First case of simultaneous heart plus kidney transplantation in Chile: case report.

Advanced renal disease is a formal contraindication to heart transplantation, and heart failure may make a patient ineligible for kidney transplantation. The International Society of Heart and Lung Transplantation has reported 336 simultaneous heart and kidney transplantations with a 70% rate of 5 year survival. Herein we have presented the first case of simultaneous heart plus kidney transplantation in Chile. The patient is a 62-year-old man with diabetes mellitus and arterial hypertension who in 1997 had a myocardial infarction with cardiogenic shock and acute renal failure. He underwent a coronary bypass but developed progressive heart failure, with an ejection fraction less than 20% and moderate mitral regurgitation. He required chronic hemodialysis and survived a cardiac arrest, receiving an implantable cardioverter defibrillator. Transplantation was performed in 2004 in 2 phases: initially a heart, followed by a kidney transplantation. Immunosuppression included Daclizumab, cyclosporine, mycophenolate mofetil (MMF) and steroids. He developed acute renal failure but did not receive dialysis. He left the hospital at 25 days posttransplantation. Two years following double transplantation, he has not shown acute rejection episodes of either the cardiac or the kidney graft. Both cardiac and renal functions are normal. In conclusion, simultaneous heart plus kidney transplantations offer a good alternative treatment for patients with advanced disease of both organs.

[Usefulness of thoracic radiography after insertion of transitory catheters for hemodialysis]. / Utilidad de la radiografía de tórax posterior a la instalación de catéteres transitorios para hemodiálisis.

A chest X-ray has been routinely used to evaluate possible complications of a catheter installed for hemodialysis. The objective of the present study was to evaluate the utility of routine chest X-ray to detect complications derived from the installation of temporary catheters through a jugular vein access. We studied prospectively 95 successive jugular catheters for hemodialysis. After installation the operator answered a questionnaire that asked for details of the procedure and his opinion of the utility of a chest X-ray to detect a complication in each particular case. A chest X-ray was done in every patient and analyzed blindly. There were 17 minor complications: 7 arterial punctures, 5 neck hamatomas and 5 malpositions of catheters. No major complications were found. Sixty per cent of the catheters that required three or more punctures had a complication vs only 10% of the ones that required two or less puncture (p < 0.05). In five occasions the catheters were malpositioned, in four of these cases a complication was suspected. The wire guide was twisted in all of these cases. The procedure was considered of medium or high difficulty in four of the five malpositioned catheters, in contrast a medium or highly difficult case was considered only in 13 of the 90 well positioned catheters (p < 0.05). The time employed for the catheters installation was significantly higher for the malpositioned catheters. In 29.5% of the cases the operator considered a chest X-ray necessary, 2/3 of the cases did not have a well founded clinical suspicion of complication. We conclude that routine chest X-ray after installation of a jugular catheter for hemodialysis has a low diagnostic value for the detection of complications derived from the procedure and should be ordered only when clinical features suggest a complication.

Utilidad de la radiografía de tórax posterior a la instalación de catéteres transitorios para hemodiálisis / Value of the chest radiograph after the insertion of temporary dialysis catheters

Para evaluar el valor de la radiografía de tórax de rutina posterior a la instalación de catéteres transitorios para hemodiálisis estudiamos prospectivamente 95 catéteres sucesivos. Una vez instalado cada catéter el operador contestó una encuesta sobre los detalles del procedimiento y manifestó su opinión sobre la utilidad de la radiografía para descartar alguna complicación en el caso en particular. En 95 catéteres hubo 17 complicaciones: 7 punciones arteriales, 5 hematomas y 5 malposiciones del catéter. No hubo hamotórax ni neumotórax. Presentaron alguna complicación el 60 % de los catéteres que requirieron 3 o más intentos antes de canular la vena y el 10% de los que requirieron menos intentos p < 0,05. En el 29,5% de los catéteres el operador consideró necesario realizar la radiografía de tórax, en el 65,4% de ellas sin una sospecha clínicamente fundada de complicación. En 5 ocasiones el catéter quedó mal posicionado, en 4 de estas se sospechó alguna complicación pero solo en 2 oportunidades se sospecho la mal posición, en las 5 oportunidades la guía de alambre salío acodada. En el 4 de 5 oportunidades en que el catéter quedó en mala posición y en 13 de las 90 en que el catéter quedó en buena posición el procedimiento fue considerado como alta o mediana dificultad por el operador p < 0,05. El tiempo necesario para la instalación fue mayor en los catéteres que quedaron en mala posición. En conclusión: La radiografía de tórax de rutina posterior a la instalación de catéteres para Hemodiálisis tiene poco rendimiento en el diagnóstico de complicaciones derivadas del procedimiento y debería ser practicada solo en presencia de hechos clínicos que sugieran una complicación

