Factores de riesgo para mortalidad en pacientes críticos posquirúrgicos tratados con técnicas continuas de reemplazo renal / Mortality risk factors in critical post-surgical patients treated using continuous renal replacement techniques

Objetivo: Determinar la influencia de las variables demográficas, médicas y quirúrgicas sobre la mortalidad a 30 días en pacientes que requieren la aplicación de técnicas continuas de reemplazo renal (TCRR) en la Unidad de Cuidados Intensivos Posquirúrgicos. Materiales y métodos: Estudio de seguimiento retrospectivo. Datos de 112 pacientes admitidos en la Unidad de Cuidados Intensivos que requirieron TCRR, entre agosto de 2006 y agosto de 2011 y seguidos durante 30 días. Se recogió la siguiente información: edad, género, historia de HTA, DM, enfermedad cardiovascular e IRC, cirugía urgente, especialidad quirúrgica, disfunción orgánica de acuerdo con la escala SOFA, número de órganos con disfunción, uso de ventilación mecánica, diagnóstico y origen de la sepsis, modalidad de TCRR y mortalidad a 30 días. Se utilizaron modelos lineales generales para estimar la fuerza de la asociación (riesgo relativo [RR] e intervalo de confianza [IC] al 95%) entre las diferentes variables y la mortalidad a 30 días. Resultados: En el análisis univariante se identificaron como factores de riesgo para la mortalidad a 30 días la edad(RR 1,04; IC 95% 1,01-1,06; p = 0,0005) y la presencia de enfermedad cardiovascular previa (RR 1,57; IC 95% 1,02-2,41; p = 0,039). Entre las variables incluidas en el análisis multivariante (edad, historia de enfermedad cardiovascular previa, presencia de sepsis y número de órganos con disfunción), solo la edad se identificó como factor de riesgo independiente para mortalidad a 30 días (RR 1,03; IC 95% 1,00-1,05; p = 0,007). Conclusión: La mortalidad a 30 días en los pacientes críticos posquirúrgicos que necesitan TCRR es alta (41,07%), identificándose la edad como factor de riesgo independiente, siendo la insuficiencia renal aguda la principal indicación para el uso de estas terapias (AU)

Objective: To determine the influence of demographics, medical, and surgical variables on 30-day mortality in patients who need continuous renal replacement therapy (CRRT). Materials and methods: A retrospective-following study was conducted using the data of 112 patients admitted to the postoperative intensive care unit who required CRRT, between August 2006 and August 2011, and followed-up for 30 days. The following information was collected: age, gender, history of HBP, DM, cardiovascular disease, and CKD, urgent surgery, surgical speciality, organic dysfunction according to the SOFA scale, the number of organs with dysfunction, use of mechanical ventilation, diagnostic and origin of sepsis, type of CRRT, and 30-day mortality. General linear models were used for estimating the strength of association (relative risk [RR], and 95% confidence interval [CI] between variables and 30-day mortality. Results: In the univariant analysis, the following variables were identified as risk factors for 30-day mortality: age(RR 1.04; 95% CI 1.01-1.06; P = .0005), and history of cardiovascular disease (RR 1.57; 95% CI 1.02-2.41; P = .039). Among the variables included in the multivariable analysis (age, history of cardiovascular disease, sepsis, and number of organs with dysfunction), only age was identified as an independent risk factor for 30-day mortality (RR 1.03; 95% CI 1.00-1.05; P = .007). Conclusion: Thirty-day mortality in postoperative, critically ill patients who require CRRT is high (41.07%). Age has been identified as an independent risk factor, with renal failure as the most common indication for the use of these therapies (AU)

Mortality risk factors in critical post-surgical patients treated using continuous renal replacement techniques.

