Abdominal wall hernias in end-stage renal disease patients on peritoneal dialysis.

OBJECTIVE: To describe our experience with hernioplasty in peritoneal dialysis patients and to identify possible risk factors for surgical complications. DESIGN: A 4-year retrospective chart review of data. SETTING: Peritoneal dialysis unit of a university hospital. PATIENTS AND METHODS: 58 hernias in 50 patients were included. Detailed surgical technique and complications were recorded. Possible risk factors included age, gender, weight, height, body mass index, previous surgery, diabetes, time on dialysis, emergency surgery, hospital stay, type of hernia, mesh use, blood hemoglobin, and serum urea, creatinine, and potassium. RESULTS: Complications occurred in 12 hernioplasties (4 wound infections, 2 peritonitis, 4 catheter dysfunction, and 5 re-operations). Recurrence rate was 12% without mesh use and 0% with mesh hernioplasty. Dialysis was re-instituted in 96% of cases within 3 days postoperatively. Identified risk factors for complications were diabetes, low weight, low height, small body mass index, and low serum creatinine. CONCLUSIONS: Mesh hernioplasty in peritoneal dialysis patients is advisable. Postoperative dialysis with low volume is feasible after surgery. Prospective studies will corroborate our risk factors for morbidity.

Pediatric renal transplantation with mycophenolate mofetil immunosuppression in a single center from Mexico.

An MMF-based immunosuppression has reduced the acute rejection rate in adults and in children in the early post-transplantation period. In the present study, pediatric renal transplantation patients on a CyA, MMF, and steroids regimen were prospectively evaluated. Patients with CyA, MMF, and steroid therapy without antibody induction were evaluated for surgical aspects, renal function, rejection, and survival, growth after transplantation, adverse events and medication discontinuation. Between February 2003 and May 2005, 21 kidney transplantation patients under 18 yr old were followed for at least 12 months. Within one year after transplantation, three patients developed four episodes of acute rejection (19%). Graft loss because of rejection occurred in one patient. One-year mean serum creatinine was 1.19 +/- 0.3 mg/dL. Mean calculated CrCl by Schwartz formula was 82.3 +/- 19.7 mL/min*1.73 m(2). Major adverse events included infections of the urinary tract and diarrhea, abdominal pain, and GI symptoms. No patients have discontinued the use of MMF. Good results in pediatric kidney transplantation can be achieved by using CyA/MMF/steroids. MMF is effective and relatively safe in reducing the incidence of acute rejection even without induction therapy 12 months after transplantation.

Living related kidney transplantation without calcineurin inhibitors: initial experience in a Mexican center.

We performed a prospective randomized trial comparing sirolimus/mycophenolate mofetil (MMF)/prednisone to cyclosporine/MMF/prednisone and selected induction therapy with basiliximab. Twenty patients received sirolimus (10 mg loading dose followed by 3 mg/m body surface area/day, keeping 24-hr trough levels at 10-15 ng/mL for six months and 5-10 ng/mL thereafter. Twenty-one patients began cyclosporine (4 to 8 mg/kg/day, keeping 12-hour trough levels at 150-300 ng/mL for 6 months and 100-200 ng/mL afterwards). Mean follow up was 15.8 months. One-year patient and graft survival was similar in both groups (>90%). Acute rejection rate was 16.6% in the sirolimus group and 5.2% in the cyclosporine group (P=NS). There were no differences in mean serum creatinine between groups. No patients who received basiliximab and had sirolimus target levels suffered acute rejection at one year. The sirolimus group had significantly higher cholesterol and triglycerides. A calcineurin inhibitor-free regimen using sirolimus produces comparable one-year transplant outcomes in living related kidney transplants compared to a calcineurin inhibitor regimen.

[Blunt trauma in kidney transplant with preservation of renal function]. / Trauma contuso en un riñón trasplantado con preservación de la función renal.

A 35-year-old male received a living related kidney transplant. At 184 months posttransplantation he suffered a direct right iliac fossa blunt trauma while working on a machine in a steel factory. Graft pain, dysuria and gross hematuria were observed and CT showed a periallograft hematoma. Because of his anemia and graft function deterioration, surgical exploration was warranted. A 500-cc perigraft hematoma was compressing the kidney and ureter, a 5-cm long, 5-mm in depth linear laceration in the lateral aspect of the superior pole of the graft and a 15-mm long, 2-mm in depth linear laceration in the medial aspect of the superior pole were actively bleeding. Major renal arteries and veins were not injured. Both lacerations were closed by suturing the renal parenchyma over gelfoam pledgets with absorbable suture in a buttress fashion. The kidney was salvaged. Serum creatinine was maintained at 1.5 mg/dl during follow-up. A review of the literature showed that few cases of traumatic renal graft rupture with kidney salvage have been reported. Our case is one of them.

Conversion from calcineurin inhibitor to sirolimus for renal function deterioration in kidney allograft recipients.