A chest X-ray has been routinely used to evaluate possible complications of a catheter installed for hemodialysis. The objetive of the present study was to evaluate the utility of routine chest X-ray to detect complications derived from the installation of temporary catheters through a jugular vein access. We studied prospectively 95 successive jugular catheters for hemodialysis. After installation the operator answered a questionnaire that asked for details of the procedure and his opinion of the utility of a chest X-ray to detect a complication in each particular case. A chest X-ray was done in every patient and analyzed blindly. There were 17 minor complications: 7 arterial punctures, 5 neck hamatomas and 5 malpositions of catheters. No major complications were found. Sixty per cent of the catheters that required three or more punctures had a complication vs only 10% of the ones that required two or less puncture (p < 0.05). In five occasions the catheters were malpositioned, in four of these cases a complication was suspected. The wire guide was twisted in all of these cases. The procedure was considered of medium or high difficulty in four of the five malpositioned catheters, in contrast a medium or highly difficult case was considered only in 13 of the 90 well positioned catheters (p < 0.05). The time employed for the catheters installation was significanthy higher for the malpositioned catheters. In 29.5% of the cases the operator considered a chest X-ray neccesary, 2/3 of the cases did not have a well founded clinical suspicion of complication. We conclude that routine chest X-ray after installation of a jugular catheter for hemodialysis has a low diagnostic value for the detection of complications derived from the procedure and should be ordered only when clinical features suggest a complication

Corrección de la anemia en hemodiálisis, efecto del fierro intravenoso sin eritropoyetina / Correction of anemia in hemodialysis, effect of intravenous iron without erythropoietin

BACKGROUND: In the last two decades, the use of erythropoietin for the correction of anemia in hemodialysis patients has been recommended. In Chile, only 10 per cent of hemodialysis patients use erythropoietin, therefore, the correction of iron deficiency must be optimized. AIM: To report the effects of intravenous iron without erythropoietin in the management of anemia in hemodialysis patients. MATERIAL AND METHODS: Retrospective analysis of 42 patients that received intravenous ferrous sacharate in doses of 100 mg/week during 5 weeks and 100 mg bimonthly during six months. These patients did not receive erythropoietin. RESULTS: Thirty six patients had iron deficiency. Basal ferritin was 137 +/- 22 micrograms/l and increased to 321 +/- 28 micrograms/l after treatment. Packed red cell volume increased from 24 +/- 2 per cent to 29 +/- 3 per cent. No adverse effects were reported. CONCLUSIONS: Iron deficiency is frequent in hemodialyzed patients. Intraveineous iron is safe and effective in the treatment of iron deficiency in these patients.

[Hepatic veno-occlusive disease associated to the use of azathioprine in a renal transplant recipient]. / Enfermedad venooclusiva hepática asociada a terapia con azatioprina en un paciente trasplantado renal.

We report a 30 years old male, recipient of a kidney allograft and treated with azathioprine, who eighteen days after transplantation had a clinically asymptomatic elevation of total bilirubin and alkaline phosphatases. Nineteen months later, he presented with mild ascites, with a total bilirubin of 3.5 mg/dl, alkaline phosphatases of 308 U/L (normal < 170 U/L) and a prothrombin time at 55% of control. A liver biopsy showed sinusoidal and perivenular fibrosis without inflammation, compatible with chronic venous obstruction. Hepatic veno-occlusive disease is an infrequent complication of azathioprine use.

[Pharmacokinetics and clearance of ciprofloxacin and amikacin in continuous hemodialysis]. / Farmacocinética y aclaramiento de ciprofloxacina y amikacina en hemodiálisis continua.