OBJECTIVE: To determine the influence of demographics, medical, and surgical variables on 30-day mortality in patients who need continuous renal replacement therapy (CRRT). MATERIALS AND METHODS: A retrospective-following study was conducted using the data of 112 patients admitted to the postoperative intensive care unit who required CRRT, between August 2006 and August 2011, and followed-up for 30 days. The following information was collected: age, gender, history of HBP, DM, cardiovascular disease, and CKD, urgent surgery, surgical speciality, organic dysfunction according to the SOFA scale, the number of organs with dysfunction, use of mechanical ventilation, diagnostic and origin of sepsis, type of CRRT, and 30-day mortality. General linear models were used for estimating the strength of association (relative risk [RR], and 95% confidence interval [CI] between variables and 30-day mortality. RESULTS: In the univariant analysis, the following variables were identified as risk factors for 30-day mortality: age (RR 1.04; 95% CI 1.01-1.06; P=.0005), and history of cardiovascular disease (RR 1.57; 95% CI 1.02-2.41; P=.039). Among the variables included in the multivariable analysis (age, history of cardiovascular disease, sepsis, and number of organs with dysfunction), only age was identified as an independent risk factor for 30-day mortality (RR 1.03; 95% CI 1.00-1.05; P=.007). CONCLUSION: Thirty-day mortality in postoperative, critically ill patients who require CRRT is high (41.07%). Age has been identified as an independent risk factor, with renal failure as the most common indication for the use of these therapies.

Analysis of patients referred to a lung transplantation unit.

This cross-sectional, concurrent and descriptive study presents the decisions regarding patients referred to our Lung Transplantation Unit (LTxU). Each patient is discussed in a multidisciplinary clinical session (phase I), rejecting some and accepting others for assessment in our LTxU (phase II) according to criteria of the National and International Guidelines for Transplantation. A protocol assessment in phase II, leads to a decision to reject, accept, or follow-up the candidate for LTx. Among 214 evaluation requests received in our unit from May 2008 to December 2011, 37 patients (17%) were rejected based on the information sent to our LTxU. Among the patients evaluated in phase II, 62 (28.9%) were put on the waiting list, 125 (58.4%) were rejected, and twenty-seven (12.6%) were postponed for future reconsideration, results that were similar to those described in the literature. The main disease referred for LTx was obstructive airflow (n = 98; 45.7%), followed by interstitial lung disease (ILD; n = 66; 30.8%), cystic fibrosis or bronchiectasis (n = 20; 9.3%), or primary pulmonary hypertension group 1 (n = 20; 9.3%). Ten patients (4.6%) were diagnosed with other respiratory diseases. Most patients (n = 165; 77.1%) lived in the region of our hospital (Madrid). The main reasons to reject patients for LTx were malnutrition, severe disease in other organs, toxic habits, and refusal of treatment. Finally, one out of four referred patients was accepted for LTx. In addition to serious comorbidities in various organs, a high percentage of patients who were not accepted for LTx because of these factors might have been of accepted had these conditions been corrected before patient referral.

[Spanish Society of Anaesthesia (SEDAR) guidelines for pre-anaesthesia checking procedures]. / Directrices de procedimientos de comprobación y validación («chequeo¼) previos a la anestesia de la Sociedad Española de Anestesiología.

