RESUMO
Brain death triggers a systemic inflammatory response. Whether systemic inflammation is different in lung donors after brain- (DBD) or circulatory-death (DCD) is unknown, but this may potentially increase the incidence of primary graft dysfunction (PGD) after lung transplantation. We compared the plasma levels of interleukin (IL)-6, IL-8, IL-10 and TNF-α in BDB and DCD and their respective recipients, as well as their relationship with PGD and mortality after LT. A prospective, observational, multicenter, comparative, cohort-nested study that included 40 DBD and 40 DCD lung donors matched and their respective recipients. Relevant clinical information and blood samples were collected before/during lung retrieval in donors and before/during/after (24, 48 and 72 h) LT in recipients. Incidence of PGD and short-term mortality after LT was recorded. Plasma levels of all determined cytokines were numerically higher in DBD than in DCD donors and reached statistical significance for IL-6, IL-10 and IL-8. In recipients with PGD the donor's plasma levels of TNF-α were higher. The post-operative mortality rate was very low and similar in both groups. DBD is associated with higher systemic inflammation than DCD donors, and higher TNF-α plasma levels in donors are associated with a higher incidence of PGD.
Assuntos
Morte Encefálica , Inflamação , Transplante de Pulmão , Disfunção Primária do Enxerto , Doadores de Tecidos , Humanos , Transplante de Pulmão/efeitos adversos , Feminino , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto , Inflamação/sangue , Disfunção Primária do Enxerto/etiologia , Disfunção Primária do Enxerto/sangue , Fator de Necrose Tumoral alfa/sangue , Interleucina-10/sangue , Interleucina-6/sangue , Interleucina-8/sangue , Transplantados , Citocinas/sangue , IdosoRESUMO
BACKGROUND AND AIMS: Hepatic ischemia-reperfusion injury (IRI) is the leading cause of early posttransplantation organ failure as mitochondrial respiration and ATP production are affected. A shortage of donors has extended liver donor criteria, including aged or steatotic livers, which are more susceptible to IRI. Given the lack of an effective treatment and the extensive transplantation waitlist, we aimed at characterizing the effects of an accelerated mitochondrial activity by silencing methylation-controlled J protein (MCJ) in three preclinical models of IRI and liver regeneration, focusing on metabolically compromised animal models. APPROACH AND RESULTS: Wild-type (WT), MCJ knockout (KO), and Mcj silenced WT mice were subjected to 70% partial hepatectomy (Phx), prolonged IRI, and 70% Phx with IRI. Old and young mice with metabolic syndrome were also subjected to these procedures. Expression of MCJ, an endogenous negative regulator of mitochondrial respiration, increases in preclinical models of Phx with or without vascular occlusion and in donor livers. Mice lacking MCJ initiate liver regeneration 12 h faster than WT and show reduced ischemic injury and increased survival. MCJ knockdown enables a mitochondrial adaptation that restores the bioenergetic supply for enhanced regeneration and prevents cell death after IRI. Mechanistically, increased ATP secretion facilitates the early activation of Kupffer cells and production of TNF, IL-6, and heparin-binding EGF, accelerating the priming phase and the progression through G1 /S transition during liver regeneration. Therapeutic silencing of MCJ in 15-month-old mice and in mice fed a high-fat/high-fructose diet for 12 weeks improves mitochondrial respiration, reduces steatosis, and overcomes regenerative limitations. CONCLUSIONS: Boosting mitochondrial activity by silencing MCJ could pave the way for a protective approach after major liver resection or IRI, especially in metabolically compromised, IRI-susceptible organs.
