 95% confidence intervals (CI) were calculated using the DerSimonian Laird method/random effects model and converted to the Odds ratio (OR). The decision tree algorithm was employed to identify the key risk factor(s) attributed to severe COVID-19 disease. RESULTS: Cohorts with elevated levels of white blood cells (WBCs) (OR = 1.75), neutrophil count (OR = 2.62), D-dimer (OR = 3.97), prolonged prothrombin time (PT) (OR = 1.82), fibrinogen (OR = 3.14), erythrocyte sedimentation rate (OR = 1.60), procalcitonin (OR = 4.76), IL-6 (OR = 2.10), and IL-10 (OR = 4.93) had higher odds of progression to severe phenotype. Decision tree model (sensitivity = 100%, specificity = 81%) showed the high performance of neutrophil count at a cut-off value of more than 3.74x109/L for identifying patients at high risk of severe COVID-19. Likewise, ICU admission was associated with higher levels of WBCs (OR = 5.21), neutrophils (OR = 6.25), D-dimer (OR = 4.19), and prolonged PT (OR = 2.18). Patients with high IL-6 (OR = 13.87), CRP (OR = 7.09), D-dimer (OR = 6.36), and neutrophils (OR = 6.25) had the highest likelihood of mortality. CONCLUSIONS: Several hematological and immunological markers, in particular neutrophilic count, could be helpful to be included within the routine panel for COVID-19 infection evaluation to ensure risk stratification and effective management.
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Betacoronavirus , Infecções por Coronavirus/sangue , Infecções por Coronavirus/diagnóstico , Pneumonia Viral/sangue , Pneumonia Viral/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Sedimentação Sanguínea , Proteína C-Reativa/análise , COVID-19 , Criança , Infecções por Coronavirus/imunologia , Infecções por Coronavirus/virologia , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Interleucina-10/sangue , Interleucina-6/sangue , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Neutrófilos , Pandemias , Pneumonia Viral/imunologia , Pneumonia Viral/virologia , Pró-Calcitonina/sangue , Prognóstico , Tempo de Protrombina , SARS-CoV-2 , Adulto JovemRESUMO
Aim: We aimed to explore the circulating expression profile of nine lncRNAs (MALAT1, HOTAIR, PVT1, H19, ROR, GAS5, ANRIL, BANCR, MIAT) in breast cancer (BC) patients relative to normal and risky individuals. Methods: Serum relative expressions of the specified long non-coding RNAs were quantified in 155 consecutive women, using quantitative reverse-transcription PCR. Random Forest (RF) and decision tree were also applied. Results: Significant MALAT1 upregulation and GAS5 downregulation could discriminate risky women from healthy controls. Overexpression of the other genes showed good diagnostic performances. Lower GAS5 levels were associated with metastasis and recurrence. RF model revealed a better performance when combining gene expression patterns with risk factors. Conclusion: The studied panel could be utilized as diagnostic/prognostic biomarkers in BC, providing promising epigenetic-based therapeutic targets.
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Biomarcadores Tumorais/genética , Neoplasias da Mama/diagnóstico , RNA Longo não Codificante/genética , Adulto , Neoplasias da Mama/genética , Egito , Feminino , Regulação Neoplásica da Expressão Gênica , Humanos , Pessoa de Meia-Idade , Fatores de Risco , TranscriptomaRESUMO
Interstitial pneumonia in a transplant patient can have a varied etiology. Sirolimus (Rapamycin; Rapamune) is a popularly used immunosuppressant in solid organ transplantation that has anecdotally been associated with pulmonary toxicity. Sirolimus-induced pulmonary toxicity consists of a range of syndromes that is characterized by the presence of organizing pneumonia, interstitial pneumonitis, pulmonary alveolar proteinosis, focal fibrosis, or by the presence of alveolar hemorrhage. Diagnosis can be challenging and is usually made by exclusion of other etiologies. In this report we present two cases of sirolimus-associated pulmonary toxicity with a review of the literature.