We present this document as a guide to preparing a specific institutional pre-anaesthesia checklist, as recommended in the Helsinki declaration on patient safety in anaesthesiology. Also, the recently recommended WHO "safe surgery check-list" includes a check-list for anaesthesia. A working group was established in accordance with the charter of the Spanish Society of Anaesthesiology and Resuscitation (Sociedad Española de Anestesiología y Reanimación [SEDAR]). The new patient safety culture introduced into medicine, and the recommendations of European anaesthesia societies has led us to design and update protocols in order to improve results in this important part of our speciality. We have prepared these recommendations or guidelines using, as examples, updates of pre-anaesthesia check-lists by other American (ASA), British, or Canadian societies of anaesthesia. With that aim, we enlisted the help of anaesthesia ventilator experts and the participation and advice of experienced anaesthesiologists from all parts of Spain. After various corrections and modifications, the document was available at www.sedar.es, so that any anaesthesiologist could propose any correction, or give their opinion. Finally, these guidelines have been approved by the SEDAR Board of Directors, before it was sent for publication in this journal. The aims of this document are to provide: a guideline applicable to all anaesthesia machines, a descriptive pre-anaesthesia check-list that include everything necessary for the anaesthesia procedure, and a resumed check-list to be available in all the anaesthesia machines or other equivalent, but prepared for each institution, which should include anaesthetic equipment and drugs. So, in order to ensure the aims and requirements of the European Board of Anaesthesiology, the European Society of Anaesthesiology, and the WHO are met, each institution should have a protocol for checking equipment and drugs. These guidelines are applicable to any anaesthesia equipment, enabling every institution to develop their own checking protocols, adapted to their anaesthesia machines and their procedures. With the consent of the SEDAR, this group will collaborate with anaesthesia machines providers in order to develop specific checklists for each of their models that will be available at www.sedar.es.

Directrices de procedimientos de comprobación y validación («chequeo») previos a la anestesia de la Sociedad Española de Anestesiología / Spanish Society of Anaesthesia (SEDAR) guidelines for pre-anaesthesia checking procedures

Este documento que presentamos pretende servir de guía para la elaboración por cada centro de una lista de chequeo previo a la anestesia o pre-anestesia, tal y como recomienda la reciente declaración de Helsinki sobre seguridad del paciente en anestesia. Además, la reciente implantación del «check-list quirúrgico de la OMS» (safe surgery check-list) incluye un epígrafe de chequeo de anestesia. El grupo de trabajo se constituyó con este fin según los estatutos de la Sociedad Española de Anestesiología, Reanimación y Tratamiento del Dolor (SEDAR). La nueva cultura de seguridad del paciente que se está implantando en la práctica médica y las recomendaciones de las sociedades europeas de anestesia nos obligan a actualizar y realizar protocolos que mejoren los resultados en este aspecto fundamental de nuestra especialidad. Tomando como ejemplo las actualizaciones de las listas de comprobación de diferentes asociaciones de anestesiólogos como la americana, británica o canadiense, hemos elaborado esta propuesta. Para ello hemos contado con la ayuda de expertos en respiradores y la colaboración y consejos de anestesiólogos expertos de todas las comunidades autónomas. Después de sucesivas correcciones, fue publicada en la página web de la SEDAR para que cualquier anestesiólogo pudiera aportar sus correcciones o su opinión. Finamente el documento ha sido aprobado por la junta directiva de la SEDAR, antes de ser enviado para su publicación en esta revista. Los objetivos de este documento son: proporcionar unas directrices o recomendaciones de comprobación aplicables a todos los sistemas de anestesia, realizar un listado descriptivo de comprobación que incluya todos los elementos necesarios para el procedimiento anestésico y aportar un listado con los elementos del chequeo en forma de esquema para disponer de él en cada equipo de anestesia o de otro similar realizado por cada centro, que incluya respirador, monitores, material auxiliar y fármacos. Por tanto, para cumplir con las recomendaciones de seguridad del paciente del European Board of Anaesthesiology (EBA), European Society of Anaesthesiology (ESA) y de la OMS, cada centro debe elaborar una lista de comprobación y verificación (en adelante «chequeo») previo a la anestesia. Este documento proporciona unas directrices aplicables a todos los sistemas de anestesia de tal manera que cada departamento pueda desarrollar sus propios protocolos de comprobación, adaptados a sus equipos de anestesia y a sus procedimientos de trabajo. De acuerdo con la directiva de la SEDAR, este grupo de trabajo colaborará con los fabricantes de equipos de anestesia para desarrollar listas de comprobación específicas de cada uno de sus modelos para que estén disponibles en www.sedar.es(AU)