Assuntos
Fígado Gorduroso/metabolismo , Regeneração Hepática/fisiologia , Ativação de Macrófagos/fisiologia , Mitocôndrias/metabolismo , Proteínas Mitocondriais , Chaperonas Moleculares , Traumatismo por Reperfusão/metabolismo , Fatores Etários , Animais , Modelos Animais de Doenças , Metabolismo Energético/fisiologia , Inativação Gênica/fisiologia , Rejeição de Enxerto/prevenção & controle , Fígado/metabolismo , Transplante de Fígado/métodos , Camundongos , Camundongos Knockout , Proteínas Mitocondriais/genética , Proteínas Mitocondriais/metabolismo , Chaperonas Moleculares/genética , Chaperonas Moleculares/metabolismo , Traumatismo por Reperfusão/prevenção & controleRESUMO
Heart transplantation from controlled donation after the circulatory determination of death (cDCDD) may help to increase the availability of hearts for transplantation. During 2020, four heart transplants were performed at three different Spanish hospitals based on the use of thoraco-abdominal normothermic regional perfusion (TA-NRP) followed by cold storage (CS). All donors were young adults <45 years. The functional warms ischemic time ranged from 8 to 16 minutes. In all cases, the heart recovered sinus rhythm within 1 minute of TA-NRP. TA-NRP was weaned off or decreased <1L within 25 minutes. No recipient required mechanical support after transplantation and all were immediately extubated and discharged home (median hospital stay: 21 days) with an excellent outcome. Four livers, eight kidneys, and two pancreata were also recovered and transplanted. All abdominal grafts recipients experienced an excellent outcome. The use of TA-NRP makes heart transplantation feasible and allows assessing heart function before organ procurement without any negative impact on the preservation of abdominal organs. The use of TA-NRP in cDCDD heart donors in conjunction with cold storage following retrieval can eliminate the need to use ex situ machine perfusion devices, making cDCDD heart transplantation economically possible in other countries.
Assuntos
Transplante de Coração , Obtenção de Tecidos e Órgãos , Morte , Humanos , Preservação de Órgãos , Perfusão , Doadores de Tecidos , Adulto JovemRESUMO
Normothermic regional perfusion (NRP) allows the in situ perfusion of organs with oxygenated blood in donation after the circulatory determination of death (DCDD). We aimed at evaluating the impact of NRP on the short-term outcomes of kidney transplants in controlled DCDD (cDCDD). This is a multicenter, nationwide, retrospective study comparing cDCDD kidneys obtained with NRP versus the standard rapid recovery (RR) technique. During 2012-2018, 2302 cDCDD adult kidney transplants were performed in Spain using NRP (n = 865) or RR (n = 1437). The study groups differed in donor and recipient age, warm, and cold ischemic time and use of ex situ machine perfusion. Transplants in the NRP group were more frequently performed in high-volume centers (≥90 transplants/year). Through matching by propensity score, two cohorts with a total of 770 patients were obtained. After the matching, no statistically significant differences were observed between the groups in terms of primary nonfunction (p = .261) and mortality at 1 year (p = .111). However, the RR of kidneys was associated with a significantly increased odds of delayed graft function (OR 1.97 [95% CI 1.43-2.72]; p < .001) and 1-year graft loss (OR 1.77 [95% CI 1.01-3.17]; p = .034). In conclusion, compared with RR, NRP appears to improve the short-term outcomes of cDCDD kidney transplants.
Assuntos
Transplante de Rim , Obtenção de Tecidos e Órgãos , Adulto , Morte , Sobrevivência de Enxerto , Humanos , Preservação de Órgãos , Perfusão , Estudos Retrospectivos , Doadores de TecidosRESUMO
Controlled donation after circulatory death donors (cDCD) are becoming a frequent source of lungs grafts worldwide. Conversely, lung transplantations (LTx) from uncontrolled donors (uDCD) are sporadically reported. We aimed to review our institutional experience using both uDCD and cDCD and compare to LTx from brain death donors (DBD). This is a retrospective analysis of all LTx performed between January 2013 and December 2019 in our institution. Donor and recipient characteristics were collected and univariate, multivariate and survival analyses were carried out comparing the three cohorts of donors. A total of 239 (84.7%) LTx were performed from DBD, 29 (10.3%) from cDCD and 14 (5%) from uDCD. There were no statistically significant differences in primary graft dysfunction grade 3 at 72 h, 30- and 90-day mortality, need for extracorporeal membrane oxygenation after procedure, ICU and hospital length of stay, airway complications, CLAD incidence or survival at 1 and 3 years after transplant (DBD: 87.1% and 78.1%; cDCD: 89.7% and 89.7%; uDCD: 85.7% and 85.7% respectively; P = 0.42). Short- and mid-term outcomes are comparable between the three types of donors. These findings may encourage and reinforce all types of donation after circulatory death programmes as a valid and growing source of suitable organs for transplantation.
