A clinical tool to risk stratify potential kidney transplant recipients and predict severe adverse events.

Preoperative risk assessment of potential kidney transplant recipients often fails to adequately balance risk related to underlying comorbidities with the beneficial impact of kidney transplantation. We sought to develop a simple scoring system based on factors known at the time of patient assessment for placement on the waitlist to predict likelihood of severe adverse events 1 year post-transplant. The tool includes four components: age, cardiopulmonary factors, functional status, and metabolic factors. Pre-transplant factors strongly associated with severe adverse events include diabetic (OR: 3.76, P<.001), coronary artery disease (OR: 3.45, P<.001), history of CABG/PCI (OR 3.1, P=.001), and peripheral vascular disease (OR 2.74, P=.008).The score was evaluated by calculation of concordance index. The C statistic of 0.74 for the risk stratification group was considered good discrimination in the validation cohort (N=127) compared to the development cohort (N=368). The pre-transplant risk group was highly predictive of severe adverse events (OR 2.36, P<.001). Patients stratified into the above average-risk group were four times more likely to experience severe adverse events compared to average-risk patients, while patients in the high-risk group were nearly 11 times more likely to experience severe adverse events. The pre-transplant risk stratification tool is a simple scoring scheme using easily obtained preoperative characteristics that can meaningfully stratify patients in terms of post-transplant risk and may ultimately guide patient selection and inform the counseling of potential kidney transplant recipients.

Safety of percutaneous endoscopic gastrostomy after trauma laparotomy.

BACKGROUND: Trauma patients frequently require long-term enteral access because of injuries to the head, neck, or gastrointestinal tract. Noninvasive methods for gastrostomy placement include percutaneous endoscopic gastrostomy (PEG) and percutaneous radiographic gastrostomy (PRG). In patients with recent trauma laparotomy, PEG placement is felt to be relatively contraindicated because of the concerns about altered anatomy. We hypothesize that there is no increased rate of complications related to PEG placement in patients with trauma laparotomy compared with those without laparotomy provided that basic safety principles are followed. MATERIALS AND METHODS: This retrospective study evaluates all percutaneous gastrostomies (both PEG and PRG) placed in trauma patients admitted at a level I trauma center between January 1, 2007 and March 30, 2010. The electronic medical records of the 354 patients were reviewed through 30 days after procedure, and patients were further subdivided by the history of laparotomy. Statistical analysis was performed using Fisher exact test or two-tailed t-test, as appropriate. RESULTS: In patients with no prior trauma laparotomy, successful PEG placement occurred in 92.2% of patients, the remainder underwent PRG placement. Of patients with prior trauma laparotomy, 82.4% had successful PEG placement. Two percent of attempted PEG placements failed in patients with no previous trauma laparotomy, whereas 11.8% failed in patients with recent trauma laparotomy. The overall complication rate was 2.0%, with no recorded complications in patients with trauma laparotomy before PEG placement. CONCLUSIONS: These data suggest that surgeons should not consider recent trauma laparotomy a contraindication to PEG placement.