Fast-Track Liver Transplantation: Six-year Prospective Cohort Study with an Enhanced Recovery After Surgery (ERAS) Protocol.

INTRODUCTION: Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs. We used this concept to design a comprehensive fast-track pathway (OR-to-discharge) before starting our liver transplant activity and then applied this protocol prospectively to every patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our first six years results. PATIENTS AND METHODS: Prospective cohort study of all the liver transplants performed at our institution for the first six years. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early. RESULTS: A total of 240 transplants were performed in 236 patients (191♂/45♀) over 74 months, mean age 56.3±9.6 years, raw MELD score 15.5±7.7. Predominant etiologies were alcohol (n = 136) and HCV (n = 82), with hepatocellular carcinoma present in 129 (54.7%). Nine patients received combined liver and kidney transplants. The mean operating time was 315±64 min with cold ischemia times of 279±88 min. Thirty-one patients (13.1%) were transfused in the OR (2.4±1.2 units of PRBC). Extubation was immediate (< 30 min) in all but four patients. Median ICU length of stay was 12.7 hours, and median post-transplant hospital stay was 4 days (2-76) with 30 patients (13.8%) going home by day 2, 87 (39.9%) by day 3, and 133 (61%) by day 4, defining our fast-track group. Thirty-day-readmission rate (34.9%) was significantly lower (28.6% vs. 44.7% p=0.015) in the fast-track group. Patient survival was 86.8% at 1 year and 78.6% at five years. CONCLUSION: Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care.

Diálisis peritoneal en pacientes incidentes con glomerulonefritis primaria. Resultados de un registro multicéntrico durante 20 años de seguimiento / Peritoneal dialysis in incident patients with primary glomerulonephritis. Results of a 20-year multicenter registry study

ANTECEDENTES Y OBJETIVOS: Las glomerulonefritis (GN) constituyen una de las principales causas de enfermedad renal crónica estadio 5 en diálisis, sin embargo, pocos estudios se centran en su pronóstico en diálisis. Analizamos la supervivencia y características de los pacientes con GN primaria (GNP) en diálisis peritoneal (DP) y comparamos sus resultados con otros enfermos. MÉTODOS: Estudio observacional con recogida de datos de manera prospectiva durante 2 décadas (1995-2014). Incluimos a todos los pacientes del registro Levante que iniciaron DP como primera técnica dialítica. Los datos se transfirieron a una base de datos anonimizada en Access. El análisis estadístico se realizó mediante el programa SPSS (versión 19.0). RESULTADOS: El estudio incluyó a 2.243 pacientes, siendo las GN la principal causa de enfermedad renal primaria (21,5%). La nefropatía IgA fue la GNP con confirmación histológica más frecuente. Comparados con el resto de la muestra, los pacientes con GNP fueron en mayor proporción varones (65 vs. 58%, p = 0,004), con menor edad (48 vs. 55 años, p < 0,001), menos comorbilidad y mayor tasa de inclusión en lista de espera de trasplante renal (87 vs. 63%, p < 0,001). Asimismo, los pacientes con GNP se trasplantaron más (48,9%, p < 0,001) y este fue su motivo más frecuente de salida de DP; además de presentar menor tasa global de peritonitis (0,34 vs. 0,45 episodios/paciente-año, p < 0,001). La supervivencia técnica fue del 90,6% al año, del 71,7% a los 3 años y del 59% a los 5 años (mediana 76,8 meses), sin diferencias entre grupos. La supervivencia de los pacientes fue del 94,9% al año, del 80,1% a los 3 años y del 63,7% a los 5 años (mediana 90,7 meses). Los enfermos con GNP presentaron mejor supervivencia media que el resto de patologías (153,5 meses [IC 95%: 137-169,9) vs. 110,3 meses [IC 95%: 100,8-119,7], p < 0,001). En el multivariante, se relacionó de manera negativa con la supervivencia técnica tener mayor transporte peritoneal (p = 0,018), y con la supervivencia del paciente tener mayor edad (p < 0,001) y alguna comorbilidad, especialmente diabetes y hepatopatía (p < 0,001). Por el contrario, la inclusión en lista de espera y la función renal residual (p < 0,001) favorecieron ambas supervivencias. CONCLUSIONES: A la vista de nuestros resultados y teniendo en cuenta las ventajas de la DP como primer tratamiento dialítico, consideramos que esta terapia es una excelente técnica para los enfermos con GNP mientras esperan un trasplante renal

BACKGROUND AND OBJECTIVES: Glomerulonephritis (GN) is one of the main causes of chronic terminal kidney disease; however, few studies assess its prognosis in dialysis. We analyze the survival and characteristics of patients on peritoneal dialysis (PD) with primary GN (PGN), and compare their results with other kidney patients. METHODS: This prospective observational study took place from 1995 to 2014. We included all incident patients who were initiated on the technique in the Levante registry. Data were transferred to an anonymized database in Access. Statistical analysis was performed using SPSS software (version 19.0). RESULTS: The study included 2,243 patients, with GN representing the main cause of primary kidney disease (21,5%). IgA nephropathy was the most frequent histologically confirmed form of PGN. Compared with the rest of the sample, patients with PGN were more often men (65% vs 58%, P =. 004), and they were on average younger (48 years vs 55 years, P < .001). They also had fewer comorbidities and a higher rate of inclusion on the waitlist for a kidney transplant (87 vs 63%, P < .001). Patients with PGN also had more transplants (48,9%, P < .001), and this was the most frequent reason for stopping PD; beyond that, their peritonitis mean rate was lower (0,34 vs 0,45 episodes/patient-year, P < .001). Technique survival was 90,6% at one year, 71,7% at 3 years, and 59,0% at 5 years (median 76,8 months); there were no differences between groups. Survival was 94,9% at one year, 80,1% at 3 years, and 63,7% at 5 years (median 90,7 months). Patients with PGN showed better mean survival than patients with other kidney pathologies (153,5 months [95% IC: 137,0 to 169,9] vs 110,3 months [95% CI: 100,8 to 119,7], P < .001). In the multivariable analysis, the main negative risk factor influencing technique survival was a higher peritoneal transport (P = .018). Factors with a negative influence on mortality were being older (P < .001) and having any comorbidity, mainly diabetes and liver disease (P < .001). By contrast, protective survival factors were inclusion on the transplant waitlist and a higher baseline residual renal function (P = .001). CONCLUSIONS: PD has several advantages as a first dialytic treatment, and our results suggest that it is an excellent technique to manage patients with PGN while they await a kidney transplant