Assuntos
Transplante de Pulmão , Obtenção de Tecidos e Órgãos , Morte Encefálica , Morte , Sobrevivência de Enxerto , Humanos , Estudos Retrospectivos , Doadores de TecidosRESUMO
Normothermic regional perfusion (NRP) in controlled donation after circulatory death is becoming a popular method due to the favorable results of the grafts procured under this technique. This procedure requires experience, and, sometimes, the availability of extracorporeal membrane oxygenation (ECMO) machines to implement NRP is limited to tertiary hospitals. In order to provide support with NRP in controlled donation after circulatory death across the different hospitals of the Autonomous Community of Madrid, a mobile NRP team was created. In the first 18 months since its creation, the mobile NRP team participated in 33 procurements across nine different hospitals, representing 72% of all controlled donations after circulatory death in the Autonomous Community of Madrid. NRP was successfully performed in 29 (88%) cases, with a mean duration of 69 ± 27 minutes. A total of 39 kidneys, 12 livers, and 5 bilateral lungs were recovered and transplanted. None of the livers were discarded due to an elevation in transaminases during NRP. A mobile NRP team is a feasible option and, in our series, aided in the optimization and recovery of organs from donors after controlled circulatory death in centers where ECMO technology was not available.
Assuntos
Oxigenação por Membrana Extracorpórea , Obtenção de Tecidos e Órgãos , Morte , Humanos , Preservação de Órgãos , Perfusão , Projetos Piloto , Doadores de TecidosRESUMO
BACKGROUND: The COVID-19 pandemic adversely affected the severity and prognosis of patients with acute myocardial infarction (MI) caused by atherothrombosis (type 1 MI). The effect, if any, of COVID-19 vaccination and natural SARS-CoV2 serologic immunity in these patients is unclear. Our aim was to analyze the association between the severity and outcome of patients with type 1 MI and their previous SARS-CoV2 vaccination and serostatus. METHODS: A single-center retrospective cohort study conducted between March 1, 2020 and March 1, 2023. Clinical and follow-up information was collected from medical records and patients. Total antibodies (IgM, IgA, IgG) to nucleocapsid (N) antigens were measured by ECLIA (electrochemiluminescence-based immunoassay) to test the immune response to natural infection. If positive, IgM and IgG antibodies to spike (S) surface antigens were measured by CLIA to test the immune response to vaccine or natural infection. Multivariable logistic regression analysis was performed, adjusting for age, sex, hypertension, diabetes, and dyslipidemia. RESULTS: Total sample of 949 patients, 656 with ST-segment elevation MI (STEMI) and 293 with non-ST-segment elevation MI (NSTEMI). Mean age was 64 (SD 13) years, 80 % men. Pre-admission vaccination status was: ≥ 1 dose, 53 % of patients; complete vaccination, 49 %; first booster dose, 25 %. The majority (84 %) of vaccines administered were mRNA-based. Six months after MI, 92 (9.7 %) patients had a major adverse cardiac event (MACE) and 50 died; 11 % of patients had severe heart failure or cardiogenic shock (Killip III-IV) after STEMI. Vaccinated patients with STEMI and positive serology (Pos/Vax group) had a higher risk of Killip III-IV on admission: OR 2.63 (1.27-5.44), p = 0.010. SARS-CoV-2 S-specific IgG titers were highest in this group (median > 2080 AU/mL, [IQR 1560- >2080] vs 91 [32-198] in the unvaccinated group). In the overall sample, a higher incidence of 6-month MACE was not demonstrated (OR 1.89 [0.98-3.61], p = 0.055). CONCLUSIONS: The combination of vaccination and natural SARS-CoV2 infection was associated with the development of severe heart failure and cardiogenic shock in patients with STEMI, possibly related to an increased serological response.
RESUMO
OBJECTIVES: The aim of this study was to compare the outcomes of lung transplantations using grafts from donors aged over 70 years against those performed using younger donors. METHODS: This retrospective single-centre analysis includes lung transplants conducted at our institution from January 2014 to June 2022. Lung recipients were classified into 2 groups based on donor age (group A <70 years; group B ≥70 years). Variables regarding demographics, peri and postoperative outcomes and survival were included. The statistical analysis approach included univariable analysis, propensity score matching to address imbalances in donor variables (smoking status), recipient characteristics (sex, age, diagnosis and lung allocation score) and calendar period and survival analysis. RESULTS: A total of 353 lung transplants were performed in this period, 47 (13.3%) using grafts from donors aged over 70 years. Donors in group B were more frequently women (70.2% vs 51.6%, P = 0.017), with less smoking history (22% vs 43%, P = 0.002) and longer mechanical ventilation time (3 vs 2 days, P = 0.025). Recipients in group B had a higher lung allocation score (37.5 vs 35, P = 0.035). Postoperative variables were comparable between both groups, except for pulmonary function tests. Group B demonstrated lower forced expiratory volume 1 s levels (2070 vs 2580 ml, P = 0.001). The propensity score matching showed a lower chance of chronic lung allograft dysfunction by 12% for group B. One-, three- and five-year survival was equal between the groups. CONCLUSIONS: The use of selected expanded-criteria donors aged over 70 years did not result in increased postoperative morbidity, early mortality or survival in this study.