We present this document as a guide to preparing a specific institutional pre-anaesthesia checklist, as recommended in the Helsinki declaration on patient safety in anaesthesiology. Also, the recently recommended WHO "safe surgery check-list" includes a check-list for anaesthesia. A working group was established in accordance with the charter of the Spanish Society of Anaesthesiology and Resuscitation (Sociedad Española de Anestesiología y Reanimación [SEDAR]). The new patient safety culture introduced into medicine, and the recommendations of European anaesthesia societies has led us to design and update protocols in order to improve results in this important part of our speciality. We have prepared these recommendations or guidelines using, as examples, updates of pre-anaesthesia check-lists by other American (ASA), British, or Canadian societies of anaesthesia. With that aim, we enlisted the help of anaesthesia ventilator experts and the participation and advice of experienced anaesthesiologists from all parts of Spain. After various corrections and modifications, the document was available at www.sedar.es, so that any anaesthesiologist could propose any correction, or give their opinion. Finally, these guidelines have been approved by the SEDAR Board of Directors, before it was sent for publication in this journal. The aims of this document are to provide: a guideline applicable to all anaesthesia machines, a descriptive pre-anaesthesia check-list that include everything necessary for the anaesthesia procedure, and a resumed check-list to be available in all the anaesthesia machines or other equivalent, but prepared for each institution, which should include anaesthetic equipment and drugs. So, in order to ensure the aims and requirements of the European Board of Anaesthesiology, the European Society of Anaesthesiology, and the WHO are met, each institution should have a protocol for checking equipment and drugs. These guidelines are applicable to any anaesthesia equipment, enabling every institution to develop their own checking protocols, adapted to their anaesthesia machines and their procedures. With the consent of the SEDAR, this group will collaborate with anaesthesia machines providers in order to develop specific checklists for each of their models that will be available at www.sedar.es(AU)

Anesthetic management of a combined heart and liver transplantation in an amyloidotic patient: a case report.

Few cases of combined heart and liver transplantation (CHLT) have been reported for familial amyloidosis. Our first CHLT was performed on a female patient with familial amyloidosis due to a genetic defect in transthyretin, characterized by deposition of amyloid in various organs and tissues. This disease produced autonomic heart dysfunction that preceded the development of clinical manifestations and may be an important factor in determining the optimal timing for liver transplantation. CHLT can be performed successfully, even in patients with advanced disease. However, the most compromised patients are more exposed to intraoperative risks, postoperative complications, and worsening of extracardiac and extrahepatic symptoms. Our patient presented severe cardiac dysfunction requiring CHLT. The operative technique is far from being consolidated, despite this, both organs were transplanted in the same day with 2 hours in the intensive care unit (ICU) between surgeries. The outcome of both organs has been favorable. The amyloidotic liver was transplanted to another patient, a sequential (domino) transplantation.

Manejo anestésico para la realización de mediastinoscopia en un caso de hipertensión pulmonar severa / Anesthetic management for mediastinoscopy in a patient with severe pulmonary hypertension

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First Spanish series of intestinal transplantation in adult recipients.

BACKGROUND: short-bowel transplantation has experienced a substantial growth worldwide following improved results from the late 1990's on, and its coverage by Medicare. According to the International Registry (1985-2005), a total of 1,292 intestinal transplants for 1,210 patients in 65 hospitals across 20 countries have been carried out thus far. OBJECTIVE: to know short-term (6 months) results regarding patient and graft survival from the first Spanish series of intestinal transplants in adult recipients. MATERIAL AND METHODS: we present our experience in the assessment of 20 potential candidates to short-bowel transplantation between June 2004 and October 2005. Of these, 10 patients were rejected and 4 were transplanted, which makes up the sample of our study. RESULTS: to this date 5 transplants have been carried out in 4 patients (2 retransplants, 2 desmoid tumors, 1 short bowel syndrome after excision as a result of mesenteric ischemia). Upon study completion and after a mean follow-up of 180 days (range 90-190 days) all recipients are alive, and all grafts but one (75%) are fully operational, with complete digestive autonomy. All patients received induction with alemtuzumab except one, who received thymoglobulin; in all induction was initiated with no steroids. CONCLUSIONS: intestinal transplantation represents a therapeutic option that is applicable in our setting and valid for recipients with an indication who have no other feasible alternative to keep their intestinal failure under control.