BACKGROUND: Calcineurin inhibitors play an important role in chronic allograft dysfunction. Sirolimus is an interesting alternative in renal transplant patients because it is less nephrotoxic than calcineurin inhibitors. METHODS: A chart review of the clinical outcome of kidney transplant patients converted to sirolimus with progressive allograft dysfunction is reported herein. Fifteen patients (average age: 32.3 years, 44 months mean time of conversion) were included. Indication for conversion was a >20% increase in serum creatinine over the last 6 months or progression to the range of 2-4.5 mg/dL. Patients underwent abrupt cessation of cyclosporine and sirolimus addition at 2-5 mg/day. RESULTS: Concomitant immunosuppression remained unchanged during conversion. Targeted sirolimus level was 8-12 ng/mL. Serum creatinine dropped from pre-conversion level of 2.75 +/- 0.83 to 2.14 +/- 0.67 and 1.97 +/- 0.66 mg/dL at 3 and 6 months (p <0.05). There was a significant decrease in blood urea nitrogen, hemoglobin and serum calcium at 3 months post-conversion as well as serum calcium and potassium at 6 months post-conversion (p <0.05). There were no rejection episodes. Patient and graft survival was 100% with three infectious complications. CONCLUSIONS: Monitored sirolimus conversion with sharp withdrawal of calcineurin inhibitor is an alternative for patients with deteriorating renal function and chronic allograft nephropathy.

Costo beneficio en utilización de catéter Mahurkar versus fístula arteriovenosa / Cost-benefice in the utilization of Mahurkar cateter versus the internal artery venous fistula

Introducción: el Instituto Mexicano de Seguro Social en su proceso de transformación hacia la calidad busca estrategias para disminuir costos y optimizar recursos; por ello, el objeto de este estudio es identificar el costo beneficio que implica el uso del catéter Mahurkar en comparación con Fístula Arteriovenosa Interna (FAVI). Material y métodos: estudio sobre costo beneficio realizado en 40 pacientes (20 con FAVI y 20 con catéter Mahurkar) en programa de hemodiálisis en el Hospital de Especialidades N° 14 de Veracruz. La información fue recolectada en una guía de observación, a través de la revisión de expedientes, con datos de la vía de acceso vascular, así como el registro de costos por insumos. Resultados: 95% del grupo Mahurkar se vio afectado por complicaciones contra 5% FAVI, proyectando un costo-beneficio de 0.22 a favor de FAVI. Aunque al inicio se observó de 2.00 a favor del catéter Mahurkar, el uso prolongado de éste causó un impacto económico para la institución, debido a las complicaciones, considerando que el promedio de vida del catéter es de 2 a 3 meses y la FAVI de 10 a 15 años. Conclusión: el costo beneficio en la utilización del acceso vascular FAVI se justifica por el beneficio mediato al paciente e institución; sugiriéndose la programación oportuna de las fístulas para brindar una mejor calidad de vida al paciente.

Objective: To identify the cost-benefit that implies the use of the Mahurkar catheter versus Internal Arteriovenous Fistula (FAVI). Material and methods: study cost benefit made in 40 patients (20 with FAVI and 20 with Mahurkar catheter) in the program of hemodialisis at the Hospital of Specialties 14 of Veracruz. The information was collected in a guide of observation and through the overhaul of files and with data of the vascular access road, as well as the registry of costs. Results: the Mahurkar group was itself affected by complications in 95% against FAVI in 5%, projecting a reason cost-benefit from 0.22 in favor of FAVI. The beginning a reason was observed cost benefit of 2.00 in favor of the Mahurkar catheter, the use prolonged of this one, caused an economic impact for the institution, due to the complications; considering that the average of life of the catheter is from two to three to 3 months and FAV110 to 15 years. Conclusions: the cost-benefit in the use of vascular access FAVI justifies by the mediate benefit to the patient and institution; suggesting the opportune programming of the fistulas in order to offer one better quality of life to the patient.

Anestesia en transplante renal / Anesthesia in renal transplant

En receptores de trasplante renal la anestesia entraña graves dificultades en lo que corresponde al metabolismo y la excreción de los fármacos que se utilizan en el procedimiento. Se requiere una técnica anestésica que brinde seguiridad transanestésica y posanestésica inmediata, tanto para el paciente como para el órgano sujeto a trasplante. Se efectuó un estudio prospectivo, longitudinal y comparativo de los 40 pacientes (sin distinción de sexo) sometidos a trasplante renal, 20 con anestesia general (AG) y 20 con bloqueo peridural (BP). La edad promedio fue de 24.10 (AG) y 28.7 años (BP). Los parámetros evaluados fueron presión venosa central, tensión arterial y frecuencias cardiaca y repiratoria en los diferentes periodos anestésicos (basal de inducción, transanestésico y posanestésico y posanestésico). Se identificaron cambios estadísticamente significativos (p<0.05) en la TA diastólica de los periodos de inducción y posanestésico. A causa de los efectos residuales de los anestésicos administrados. ocurrió una variación (30 por ciento) en la frecuencia respiratoria posoperatoria de los pacientes sometidos a anestesia general. Cabría concluir que son dignos de confianza ambos procedimientos anestésicos; desde luego, el comité de trasplantes de esta institución considera que la mejor técnica anestésica es el bloqueo peridural. PALABRAS CLAVES: Anestesia general, bloqueo peridural, estabilidad hemodinámica receptor de transplante renal, transplante renal.