Assuntos
Transplante de Pulmão , Doadores de Tecidos , Humanos , Feminino , Idoso , Idoso de 80 Anos ou mais , Estudos Retrospectivos , Resultado do Tratamento , Taxa de Sobrevida , Fatores EtáriosRESUMO
INTRODUCTION: Cold static donor lung preservation at 10°C appears to be a promising method to safely extend the cold ischemic time (CIT) and improve lung transplant (LTx) logistics. METHODS: LTx from November 2021 to February 2023 were included in this single institution, prospective, non-randomized study comparing prolonged preservation at 10°C versus standard preservation on ice. The inclusion criteria for 10°C preservation were suitable grafts for LTx without any donor retrieval concerns. PRIMARY ENDPOINT: primary graft dysfunction (PGD) grade-3 at 72-h. Secondary endpoints: clinical outcomes, cytokine profile and logistical impact. RESULTS: Thirty-three out of fifty-seven cases were preserved at 10°C. Donor and recipient characteristics were similar across the groups. Total preservation times (h:min) were longer (p<0.001) in the 10°C group [1st lung: median 12:09 (IQR 9:23-13:29); 2nd: 14:24 (12:00-16:20)] vs. standard group [1st lung: median 5:47 (IQR 5:18-6:40); 2nd: 7:15 (6:33-7:40)]. PGD grade-3 at 72-h was 9.4% in 10°C group vs. 12.5% in standard group (p=0.440). Length of mechanical ventilation (MV), ICU and hospital stays were similar in both groups. Thirty and ninety-day mortality rates were 0% in 10°C group (vs. 4.2% in standard group). IL-8 concentration was significantly higher 6-h post-LTx in the standard group (p=0.025) and IL-10 concentration was increased 72-h post-LTx in the 10°C group (p=0.045). CONCLUSIONS: Preservation at 10°C may represent a safe and feasible strategy to intentionally prolong the CIT. In our center, extending the CIT at 10°C may allow for semi-elective LTx and improve logistics with similar outcomes compared to the current standard preservation on ice.
Assuntos
Transplante de Pulmão , Preservação de Órgãos , Disfunção Primária do Enxerto , Humanos , Preservação de Órgãos/métodos , Masculino , Feminino , Estudos Prospectivos , Pessoa de Meia-Idade , Disfunção Primária do Enxerto/prevenção & controle , Adulto , Doadores de Tecidos , Isquemia Fria , Interleucina-8/análise , Interleucina-8/sangue , Pulmão , Fatores de Tempo , Interleucina-10/sangue , Tempo de Internação/estatística & dados numéricos , Respiração Artificial , Citocinas/sangueRESUMO
Donor lung preservation at 10 °C appears to be an innovative and promising method that may improve transplant logistics by extending the cold ischemia time with excellent outcomes. We report the case of two lung transplants from two different donors involving the use of two different preservation methods, highlighting the benefits of using 10 °C lung storage.