Schwannoma de plexo braquial en el diagnóstico diferencial del hombro doloroso / Brachial plexus schwannoma. Diferential diagnostic in the shoulder pain

Los schwannomas son tumores derivados de las célulasde Schwann, infrecuentes y generalmente de comportamientobenigno. El dolor y la radiculopatía son los síntomas inicialesmás frecuentes. El diagnóstico se realiza medianteresonancia magnética y la resección quirúrgica es el tratamientode elección.Presentamos el caso de una paciente de 50 años conomalgia atraumática izquierda de 5 años de evolución, durantelos cuáles fue valorada por diferentes especialistas que incluíantraumatólogos, reumatólogos, neurólogos y rehabilitadores.Inicialmente la paciente fue tratada con diversos AINES,rehabilitación (fisioterapia, onda corta, magnetoterapia) sinmejoría. Como pruebas complementarias se realizaron un estudioneurofisiológico del miembro superior izquierdo (informadocomo normal), una resonancia magnética (RM) cervicaly una RM de hombro donde se informa de una rotura parcialdel tendón supraespinoso y bursitis subacromial, por lo quese decide llevar a cabo una descompresión subacromial artroscópica.A pesar del tratamiento quirúrgico la paciente nomejora y se mantiene un dolor severo (EVA > 6). Posteriormentefue tratada con AINEs asociados a parches de fentanilo,pregabalina, infiltraciones de corticoides y nuevas sesionesde rehabilitación sin mejoría. Se decidió ampliar las pruebasde imagen y realizar una tomografia axial computerizada(TAC) torácica, ecografía de hombro izquierdo y RM de plexobraquial que mostraron la existencia de una lesión compatiblecon schwannoma del plexo braquial. La paciente fue intervenidaquirúrgicamente para resección del tumor mejorando del dolor progresivamente encontrándose actualmente asintomática (AU)

Schwannomas are tumors origined from Schwann cells, unfrequent, and generally benign. Pain and radiculopathy arecommon initial symptoms. Diagnosis is based in magnetic resonanceimaging (MRI) and surgery is the election treatment.We describe the case of a 50 years old woman, with a fiveyears long left atraumatic omalgia. During this time, shewas evaluated by different physicians such as traumatologist,neurologist, rheumatologist and rehabilitation doctor. Initiallyshe was treated with NSAID, rehabilitation (physiotherapy,short wave and magnetotherapy) without improvement. Diagnosticprocedures underwent were neurophysiologic study ofleft upper-extremity, wich was normal; cervical and shoulderMRI with partial tear of supraspinatus tendon and subacromialbursitis; the patient underwent an arthroscopic subacromialdecompression. This treatment did not relieve the pain of thepatient with an AVS > 6 at that moment. Subsequently shewas treated with NSAID associated to transdermic fentanyl,pregabalin, join steroid injections and new sessions of rehabilitationwithout improvement.It was decided to make more imaging procedures to finda clear aetiology for upper-extremity pain. A thoracic scanner,a left shoulder ecography and a brachial plexus MRI weremade and showed a lesion that was compatible with abrachial plexus schwannoma. After surgical treatment and tumorexcision the patient had a progressive pain relief. At thistime the patient has no pain nor any neurological damage (AU)

Primera serie nacional de trasplante de intestino en receptores adultos / First Spanish series of intestinal transplantation in adult recipients