Peritoneal dialysis in incident patients with primary glomerulonephritis. Results of a 20-year multicenter registry study.

BACKGROUND AND OBJECTIVES: Glomerulonephritis (GN) is one of the main causes of chronic terminal kidney disease; however, few studies assess its prognosis in dialysis. We analyze the survival and characteristics of patients on peritoneal dialysis (PD) with primary GN (PGN), and compare their results with other kidney patients. METHODS: This prospective observational study took place from 1995 to 2014. We included all incident patients who were initiated on the technique in the Levante registry. Data were transferred to an anonymized database in Access. Statistical analysis was performed using SPSS software (version 19.0). RESULTS: The study included 2243 patients, with GN representing the main cause of primary kidney disease (21,5%). IgA nephropathy was the most frequent histologically confirmed form of PGN. Compared with the rest of the sample, patients with PGN were more often men (65% vs 58%, p = .004), and they were on average younger (48 years vs 55 years, p < .001). They also had fewer comorbidities and a higher rate of inclusion on the waitlist for a kidney transplant (87 vs 63%, p < .001). Patients with PGN also had more transplants (48,9%, p < .001), and this was the most frequent reason for stopping PD; beyond that, their peritonitis mean rate was lower (0,34 vs 0,45 episodes/patient-year, p < .001). Technique survival was 90,6% at one year, 71,7% at 3 years, and 59,0% at 5 years (median 76,8 months); there were no differences between groups. Survival was 94,9% at one year, 80,1% at 3 years, and 63,7% at 5 years (median 90,7 months). Patients with PGN showed better mean survival than patients with other kidney pathologies (153,5 months [95% IC: 137,0-169,9] vs 110,3 months [95% CI: 100,8-119,7], p < .001). In the multivariable analysis, the main negative risk factor influencing technique survival was a higher peritoneal transport (p = .018). Factors with a negative influence on mortality were being older (p < .001) and having any comorbidity, mainly diabetes and liver disease (p < .001). By contrast, protective survival factors were inclusion on the transplant waitlist and a higher baseline residual renal function (p = .001). CONCLUSIONS: PD has several advantages as a first dialytic treatment, and our results suggest that it is an excellent technique to manage patients with PGN while they await a kidney transplant.

Peritoneal dialysis in incident patients with primary glomerulonephritis. Results of a 20-year multicenter registry study. / Diálisis peritoneal en pacientes incidentes con glomerulonefritis primaria. Resultados de un registro multicéntrico durante 20 años de seguimiento.

BACKGROUND AND OBJECTIVES: Glomerulonephritis (GN) is one of the main causes of chronic terminal kidney disease; however, few studies assess its prognosis in dialysis. We analyze the survival and characteristics of patients on peritoneal dialysis (PD) with primary GN (PGN), and compare their results with other kidney patients. METHODS: This prospective observational study took place from 1995 to 2014. We included all incident patients who were initiated on the technique in the Levante registry. Data were transferred to an anonymized database in Access. Statistical analysis was performed using SPSS software (version 19.0). RESULTS: The study included 2,243 patients, with GN representing the main cause of primary kidney disease (21,5%). IgA nephropathy was the most frequent histologically confirmed form of PGN. Compared with the rest of the sample, patients with PGN were more often men (65% vs 58%, P=.004), and they were on average younger (48 years vs 55 years, P<.001). They also had fewer comorbidities and a higher rate of inclusion on the waitlist for a kidney transplant (87 vs 63%, P<.001). Patients with PGN also had more transplants (48,9%, P<.001), and this was the most frequent reason for stopping PD; beyond that, their peritonitis mean rate was lower (0,34 vs 0,45 episodes/patient-year, P<.001). Technique survival was 90,6% at one year, 71,7% at 3 years, and 59,0% at 5 years (median 76,8 months); there were no differences between groups. Survival was 94,9% at one year, 80,1% at 3 years, and 63,7% at 5 years (median 90,7 months). Patients with PGN showed better mean survival than patients with other kidney pathologies (153,5 months [95% IC: 137,0 to 169,9] vs 110,3 months [95% CI: 100,8 to 119,7], P<.001). In the multivariable analysis, the main negative risk factor influencing technique survival was a higher peritoneal transport (P=.018). Factors with a negative influence on mortality were being older (P <.001) and having any comorbidity, mainly diabetes and liver disease (P <.001). By contrast, protective survival factors were inclusion on the transplant waitlist and a higher baseline residual renal function (P=.001). CONCLUSIONS: PD has several advantages as a first dialytic treatment, and our results suggest that it is an excellent technique to manage patients with PGN while they await a kidney transplant.