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Rejeição de Enxerto/prevenção & controle , Imunossupressores/efeitos adversos , Doenças Pulmonares Intersticiais/induzido quimicamente , Doenças Pulmonares Intersticiais/diagnóstico , Sirolimo/efeitos adversos , Humanos , Imunossupressores/administração & dosagem , Transplante de Fígado/imunologia , Pulmão/diagnóstico por imagem , Pulmão/patologia , Masculino , Pessoa de Meia-Idade , Sirolimo/administração & dosagem , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: This study aims to examine potential disparities in scholarly performance based on sex, academic rank, leadership positions, and regional distribution of faculty in accredited Head and Neck Surgery fellowships in the United States. METHODS: Online faculty listings for 37 accredited fellowships were organized according to academic rank, leadership position, sex, and institutional location. Academic productivity was measured with three bibliometric indices: h-index, m-index, and the weighted relative citation ratio. RESULTS: A total of 732 faculty members were included, of which 153 (21%) were female. Fifty-eight males (89.2%) held leadership positions, compared to seven females (10.8%). There was no significant difference in overall productivity between male and female senior faculty. There were regional differences in productivity by sex. CONCLUSIONS: Females are underrepresented in senior faculty and within three common leadership positions, although scholarly productivity for male and female senior faculty and for those in leadership positions is similar.
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Pesquisa Biomédica/estatística & dados numéricos , Docentes de Medicina/estatística & dados numéricos , Bolsas de Estudo/estatística & dados numéricos , Internato e Residência/estatística & dados numéricos , Liderança , Otolaringologia/estatística & dados numéricos , Bibliometria , Eficiência , Feminino , Humanos , Masculino , Otolaringologia/educação , Fatores Sexuais , Razão de Masculinidade , Estados UnidosRESUMO
BACKGROUND/AIM: Immunotherapy combined with surgery is associated with better survival than surgery alone in patients with advanced melanoma. This study examined the utilization of immunotherapy in relation to population characteristics and the associated survival benefit. MATERIALS AND METHODS: This was a retrospective cohort study utilizing the US National Cancer Database. The study population included 6,165 adult patients (≥18 years) with stage III cutaneous melanoma (median follow-up=32 months). RESULTS: A total of 1,854 patients underwent immunotherapy in addition to surgery, which was associated with a survival benefit over surgery alone (hazard ratio(HR)=0.66, 95% confidence interval(CI)=0.56-0.77, p<0.001). Older age, presence of comorbidities, Medicaid/Medicare insurance, and living in a community with lower average education level were associated with less immunotherapy utilization (all p<0.05). No statistically significant racial disparity in immunotherapy usage was found (p=0.07). CONCLUSION: Compared to other demographic factors, insurance status was associated with the greatest disparities in immunotherapy utilization and mortality for patients who underwent surgery for advanced melanoma.
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Imunoterapia/estatística & dados numéricos , Melanoma/terapia , Neoplasias Cutâneas/terapia , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Melanoma/mortalidade , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Neoplasias Cutâneas/mortalidade , Resultado do Tratamento , Estados Unidos , Melanoma Maligno CutâneoRESUMO
The use of living donor kidneys has dramatically increased the number and success of kidney transplants across the world. But questions remain regarding the subjection of a healthy individual to surgery for the benefit of another. Donors do have medical and financial risks. The stigma of organ brokering remains today, with evidence of commercial transplantation in other countries. Here in the US, we are exposed to advertising for donors using the media. In the hope of increasing living donations, we run the risk of stretching altruism too far. In this manuscript, we highlight and discuss some of the current controversies surrounding living donor kidney transplantation across the world.
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Transplante de Rim , Doadores Vivos , Publicidade , Compensação e Reparação , Humanos , Internacionalidade , Transplante de Rim/efeitos adversos , Transplante de Rim/ética , Transplante de Rim/legislação & jurisprudência , Doadores Vivos/ética , Doadores Vivos/legislação & jurisprudência , Meios de Comunicação de Massa , Medição de Risco , Doadores de Tecidos/éticaRESUMO
Pancreas transplantation has been mired in controversy throughout its existence. Arguments have erupted regarding its actual indications, the way the surgical procedure should be performed, its benefits, and today, the concept of pancreas islet cell transplantation remains controversial as well. If diabetic patients had a choice between life long insulin therapy and a major operation with immunosuppression afterward, what would they choose? The answer may not be as easy as one thinks. Pancreas transplantation has come a long way. This manuscript discusses the history of pancreas transplantation, how the indications are starting to be defined, evolution of the surgical procedure, current success rates of this procedure, the current scenario of pancreas islet transplantation, and newer developing technologies.