Assuntos
Transplante de Pulmão , Preservação de Órgãos , Humanos , Pulmão/cirurgia , Doadores de TecidosRESUMO
BACKGROUND: To better define the risk of malignancy transmission through organ transplantation, we review the Spanish experience on donor malignancies. METHODS: We analyzed the outcomes of recipients of organs obtained from deceased donors diagnosed with a malignancy during 2013-2018. The risk of malignancy transmission was classified as proposed by the Council of Europe. RESULTS: Of 10 076 utilized deceased donors, 349 (3.5%) were diagnosed with a malignancy. Of those, 275 had a past (n = 168) or current (n = 107) history of malignancy known before the transplantation of organs into 651 recipients. Ten malignancies met high-risk criteria. No donor-transmitted cancer (DTC) was reported after a median follow-up of 24 (interquartile range [IQR]: 19-25) mo. The other 74 donors were diagnosed with a malignancy after transplantation. Within this group, 64 donors (22 with malignancies of high or unacceptable risk) whose organs were transplanted into 126 recipients did not result in a DTC after a median follow-up of 26 (IQR: 22-37) mo, though a prophylactic transplantectomy was performed in 5 patients. The remaining 10 donors transmitted an occult malignancy to 16 of 25 recipients, consisting of lung cancer (n = 9), duodenal adenocarcinoma (n = 2), renal cell carcinoma (n = 2), extrahepatic cholangiocarcinoma (n = 1), prostate cancer (n = 1), and undifferentiated cancer (n = 1). After a median follow-up of 14 (IQR: 11-24) mo following diagnosis, the evolution was fatal in 9 recipients. In total, of 802 recipients at risk, 16 (2%) developed a DTC, which corresponds to 6 cases per 10 000 organ transplants. CONCLUSIONS: Current standards may overestimate the risk of malignancy transmission. DTC is an infrequent but difficult to eliminate complication.
Assuntos
Carcinoma de Células Renais , Neoplasias Renais , Transplante de Órgãos , Transplantes , Humanos , Masculino , Transplante de Órgãos/efeitos adversos , Doadores de TecidosRESUMO
OBJECTIVES: Bronchial anastomotic complications remain a major concern in lung transplantation. We aim to compare 2 different techniques, continuous suture (CS) versus interrupted suture (IS) by analysing airway complications requiring intervention. METHODS: Lung transplantations between January 2015 and December 2020 were included. Airway complications requiring intervention were classified following the 2018 International Society for Heart and Lung Transplantation consensus and analysed comparing 3 groups of patients according to surgical technique: group A, both anastomosis performed with CS; group B, both with interrupted; and group C, IS for 1 side and CS for the contralateral side. RESULTS: A total of 461 anastomoses were performed in 245 patients. The incidence of airway complications requiring intervention was 5.7% [95% confidence interval (CI): 2.8-8.6] per patient (14/245) and 3.7% (95% CI: 2.0-5.4) per anastomosis (17/461). Complications that required intervention were present in 5 out of 164 (3.1%) anastomosis with interrupted technique, and in 12/240 (5%) with CS. No significant differences were found between techniques (P = 0.184). No statistical differences were found among group A, B or C in terms of incidence of anastomotic complications, demographics, transplant outcomes or overall survival (log-rank P = 0.513). In a multivariable analysis, right laterality was significantly associated to complications requiring intervention (OR 3.7 [95% CI: 1.1-12.3], P = 0.030). Endoscopic treatment was successful in 12 patients (85.7%). Retransplantation was necessary in 2 patients. CONCLUSIONS: In summary, although it seems that anastomotic complications requiring intervention occur more frequently with CS, there are no statistical differences compared to IS. Endoscopic treatment offers good outcomes in most of the airway complications after lung transplantation.
Assuntos
Transplante de Pulmão , Técnicas de Sutura , Humanos , Técnicas de Sutura/efeitos adversos , Resultado do Tratamento , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Suturas , Transplante de Pulmão/métodosRESUMO
BACKGROUND: Controlled donation after circulatory death (cDCD) has emerged as one of the main strategies for increasing the organ donor pool. Because of the ischemic injury that follows the withdrawal of life-sustaining therapies, hearts from cDCD donors have not been considered for transplantation until recently. The ex-situ perfusion of hearts directly procured from cDCD donors has been used to allow the continuous perfusion of the organ and the assessment of myocardial viability prior to transplantation. Based on our experience with abdominal normothermic regional perfusion in cDCD, we designed a protocol to recover and validate hearts from cDCD donors using thoraco-abdominal normothermic regional perfusion without the utilization of an ex-situ device. CASE PRESENTATION: We describe the first case of a cDCD heart transplant performed with this approach in Spain. The donor was a 43-year-old asthmatic female diagnosed with severe hypoxic encephalopathy. She was considered a potential cDCD donor and a suitable candidate for multiorgan procurement including the heart via thoraco-abdominal normothermic regional perfusion. The heart recipient was a 60-year-old male diagnosed with amyloid cardiomyopathy. Cold ischemia time was 55 min. The surgery was uneventful. CONCLUSIONS: This case report, the first of its kind in Spain, supports the feasibility of evaluating and successfully transplanting cDCD hearts without the need for ex-situ perfusion based on the use of thoraco-abdominal normothermic regional perfusion opening the way for multiorgan donation in cDCD.