Introducción: el trasplante de intestino, con la mejoría en los resultadosdesde finales de los años 90 y desde su cobertura por el Medicare,ha experimentado un crecimiento sustancial a nivel internacional.En la actualidad, según el Registro Internacional (1985-2005),se han realizado un total de 1.292 trasplantes de intestino en 1.210pacientes en 65 hospitales distribuidos por 20 países.Objetivo: conocer los resultados a corto plazo (6 meses) entérminos de supervivencia del paciente y del injerto de la primeraserie nacional de trasplante de intestino en receptores adultos.Material y métodos: presentamos nuestra experiencia en laevaluación de 20 potenciales candidatos a trasplante intestinal entrejunio de 2004 y octubre de 2005. De ellos, fueron desestimadosun total 10 pacientes y fueron trasplantados 4, lo que constituyela muestra de nuestro estudio.Resultados: hasta la fecha se han realizado 5 trasplantes en 4pacientes (2 retrasplantes, 2 tumores desmoides, y 1 síndrome deintestino corto tras exéresis por isquemia mesentérica). Al final delestudio y tras un seguimiento medio de 180 días (rango, 90-190días), todos los receptores están vivos, y todos los injertos, a excepciónde uno (75%), están funcionando plenamente, con autonomíadigestiva completa. Todos los pacientes recibieron induccióncon alemtuzumab excepto uno que recibió timoglobulina y entodos se inició la inducción sin esteroides.Conclusiones: el trasplante intestinal constituye una opciónterapéutica aplicable en nuestro medio y válida en receptores enquienes está indicado y que no tienen otra alternativa válida paracontrolar su insuficiencia intestinal

Background: short-bowel transplantation has experienced asubstantial growth worldwide following improved results from thelate 1990s on, and its coverage by Medicare. According to the InternationalRegistry (1985-2005), a total of 1,292 intestinal trasplantsfor 1,210 patients in 65 hospitals across 20 countries have been carriedout thus far.Objective: to know short-term (6 months) results regardingpatient and graft survival from the first Spanish series of intestinaltransplants in adult recipients.Material and methods: we present our experience in the assessmentof 20 potential candidates to short-bowel transplantationbetween June 2004 and October 2005. Of these, 10 patientswere rejected and 4 were transplanted, which makes up thesample of our study.Results: to this date 5 transplants have been carried out in4 patients (2 retransplants, 2 desmoid tumors, 1 short bowelsyndrome after excision as a result of mesenteric ischemia).Upon study completion and after a mean follow-up of 180days (range 90-190 days) all recipients are alive, and all graftsbut one (75%) are fully operational, with complete digestiveautonomy. All patients received induction with alemtuzumabexcept one, who received thymoglobulin; in all induction wasinitiated with no steroids.Conclusions: intestinal transplantation represents a therapeuticoption that is applicable in our setting and valid for recipientswith an indication who have no other feasible alternative tokeep their intestinal failure under control

Manejo anestésico de un paciente con displasia arritmogénica de ventrículo derecho, ascitis y colitis ulcerosa para una cirugía abdominal mayor / Patient with right ventricular arrhythmogenic dysplasia, ascites and ulcerative colitis: anesthetic management during major abdominal surgery

Presentamos el caso de un varón de 43 años con colitis ulcerosa y displasia arritmogénica de ventrículo derecho con deterioro de la función ventricular y portador de un desfibrilador automático implantable programado para pancolectomía por transformación adenomatosa de pólipos de colon. Se discuten aspectos básicos sobre la displasia arritmogénica de ventrículo derecho, su manejo y monitorización de cara a una cirugía mayor abdominal y el manejo perioperatorio de un enfermo con un desfibrilador automático implantable, con especial atención a la influencia de las interferencias electromagnéticas que pueden alterar su funcionamiento en un contexto quirúrgico. Por último se detallan los datos de la historia de un enfermo asintomático que deben hacer sospechar la presencia de una displasia arritmogénica de ventrículo derecho

