Consensus on definition and severity grading of lymphatic complications after kidney transplantation.

BACKGROUND: The incidence of lymphatic complications after kidney transplantation varies considerably in the literature. This is partly because a universally accepted definition has not been established. This study aimed to propose an acceptable definition and severity grading system for lymphatic complications based on their management strategy. METHODS: Relevant literature published in MEDLINE and Web of Science was searched systematically. A consensus for definition and a severity grading was then sought between 20 high-volume transplant centres. RESULTS: Lymphorrhoea/lymphocele was defined in 32 of 87 included studies. Sixty-three articles explained how lymphatic complications were managed, but none graded their severity. The proposed definition of lymphorrhoea was leakage of more than 50 ml fluid (not urine, blood or pus) per day from the drain, or the drain site after removal of the drain, for more than 1 week after kidney transplantation. The proposed definition of lymphocele was a fluid collection of any size near to the transplanted kidney, after urinoma, haematoma and abscess have been excluded. Grade A lymphatic complications have a minor and/or non-invasive impact on the clinical management of the patient; grade B complications require non-surgical intervention; and grade C complications require invasive surgical intervention. CONCLUSION: A clear definition and severity grading for lymphatic complications after kidney transplantation was agreed. The proposed definitions should allow better comparisons between studies.

ANTECEDENTES: La incidencia de complicaciones linfáticas tras el trasplante renal (post-kidney-transplantation lymphatic, PKTL) varía considerablemente en la literatura. Esto se debe en parte a que no se ha establecido una definición universalmente aceptada. Este estudio tuvo como objetivo proponer una definición aceptable para las complicaciones PKTL y un sistema de clasificación de la gravedad basado en la estrategia de tratamiento. MÉTODOS: Se realizó una búsqueda sistemática de la literatura relevante en MEDLINE y Web of Science. Se logró un consenso para la definición y la clasificación de gravedad de las PKTL entre veinte centros de trasplante de alto volumen. RESULTADOS: En 32 de los 87 estudios incluidos se definía la linforrea/linfocele. Sesenta y tres artículos describían como se trataban las PKTL, pero ninguno calificó la gravedad de las mismas. La definición propuesta para la linforrea fue la de un débito diario superior a 50 ml de líquido (no orina, sangre o pus) a través del drenaje o del orificio cutáneo tras su retirada, más allá del 7º día postoperatorio del trasplante renal. La definición propuesta para linfocele fue la de una colección de líquido de tamaño variable adyacente al riñón trasplantado, tras haber descartado un urinoma, hematoma o absceso. Las PKTL de grado A fueron aquellas con escaso impacto o que no requirieron tratamiento invasivo; las PKTL de grado B fueron aquellas que precisaron intervención no quirúrgica y las PKTL de grado C aquellas en que fue necesaria la reintervención quirúrgica. CONCLUSIÓN: Se propone una definición clara y una clasificación de gravedad basada en la estrategia de tratamiento de las PKTLs. La definición propuesta y el sistema de calificación en 3 grados son razonables, sencillos y fáciles de comprender, y servirán para estandarizar los resultados de las PKTL y facilitar las comparaciones entre los diferentes estudios.

Modified Spiral Intestinal Lengthening and Tailoring for Short Bowel Syndrome.

BACKGROUND: The spiral intestinal lengthening and tailoring (SILT) procedure is a new surgical technique for autologous intestinal reconstruction in patients with short bowel syndrome. The aim of this work is to present a first description of a modified SILT technique by which the mucosal layer is left intact to possibly reduce the severe postoperative complications of intestinal leakage and abdominal abscess formation. MATERIALS AND METHODS: The modified SILT technique was performed on a 10-cm-long intestinal segment in 2 pigs to determine the technical feasibility. Thereafter, the short-term clinical feasibility was monitored clinically in 2 dogs by gastrointestinal X-ray series at postoperative day 4 and by relaparotomy postoperative day 10. RESULTS: It was technically feasible to lengthen the intestinal segment from 10 cm to 20 cm and tailoring it from 3 cm to 1.7 cm in diameter, while leaving the intestinal mucosal layer intact. The postoperative course was uneventful for both dogs. The gastrointestinal X-ray series showed an inconspicuous intestinal transit time without any signs of stricture, perforation, or leakage. In the relaparotomy, the initially achieved lengthening and tailoring extents were preserved and the operated intestinal segment was well perfused with no early signs of necrosis, stenosis, or leakage. CONCLUSIONS: Leaving the mucosal layer intact during SILT is technically and clinically feasible in the short term in a large animal model. Further studies are needed to fully assess the impact of this technical modification on the long-term outcome of larger series.

Effects of fat-enriched diet and methionine on insulin sensitivity in lactating cows.

