"Assessment of RIFLE and AKIN criteria to define acute renal dysfunction for HIPEC procedures for ovarian and non ovarian peritoneal malignances".

BACKGROUND: The acute renal dysfunction (ARD) is a common complication in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Our aim is evaluate the ARD post-HIPEC procedures using the RIFLE and AKIN criteria. Evaluate the risk factors and analyze ARD's impact on postoperative course. METHODS: From 2011 to 2014, in a retrospective way using a prospective database were operated by HIPEC procedure. The ARD was analyzed by RIFLE and AKIN criteria. The perioperative features were analyzed and a multivariate analysis was performed to define the risk factors to develop the ARD. RESULTS: 141 patients were treated and analyzed. The ARD was detected in 30.5% (Injury 18.4% and Failure 12.1%) when RIFLE criteria were applied. The multivariate analysis detected that decrease of pH during HIPEC [OR = 29.39 (5.09-169.76)], PCI [OR = 1.07 (1.01-1.15)] and ureteral catheters [OR = 12.71 (1.44-111.85)] were associated to the development of acute renal injury (ARI) post-HIPEC. Decrease of Na during HIPEC [OR = 1.15 (1.01-1.30)], intraoperative inotrope use [OR = 3.83 (1.12-13.09)] and PCI [OR = 1.06 (1.0-1.14)] were associated to acute renal failure (ARF) post-HIPEC. The ARD was related to a higher length of stay hospital (17.2 ± 11 vs. 13.8 ± 8 days) (p = 0.05) but no impact in early survival was observed in ARD group. CONCLUSIONS: The widespread use of RIFLE criteria for ARD would have major benefits in terms of accurately diagnosing patients undergone HIPEC procedures. The ARD has a detrimental impact in length of stay hospital. The knowledge of risk factors helps us to prevent the ARD post-HIPEC by means of an aggressive and multidisciplinary perioperative management.

Incidence and Long-Term Prognosis of Cancer After Kidney Transplantation.

BACKGROUND: Malignancy is an important cause of mortality in renal transplants recipients. The incidence of cancer is increased by immunosuppressive treatment and longer kidney graft survival. The aim of this study was to evaluate the incidence, prognosis and survival of posttransplant malignancies: solid organ cancer (SOC), posttransplant lymphoproliferative disorder (PTLD), and nonmelanoma skin cancer (NMSC). METHODS: We retrospectively studied the development of cancers among kidney transplants patients in our hospital from January 1979 to January 2015. We analyzed demographic and clinical characteristics, risk factors, and patient survival after tumor diagnosis. RESULTS: We included 1450 kidney transplants recipients with a mean follow-up was 10 years; among them, 194 developed malignancies. The mean age at presentation was 59 ± 10 years. The SOC, PTLD, and NMSC incidences were 6.2%, 1.2%, and 6%, respectively. The most common tumors were kidney (16.6%), colon (11%), bladder (10%), breast (10%), prostate (10%), and lung (8.8%). The median times to development of a SOC, PTLD, and NMSC were 6.86 (range, 3.7-12), 4.43 (range, 1.8-5.7), and 8.19 (range, 3.8-12.2) years, respectively. Risk factors associated with developing SOC and PTLD were patient age (odds ratio [OR], 1.03; P < .001) and time posttransplant (OR, 1.05; P = .02), whereas for NMSC were to be male (OR, 3.61; P < .001), to take calcineurin inhibitors (OR, 2.17; P = .034), patient age (OR, 1.05; P < .001) and time posttransplant (OR, 1.15; P < .01). The mean survival time from the diagnosis of SOC, PTLD, and NMSC were 2.09 (range, 0.1-5.3), 0.22 (range, 0.05-1.9), and 7.68 (range, 3.9-10.5) years, respectively (P < .001). CONCLUSIONS: SOC occurs more frequently than other malignancies among renal transplant patients. NMSC has better survival and prognosis. Older patients and prolonged graft function have a greater risk of developing malignancies.

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.

Index high insulin resistance in pancreas-kidney transplantation contributes to poor long-term survival of the pancreas graft.

BACKGROUND: Pancreas-kidney transplantation (PKT) is the best therapeutic option for diabetic patients with end-stage renal failure. Peripheral insulin resistance and the percentage of remaining ß-cells in the PKT have been little studied in medical literature. METHODS: We analyzed PKT performed in our hospital from January 1992 to January 2014, with follow-up for 5 years. Metabolic values related to glycemic were studied, namely, proteinuria, peptide C, glucose, insulin, and glycosylated hemoglobin. We analyzed insulin resistance (homeostatic model assessment [HOMA]-IR), the percentage of remaining ß-cells (HOMA-ß), and the influence of these variables on the glycemic profile and graft survival. RESULTS: In the study period, 156 simultaneous PKT were performed in our center. At 2 years posttransplantation, the median value of HOMA-IR kidney-pancreas was 4. We compared transplantation with lower HOMA-IR (<4) and higher HOMA-IR (>4). HOMA-ß (36 [26-67] vs 29 [14-42]; P = .04), glucose (86 [80-90] vs 81 [74-89]; P = .018), and body mass index (BMI; 24 [21-27] vs 21 [19-24]; P = .013) were greater in the group HOMA-IR>4 versus HOMA-IR<4 group, respectively, after 3 months. These differences in glycemic profile were maintained until the first year after transplantation. At 2 and 5 years of follow-up, the HOMA-IR>4 group showed higher glucose levels and greater BMI, but not differences in HOMA-ß. At 1 and 5 years posttransplantation, pancreatic graft survival in the HOMA-IR>4 group (82.9% vs 92.5%) was lower compared with the HOMA-IR<4 group (67% vs 87.5%; P = .016). CONCLUSIONS: PKT exhibit an altered glycemic profile in the posttransplantation follow-up associated with the percentage of remaining ß-cells and peripheral insulin resistance. PKT patients with peripheral insulin resistance showed decreased pancreatic graft 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.