Assuntos
Oxigenação por Membrana Extracorpórea , Transplante de Coração , Perfusão/métodos , Coleta de Tecidos e Órgãos/métodos , Abdome , Adulto , Morte , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Espanha , Tórax , Doadores de TecidosRESUMO
OBJECTIVES: Controlled donation after circulatory death (cDCD) donors are becoming a common source of organs for transplantation globally. However, the graft survival rate of cDCD abdominal organs is inferior to that of organs from brain-dead donors. The rapid retrieval (RR) technique is used by most donor organ procurement teams. The abdominal normothermic regional perfusion (A-NRP) technique has been implemented to minimize warm ischaemic damage to the abdominal organs. However, there is limited information on the effect of A-NRP on the quality of the donor lungs. This study aimed to compare lung transplantation outcomes using lungs procured from cDCD donors using the A-NRP and abdominal RR techniques. METHODS: A single-centre retrospective analysis of consecutive transplant recipients of cDCD lungs from June 2013 to December 2019 was performed. The recipients were divided into 2 cohorts according to the abdominal procurement technique used. The recipient and donor characteristics (age, sex, cause of brain injury, warm ischaemic time, diagnosis, lung allocation score and other factors), incidence of primary graft dysfunction and early survival were monitored. RESULTS: Twenty-eight consecutive lung transplantation recipients were identified (median age 59 years; 61% male); 14 recipients received lungs using the A-NRP and 14 using abdominal RR for abdominal organ retrieval. There were no significant differences in the baseline characteristics, primary graft dysfunction (P = 0.70), hospital mortality (P = 1.0) and 1-year survival rate (P = 1.0) between the 2 groups. CONCLUSIONS: No difference was observed in lung transplantation outcomes irrespective of the abdominal organ procurement technique used (A-NRP or abdominal RR).
RESUMO
BACKGROUND AND OBJECTIVE: To describe the characteristics and the evolution of patients with solid tumours admitted to the ICU and to identify factors associated with hospital mortality and to evaluate three illness severity scores. MATERIAL AND METHODS: Descriptive study including 132 patients with solid tumour admitted to the ICU (2010-2016). Demographics and cancer-related data, organ failures, life-supporting therapies and severity scores: APACHE II, SOFA and ICU Cancer Mortality Model (ICMM) were collected. RESULTS: There were 58 patients admitted for medical reasons and 74 for scheduled surgery. The ICU and hospital mortality rate were 12.9% and 19.7%, respectively. The medical reason for admission, the number of organ failures, and the need of life-supporting therapies were significantly associated with a higher mortality (p<0.05). In the logistic regression analysis, the three severity scores: SOFA (OR 1.18, 95% IC 1.14-1.48), APACHE II (OR 1.11, 95% CI 1.09-1.27), and ICMM (OR 1.03, 95% CI 1.02-1.07) were independently associated with a higher mortality (p<0.05). To evaluate the discrimination, the area under the receiver operating characteristics curves (AUROC) were calculated: APACHE II (0.795, 95% CI 0.69-0.9), SOFA (0.77, 95% CI 0.69-0.864) and ICMM (0.794, 95% CI 0.697-0.891). The comparison of AUC ROC after DeLong's test showed no difference between them. CONCLUSION: Hospital mortality was associated with the type and severity of acute illness. The three severity scores were useful to assess outcome and accurate in the discrimination, but we did not find a significant difference between them.