The hyperinsulinemic-euglycemic clamp (EGC) technique was used to investigate the effects of calcium salts of long-chain fatty acids (LCFA-Ca) and rumen-protected Met (RPM) on insulin sensitivity in the peripheral tissues of lactating cows. Six multiparous Holstein cows were used in a 3 × 3 Latin square experiment in each 14-d period. Dietary treatments were 0 (RPM0), 20 (RPM20), and 60 (RPM60) g/d of RPM, supplemented with a diet containing 1.5% of LCFA-Ca equal to 110% of the cows' ME requirement. And as a control for the 3 LCFA-Ca-containing diets, a dietary treatment without LCFA-Ca (Con) was also included. After a 10-d adaptation period, milk samples were collected for 4 d, and EGC experiments were performed on d 14 of each treatment period. Insulin solution was infused through a jugular vein catheter at a rate of 0.1, 0.2, 0.3, and 0.4 milliunits·kg BW-1·min-1 for 30 min and then at a rate of 0.5 milliunits·kg BW-1·min-1 for 60 min. Glucose solution was variably infused to maintain plasma glucose at steady state through the same catheter. Blood samples for measurements were taken using the contralateral catheter. Plasma total cholesterol, cholesterol ester, free cholesterol, and phospholipid concentrations in RPM0 and RPM20 were higher than those in Con, whereas the concentrations in RPM60 were low at the same degree of those in RPM0 (P < 0.05). Plasma Met concentration was greatest in RPM60 (P < 0.05). In the EGC experiment, the glucose infusion rate was greater in RPM60 than in RPM0 and RPM20 and an effective concentration of insulin resulting in 50% maximal glucose infusion rate was lower in RPM60 compared with RPM0 (P < 0.05), indicating that insulin sensitivity was intensified in RPM60. Although the insulin sensitivity evaluated from the EGC data in RPM0, RPM20, and RPM60 was not different from Con, a slight decline was observed in RPM0 and insulin sensitivity in RPM60 was higher than Con. Our results from the EGC experiment demonstrated that the feeding RPM lead to increased insulin sensitivity, which suggests that dietary Met affects lipid metabolism via insulin action in lactating dairy cows fed a LCFA-Ca-containing diet.

Energy metabolism by splanchnic tissues of mature sheep fed varying levels of lucerne hay cubes.

The objective of this study was to determine the pattern of energy metabolites net flux across the portal-drained viscera (PDV) and total splanchnic tissues (TSP) in mature sheep fed varying levels of lucerne hay cubes. Four Suffolk mature sheep (61.4 ± 3.6 kg BW) surgically fitted with multi-catheters were fed four levels of dry matter intake (DMI) of lucerne hay cubes ranging from 0.4- to 1.6-fold the metabolizable energy (ME) requirements for maintenance. Six sets of blood samples were simultaneously collected from arterial and venous catheters at 30-min intervals. With increasing DMI, apparent total tract digestibility increased linearly and quadratically for dry matter (P < 0.05), quadratically (P < 0.05) with a linear tendency (P < 0.1) for organic matter and tended to increase quadratically (P < 0.1) for NDF. PDV release of volatile fatty acids (VFA) and ß-hydroxybutyric acid was relatively low at 0.4 M and then linearly increased (P < 0.05) with increasing DMI. Net PDV flux of non-esterified fatty acids showed curvilinear decrease from 0.4 to 1.2 M and then increased at 1.6 M. The respective proportions of each VFA appearing in the portal blood differed (P < 0.05) with DMI and this difference was more obvious from 0.4 to 0.8 M than from 0.8 to 1.6 M. Heat production, as a percentage of ME intake (MEI), decreased linearly (P < 0.05) with increasing DMI accounting for 37%, 21%, 16% and 13% for PDV and 62%, 49%, 33% and 27% for TSP at 0.4, 0.8, 1.2 and 1.6 M, respectively. As a proportion of MEI, total energy recovery including heat production, decreased linearly with increasing DMI (P < 0.05) accounting for 113%, 83%, 62% and 57% for PDV and 140%, 129%, 86% and 83% for TSP at 0.4, 0.8, 1.2 and 1.6 M, respectively. Regression analysis revealed a linear response between MEI (MJ/day per kg BW) and total energy release (MJ/day per kg BW) across the PDV and TSP, respectively. However, respective contributions of energy metabolites to net energy release across the PDV and TSP were highly variable among treatments and did not follow the same pattern of changes in DMI.

Effects of forage intake level on nitrogen net flux by portal-drained viscera of mature sheep with abomasal infusion of an amino acid mixture.