Recurrent membranoproliferative glomerulonephritis after second renal graft treated with plasmapheresis and rituximab.

We present a case of a 45-year-old man who suffered from idiopatic membranoproliferative glomerulonephritis (MPGN) in the native kidney that relapsed after his first and second renal grafts. The patient was diagnosed in 1990 with lobular MPGN type I, receiving his first renal graft in 1996. In 2001, a biopsy showed recurrence of MPGN type I (rMPGN). He underwent a second renal graft in 2008. In January 2010, he experienced increased proteinuria and creatinine. Upon electron microscopy of a renal graft biopsy we diagnosed a new rMPGN. At the time of the biopsy, complement levels were normal, although C3 and C4 decreased further. We administered 12 plasmapheresis (PP) sessions and four doses of rituximab. Due to persistent renal impairment, we performed a new biopsy 3 months later, showing less severity of the acute lessions. He received a new cycle of treatment (PP+rituximab). One year later, his renal function was stable with a creatinine ranging between 2 and 2.5 mg/dL and a protein/creatinine ratio less than 1 mg/mg. We concluded that the treatment stopped the disease progression.

Glomerulonefritis extracapilar tipo I con coexistencia de anticuerpos anti-MBG y ANCA-p positivos / No disponible

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Consolidation of enteric drainage for exocrine secretions in simultaneous pancreas-kidney transplant.

INTRODUCTION: Management of the exocrine drainage of the pancreatic graft in simultaneous pancreas kidney (SPK) transplantation has been a matter of debate for years. There is currently a trend toward a more physiological enteric drainage (ED). This study compared short- and long-term complications and graft survival in patients with enteric versus bladder exocrine secretion drainage. PATIENTS AND METHODS: Between January 1995 and November 2005, we performed 75 SPK transplants: 55 with ED and 20 with bladder drainage (BD). The rates of complications and graft survival were monitored over at least 36 months after transplantation. RESULTS: Mean posttransplant follow-up was 119.5 +/- 6.6 months. Urinary infection, hematuria, reflux pancreatitis, and repeat surgery rates were all significantly higher among the BD area. There was no intergroup difference in rejection rates or in the incidence of graft thrombosis, transplantectomy, anastomotic dehiscence, or intra-abdominal abscesses. Pancreas and kidney graft survival rates were similar in the two groups. CONCLUSIONS: In our experience, ED was more physiological than BD, and was associated with fewer complications.

Marcadores de desdiferenciación podocitaria en un paciente con glomerulonefritis colapsante / No disponible

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Cancer incidence and survival in kidney transplant patients.

Immunosuppression after organ transplantation is associated with a markedly increased risk of nonmelanoma skin cancer (NMSC) and malignancies, including posttransplant lymphoproliferative disorder (PTLD) and solid organ cancer. This study sought to investigate the incidence of malignancies and the clinical characteristics and risk factors of the renal transplant patients with solid organ tumors and NMSC. We included 1017 patients who received a kidney transplant in our hospital from 1979 to 2007. Results were contrasted with a cohort of patients from the same center without malignancies. The mean follow-up of patients in our series was 10 years. The mean age at presentation of the malignancy was 61 +/- 5 years. The malignancy and NMSC incidences were 6% and 5%, respectively. Patients with malignancy had a longer posttransplant time and greater recipient and donor age. In the multivariate analysis, independent risk factors for developing NMSC were: male sex (hazard ratio [HR] 3.1, P = .004); greater patient age (HR 1.09, P < .001), longer posttransplant time (HR 1.2, P = .004) and tacrolimus treatment (HR 4.4, P = .001). Risk factors associated with developing any malignancy were: patient age (HR 1.06, P < .001), number of grafts (HR 3.2, P = .019), tacrolimus treatment (HR 2.5, P = .035), and time posttransplantation (HR 1.2, P = .011). The mean times to development of an NMSC, solid organ malignancy, on PTLD were 7.5, 6.1, or 3.9 years, respectively. The mean survival time from the diagnosis of any malignancy was 9.6 months (95% confidence interval, 0.12-30) for solid organ malignancies and 1 month (95% confidence interval, 0.24-1.87) for PTLD.