Assuntos
Mortalidade Hospitalar , Unidades de Terapia Intensiva , Neoplasias/mortalidade , Admissão do Paciente , Índice de Gravidade de Doença , APACHE , Idoso , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação , Cuidados para Prolongar a Vida/métodos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Neoplasias/tratamento farmacológico , Neoplasias/cirurgia , Escores de Disfunção Orgânica , Curva ROC , Estudos RetrospectivosRESUMO
AIMS: The aim of this study was to evaluate the effectiveness of local low-dose urokinase thrombolysis (LLDUT) in haemodynamically stable pulmonary embolism with right ventricular dysfunction (RVD). METHODS AND RESULTS: This was a prospective study. LLDUT with a 200,000 IU bolus followed by a 100,000 IU/hr infusion was given. Treatment duration was determined through radiological control performed 48-72 hrs into treatment. A follow-up echocardiogram was performed within seven days after LLDUT completion. Evolution of thrombus burden, pulmonary artery pressures (PAP) and RVD were studied, and haemorrhagic complications and mortality were recorded. Eighty-seven patients were included (62.5±16.5 years). In 67 patients (77%), the baseline echocardiogram showed mild-to-severe RVD, a dilated right ventricle (diameter: 44.4±6.2 mm) and a decreased tricuspid annular plane systolic excursion (14 mm [12-17]). Seventy-six patients (87.4%) experienced radiological improvement. Initially high PAP (mmHg) decreased after LLDUT: systolic 52.4 vs. 35.2 (17.2 [95% CI: 14.5-19.9]; p<0.0001), mean 34.2 vs. 23.5 (10.7 [95% CI: 9.0-12.5]; p<0.0001) and diastolic 23.9 vs. 16.0 (7.9 [95% CI: 6.1-9.7]; p<0.0001). Follow-up echocardiography showed overall improvement of RVD. No life-threatening haemorrhagic complications were reported. Six-month survival was 96.5%. CONCLUSIONS: LLDUT rapidly decreased thrombus burden and PAP, improving right ventricular function, and was not associated with any life-threatening complications or pulmonary embolism (PE)- or treatment-related mortality.
Assuntos
Embolia Pulmonar , Disfunção Ventricular Direita , Humanos , Estudos Prospectivos , Terapia Trombolítica , Ativador de Plasminogênio Tipo UroquinaseRESUMO
Although the number of lung transplants in Spain is increasing annually, more organs are required to ease waiting lists. Controlled non-heart beating donors (NHBD) (Maastricht III) are a reality at international level, and contribute significantly to increasing donor numbers. In this study, we present our NHBD protocol and the initial experience in Spain using lung grafts from this type of donor. Three bilateral lung transplants were performed between January 2012 and December 2014. Preservation was by ex-vivo lung perfusion in 2 cases and by traditional cold ischemia in the other. None of the patients developed grade 3 primary graft dysfunction, no in-hospital mortality was recorded and 1-year survival was 100%. These initial results, and international experience, should help to develop similar protocols to encourage the use of controlled non-heart beating donors.
Assuntos
Transplante de Pulmão , Adulto , Feminino , Humanos , Transplante de Pulmão/métodos , Masculino , Pessoa de Meia-Idade , Espanha , Doadores de TecidosRESUMO
Donor lung preservation at 10 °C appears to be an innovative and promising method that may improve transplant logistics by extending the cold ischemia time with excellent outcomes. We report the case of two lung transplants from two different donors involving the use of two different preservation methods, highlighting the benefits of using 10 °C lung storage. (AU)
La preservación pulmonar a 10 °C es una estrategia innovadora que podría mejorar la logística del trasplante pulmonar permitiendo prolongar el tiempo de isquemia fría de los injertos pulmonares con excelentes resultados. Presentamos el caso de dos trasplantes pulmonares de dos donantes diferentes empleando dos métodos de preservación distintos, recalcando los beneficios de utilizar este novedoso método de preservación a 10 °C. (AU)
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Idoso , Transplante de Pulmão , Pulmão/cirurgia , Isquemia Fria , Doadores de Tecidos , Preservação de ÓrgãosRESUMO
Aunque el número de trasplantes pulmonares en España es cada año mayor, es necesario aumentar el número de órganos disponibles para aliviar las listas de espera. Los donantes en asistolia controlada (DAC) (Maastricht III) son una realidad a nivel internacional y contribuyen significativamente a aumentar el número de donantes. En este trabajo presentamos nuestro protocolo de DAC y la experiencia inicial en España usando injertos pulmonares provenientes de este tipo de donantes. Desde enero 2012 a diciembre 2014, se han realizado 3 trasplantes pulmonares bilaterales. De ellos, en 2 casos se realizó preservación ex vivo y en el otro preservación tradicional en frío. Ninguno de los pacientes desarrolló disfunción primaria del injerto grado 3, no se registró mortalidad hospitalaria y la supervivencia al primer año fue del 100%. Estos resultados iniciales, y la experiencia internacional, deberían contribuir al desarrollo de protocolos similares para fomentar el aprovechamiento de los DAC