This study aimed to investigate the pattern of nitrogen (N) metabolites flux across the portal-drained viscera (PDV) of mature sheep over a wide range of forage intake, and to determine the effect of dry matter intake (DMI) on the PDV recovery of an abomasally infused amino acids (AA) mixture. Four Suffolk mature sheep (61.4 ± 3.6 kg BW) surgically fitted with abomasal cannulae and multi-catheters were fed four levels of DMI of lucerne hay cubes ranging from 0.4 to 1.6 fold the metabolizable energy requirements for maintenance. Each period lasted for 17 days: 7 days for diet adaptation, 5 days for measurement of N balance and N metabolites flux under basal pre-infusion conditions (basal phase) and 5 days for determining the recovery of the infused AA (584 mmol/day) across the PDV (infusion phase). Six sets of blood samples were collected on the last day of both basal and infusion phases. Increasing DMI increased portal release of AA and enhanced N retention. At 0.4 M and as a proportion of digested N, there was a marked drop in total AA-N release accompanied by greater ammonia-N release and urea-N uptake across the PDV. The incremental recovery ratio of infused AA across the PDV was altered with increasing DMI accounting for 0.88, 1.12, 1.23 and 1.31 at 0.4, 0.8, 1.2 and 1.6 M, respectively. In addition, across the individual AA, the net portal recovery ratio of infused methionine and valine increased linearly (P < 0.05) while that of phenylalanine, branched-chain AA and total essential AA tended to increase linearly (P < 0.10) with increasing DMI. These results indicated that DMI affects the net portal recovery of AA available in the small intestine of mature sheep.

Utilidad de la lipocalina asociada a la gelatinasa de neutrófilo urinaria como marcador temprano de insuficiencia renal aguda posterior a una cirugía cardíaca / Utility of the associated lipocalin to neutrophil gelatinase urinary as a marker early of renal failure acute after surgery cardiac

El objetivo del trabajo es determinar los niveles urinarios de la lipocalina asociada a la gelatinasa del neutrófilo (neutrophil gelatinase-associated lipocalin, NGAL) en los pacientes que desarrollan insuficiencia renal aguda después de una cirugía cardíaca y su comparación con las concentraciones de creatinina sérica. El estudio incluyó una cohorte de 21 pacientes de entre 32 y 80 años, sometidos a una cirugía cardíaca en el Servicio de Salud Pública (Hospital San Roque) entre abril y agosto de 2011. Se determinaron los niveles urinarios de NGAL antes de la cirugía, a las 2 horas y a las 6 horas de la intervención. Los pacientes con insuficiencia renal aguda fueron diagnosticados según el criterio de clasificación AKIN. Seis pacientes (30%) desarrollaron insuficiencia renal aguda, cuyo diagnóstico basado en la creatinina sérica se retrasó por 2 o 3 días poscirugía. Por el contrario, los niveles urinarios de NGAL se elevaron significativamente a las 2 horas. En la medición de la NGAL urinaria a las 2 horas de la cirugía, el área bajo la curva ROC fue de 0,962; con una sensibilidad del 100% y una especificidad del 84,6% para predecir insuficiencia renal aguda con un valor de corte de 6,2 ng/ml. Se obtuvieron valores similares cuando se los corrigió por creatinina urinaria. La NGAL urinaria a las 2 horas poscirugía cardíaca fue un marcador precoz para predecir la insuficiencia renal aguda.(AU)

The objective of the study was to determine urinary levels of neutrophil gelatinase-associated lipocalin (NGAL) in patients who develop acute renal failure after cardiac surgery and its comparison with serum creatinine concentrations. The study included a cohort of 21 patients between 32 and 80 years who underwent cardiac surgery in the Public Health Service (Hospital San Roque) during April and August 2011. Urinary NGAL levels were measured before surgery, 2 hours and 6 hours after the intervention. Patients with acute renal failure were diagnosed according to the AKIN classification criteria. Six patients (30%) developed acute renal failure and diagnosis based on serum creatinine was delayed by 2 to 3 days after surgery. By contrast, urinary NGAL levels were significantly elevated 2 hours after surgery. In the measurement of urinary NGAL at 2 hours post-surgery, the area under the ROC curve was 0.962, with a sensitivity 100% and specificity 84.6% to predict acute renal failure with a cut-off point of 6.2 ng/mL, similar values were obtained when they were corrected by urinary creatinine. Urinary NGAL levels 2 hours post-cardiac surgery proved to be an early marker for predicting acute renal failure.(AU)

[Cerebral necrosis found 13 years after irradiation of osteosarcoma of the cranial vault]. / Nécrose cérébrale découverte 13 ans après irradiation d'un ostéosarcome de la voûte du crâne.

Delayed cerebral radiation necrosis was discovered 13 years after irradiation of the skull for osteosarcoma. Conservative treatment with glucocorticoids is discussed.