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Transplante de Pâncreas/estatística & dados numéricos , Pâncreas/patologia , Pancreatopatias/cirurgia , Resultado do Tratamento , Diabetes Mellitus Tipo 1 , Humanos , Pâncreas/cirurgia , Transplante de Pâncreas/mortalidade , Transplante de Pâncreas/tendências , Pancreatopatias/mortalidade , Fatores de RiscoRESUMO
Obesity is a worldwide epidemic leading to severe comorbidity that damages end-organ function. Overall transplant outcomes in this population are inferior to those in nonobese patients. Large population studies show decreased patient and graft survival in obese kidney transplant patients. Despite the poorer outcomes, kidney transplantation is considered because of the survival benefit as compared with the wait-listed dialysis patients. In liver transplantation, the benefit to transplantation as compared with remaining on the list is obvious, as there is no viable liver dialysis at this time. Obesity in potential organ donors impacts both medical and surgical issues. Obesity-related kidney disease affects both the remaining and transplanted kidney. Pancreas donor organs are associated with decreased early graft survival. Liver donor organs with significant steatosis lead to an increased risk for delayed or nonfunction of the organ. Immunosuppressive drugs with variable lipophilicity and altered volume of distribution can greatly affect the therapeutic usefulness of these drugs. Transplant candidates benefit from a multidisciplinary team approach to their care. As the epidemic progresses and less-invasive treatments for metabolic surgery evolve, we are likely to require more patients to lose weight prior to transplantation as we continue to strive for improved outcomes.
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Imunossupressores/uso terapêutico , Transplante de Rim , Transplante de Fígado , Obesidade/complicações , Transplante de Pâncreas , Diabetes Mellitus Tipo 1 , Humanos , Obesidade/cirurgia , Seleção de Pacientes , Insuficiência Renal , Medição de Risco/métodosRESUMO
BACKGROUND: Kidney transplantation (KTx) alone in patients with cirrhosis and renal failure (end-stage renal disease [ESRD]) infected with hepatitis C virus (HCV) is controversial. The aim of this study was to compare outcomes of HCV+ patients with ESRD and cirrhosis (C group) versus HCV+ patients with ESRD but with no cirrhosis (NC group) listed for KTx. METHODS: Ninety HCV+ patients with ESRD were evaluated for KTx between 2003 and 2010. Listed patients underwent transjugular liver biopsy with hepatic portal venous gradient (HPVG) measurements. Only patients with HPVG less than 10 mm Hg were considered for KTx alone. We analyzed patient demographics, waitlist/liver disease characteristics, and posttransplant outcomes between groups. RESULTS: Sixty-four patients listed for KTx alone were studied. Twelve patients (18.75%) showed biopsy-proven cirrhosis. Thirty-seven patients underwent KTx alone (9 from C and 28 from NC). No patients developed decompensation of their liver disease, although one patient for NC group developed metastatic hepatocellular carcinoma 16 months after transplantation. One- and three-year graft survival rates were 75% and 75% versus 92.1% and 75.1% for groups C and NC, respectively (P=0.72). One- and three-year patient survival rates were 88.9% and 88.9% versus 96.3% and 77.9% for groups C and NC, respectively (P=0.76). Only increasing recipient age and decreasing albumin levels were significantly associated with worse graft and patient survival. CONCLUSIONS: Our study suggests that KTx alone may be safe in patients with compensated HCV, cirrhosis, and ESRD with HPVG less than 10 mm Hg. A simultaneous liver-kidney transplantation may be an unnecessary use of a liver allograft in these patients.