Although the number of lung transplants in Spain is increasing annually, more organs are required to ease waiting lists. Controlled non-heart beating donors (NHBD) (Maastricht III) are a reality at international level, and contribute significantly to increasing donor numbers. In this study, we present our NHBD protocol and the initial experience in Spain using lung grafts from this type of donor. Three bilateral lung transplants were performed between January 2012 and December 2014. Preservation was by ex-vivo lung perfusion in 2 cases and by traditional cold ischemia in the other. None of the patients developed grade 3 primary graft dysfunction, no in-hospital mortality was recorded and 1-year survival was 100%. These initial results, and international experience, should help to develop similar protocols to encourage the use of controlled non-heart beating donors
Assuntos
Adulto , Humanos , Masculino , Transplante de Pulmão , Parada Cardíaca , Cuidados para Prolongar a Vida , Suspensão de Tratamento , Monitoramento Epidemiológico/tendências , Taxa de Sobrevida , Preservação de Órgãos/métodos , Unidades de Terapia Intensiva , Heparina/administração & dosagem , Fidelidade a Diretrizes , Espanha/epidemiologiaRESUMO
Background and objective: To describe the characteristics and the evolution of patients with solid tumours admitted to the ICU and to identify factors associated with hospital mortality and to evaluate three illness severity scores. Material and methods: Descriptive study including 132 patients with solid tumour admitted to the ICU (2010-2016). Demographics and cancer-related data, organ failures, life-supporting therapies and severity scores: APACHE II, SOFA and ICU Cancer Mortality Model (ICMM) were collected. Results: There were 58 patients admitted for medical reasons and 74 for scheduled surgery. The ICU and hospital mortality rate were 12.9% and 19.7%, respectively. The medical reason for admission, the number of organ failures, and the need of life-supporting therapies were significantly associated with a higher mortality (p<0.05). In the logistic regression analysis, the three severity scores: SOFA (OR 1.18, 95% IC 1.14-1.48), APACHE II (OR 1.11, 95% CI 1.09-1.27), and ICMM (OR 1.03, 95% CI 1.02-1.07) were independently associated with a higher mortality (p<0.05). To evaluate the discrimination, the area under the receiver operating characteristics curves (AUROC) were calculated: APACHE II (0.795, 95% CI 0.69-0.9), SOFA (0.77, 95% CI 0.69-0.864) and ICMM (0.794, 95% CI 0.697-0.891). The comparison of AUC ROC after DeLong's test showed no difference between them. Conclusion: Hospital mortality was associated with the type and severity of acute illness. The three severity scores were useful to assess outcome and accurate in the discrimination, but we did not find a significant difference between them
Introducción y objetivo: Describir las características generales y la evolución de los pacientes con tumores sólidos ingresados en una unidad de cuidados intensivos (UCI), identificar los factores asociados a la mortalidad y evaluar el valor pronóstico de 3 escalas de gravedad. Material y métodos: Estudio descriptivo de 132 pacientes con diagnóstico de tumour sólido admitidos en la UCI (2010-2016). Se analizaron los datos demográficos relacionados con el tumour, la disfunción orgánica y las terapias de soporte vital, así como las escalas de gravedad APACHE II, SOFA e ICMM. Resultados: Ingresaron 58 pacientes por causa médica y 74 tras cirugía programada. La tasa de mortalidad en la UCI y hospitalaria fue del 12,9% y 19,7%, respectivamente. La causa médica de ingreso, el número de fallos orgánicos y la necesidad de terapias de soporte vital se asociaron significativamente con mayor mortalidad (p<0,05). En el análisis por regresión logística las 3 escalas evaluadas: SOFA (OR: 1,18; IC 95%: 1,14-1,48), APACHE II (OR: 1,11; IC 95%: 1,09-1,27) e ICMM (OR: 1,03; IC 95%: 1,02-1,07) se asociaron de forma independiente con una mayor mortalidad (p<0,05). Para evaluar la discriminación, se calcularon las AUROC: APACHE II (0,795; CI 95%: 0,69-0,9), SOFA (0,77; CI 95%: 0,69-0,864) e ICMM (0,794; CI 95%: 0,697-0,891). La comparación de las mismas por el test DeLong no mostró diferencias entre los sistemas de puntuación. Conclusiones: La mortalidad hospitalaria se asoció con el tipo y la gravedad de la enfermedad aguda. Las e escalas de gravedad evaluadas fueron igualmente útiles para evaluar el pronóstico, sin mostrar diferencias entre ellas