We studied the pharmacokinetic and clearance of a 200 mg ciprofloxacin and a 500 mg amikacin intravenous dose during 5 continuous hemodialysis procedures in 5 patients with acute oliguric renal failure. Hourly blood and ultrafiltrate drug concentrations were measured during 8 hours. Dialysate flux (Qd) was 16.6 ml/min during the first hours and 33.2 ml/min thereafter. For each Qd, total ciprofloxacin clearance was 1.13 +/- 0.99 and 2.8 +/- 1.71 ml/min (p < 0.001), diffusive clearance was 0.96 +/- 0.87 and 2.47 +/- 1.56 ml/min (p < 0.005) and convective clearance was 0.16 +/- 0.17 and 0.33 +/- 0.2 ml/min (p < 0.05). Likewise, total amikacin clearance was 3.47 +/- 1.31 and 4.18 +/- 0.53 ml/min (p < 0.001), diffusive clearance was 2.97 +/- 1.24 and 3.86 +/- 0.52 ml/min and convective clearance was 0.50 +/- 0.47 and 0.32 +/- 0.29 ml/min (p = NS). Protein binding was 84% for ciprofloxacin and 77% for amikacin. It is concluded that during continuous hemodialysis with cuprofan membrane, the main transport mechanism of ciprofloxacin and amikacin is diffusive. Very low amounts of ciprofloxacin are depurated by the dialyser. Likewise, the shortening of amikacin half life suggests the presence of other elimination pathway and the need to use supplementary doses every 24 hours.

[Continuous hemodialysis with cuprophan membranes in critical patients]. / Hemodiálisis continua con membrana de cuprofán en pacientes críticos.

The aim of this work was to evaluate the use of 1 m2 Cuprophan hollow fiber filters for continuous arteriovenous hemodialysis procedures. Thirty one critically ill patients (18 male) aged between 20 and 80 years old, subjected to 35 hemodialysis procedures were studied. Sixteen patients had acute renal failure (10 of these had multiorgan failures) and 15 terminal chronic renal failure. Femoral vessels were used for vascular access and isotonic peritoneal dialysis solution flowing at 16.6 ml/seg as dialyzing solution. No extracorporeal pump assistance was used. Mean procedure time was 76 +/- 69.7 h, filter consumption was 2.8 +/- 2.1 filters/procedure, ultrafiltration rate was 168 ml/min and urea clearance was 19.9 +/- 4.4 ml/min. No replacement solutions were required and good electrolyte and circulating volume control was achieved with excellent hemodynamic stability. Blood urea fell from 116.9 +/- 49.1 to 64 +/- 27.2 mg/dl after the procedure (p < 0.001). Hyperglycemia was observed in eight procedures, six patients developed non infectious vascular access complications and two patients catheter related sepsis. We conclude that continuous arteriovenous hemodialysis using cuprophan membranes is a good renal substitution technique for critically ill patients.

[Continuous hemodialysis in the treatment of chronic renal insufficiency in emergencies]. / Hemodiálisis continua en el tratamiento de la insuficiencia renal crónica en emergencia.

Continuous hemodialysis is advantageous for the treatment of renal failure in critically ill patients. This study reports our experience in the treatment of emergencies during chronic renal failure with continuous hemodialysis using a Cuprofane membrane. Eighteen patients with acute decompensations of chronic renal failure were treated with continuous hemodialysis (14 arteriovenous and 4 veno-venous). Procedures lasted a mean of 44.2 h, blood urea nitrogen decreased from 150.3 +/- 49.8 to 60.6 +/- 30.7 mg/dl, metabolic acidosis was corrected raising serum bicarbonate from 10.1 +/- 44 to 17.8 +/- 3.3 mEq/L and hyperkalemia was corrected. Mean ultrafiltration was 239.6 +/- 124.6 ml/h which allowed to withdraw a mean 10.590 ml of ultrafiltrate. Two patients were complicated with femoral artery pseudoaneurysms and one patient with a catheter related sepsis. Global mortality was 16.7%, which compared favorably with the 32.1% predicted mortality according to the Simplified Acute Physiology Score. It is concluded that continuous hemodialysis, a readily available procedure, is suitable for the treatment of emergencies during chronic renal failure.

[B-DR (HLA) linkage imbalance and transplants in Chile: a preliminary report]. / Desequilibrio de ligamento B-DR (HLA) y trasplantes en Chile: comunicación preliminar.

Linkage imbalance for the B and DR loci (HLA) was found in a Chilean sample of families where a member had been proposed for transplantation. The B7-DR2 and B14-DR1 haplotypes were significantly more frequent than expected. Most associations were those found in Caucasian populations.