A 43-year-old man with ulcerative colitis was scheduled for pancolectomy owing to adenomatous transformation of polyps. The patient had right ventricular arrhythmogenic dysplasia, with deteriorating ventricular function, and carried an automatic implantable defibrillator. We discuss the general features of arrhythmogenic right ventricular dysplasia and its implications for management and monitoring during major abdominal surgery. Perioperative management of a patient with an implantable defibrillator is also discussed, with special attention to the influence of electromagnetic interference that can affect how the device functions during surgery. Finally, we list signs that should lead to suspicion of arrhythmogenic right ventricular dysplasia in an asymptomatic patient

[Patient with right ventricular arrhythmogenic dysplasia, ascites and ulcerative colitis: anesthetic management during major abdominal surgery]. / Manejo anestésico de un paciente con displasia arritmogénica de ventrículo derecho, ascitis y colitis ulcerosa para una cirugía abdominal mayor.

A 43-year-old man with ulcerative colitis was scheduled for pancolectomy owing to adenomatous transformation of polyps. The patient had right ventricular arrhythmogenic dysplasia, with deteriorating ventricular function, and carried an automatic implantable defibrillator. We discuss the general features of arrhythmogenic right ventricular dysplasia and its implications for management and monitoring during major abdominal surgery. Perioperative management of a patient with an implantable defibrillator is also discussed, with special attention to the influence of electromagnetic interference that can affect how the device functions during surgery. Finally, we list signs that should lead to suspicion of arrhythmogenic right ventricular dysplasia in an asymptomatic patient.

Simultaneous liver-kidney transplantation for adult recipients with irreversible end-stage renal disease.

HYPOTHESIS: Combined liver-kidney transplantation is safe (low morbidity and acceptable mortality) and effective in patients with end-stage liver disease. Although refinements in surgical technique have resulted in better patient and allograft outcomes, the negative impact of renal insufficiency on survival in patients undergoing liver transplantation has been widely reported, although some aspects are controversial. DESIGN: Analysis of the clinical characteristics and outcome in the management of patients undergoing combined liver-kidney transplantation. The end points were operative mortality, morbidity, and long-term survival. SETTING: University Hospital 12 de Octubre. PATIENTS: Between May 1986 and December 2001, 820 liver transplantations were performed. There were 16 cases (1.96%) of combined liver-kidney transplantations, which represent the sample of this study. RESULTS: Mean +/- SD follow-up of 42.2 +/- 29 months: 6 patients died (37.5% mortality rate). There were 4 (25%) hospital deaths within 6 months following surgery and 2 after 6 months (4 sepsis, 1 refractory heart failure, and 1 recurrent hepatitis C virus disease). Univariate analysis related to mortality included age, sex, etiology, preoperative creatinine level, United Network for Organ Sharing status, Child-Pugh score, type of hepatectomy (piggyback), intraoperative blood product administration, and the presence of postoperative complications. The only 2 significant factors were the presence of postoperative complications (P = .01) and the United Network for Organ Sharing status (P = .02). Crude survival rate was 62.5%. Actuarial survival rates were 80%, 71%, and 60% at 1, 3, and 5 years, respectively. CONCLUSION: Because end-stage renal disease is not a formal contraindication for liver transplantation, a combined liver-kidney transplantation for adults with end-stage renal disease can be done safely and effectively.

Simultaneous liver-kidney transplant for combined renal and hepatic end-stage disease.

INTRODUCTION: After the first combined liver-kidney transplantation (CLKT) reported by Margreiter in 1984, it became clear that renal failure was no longer an absolute contraindication. OBJECTIVE: Our goal was to assess our results with combined liver-kidney transplant. Among 875 liver transplants performed between May 1986 and October 2002, there were 17 cases (1.96%) of combined liver-kidney transplant. RESULTS: With a mean follow-up of 42.2+/-29 months (range, 1-90), six patients had died (mortality: 37.5%). There were four (25%) operative in-hospital deaths, and two late mortality cases (beyond the month 6 after hospital discharge). The causes were sepsis (four cases, three postoperative and one in later follow-up), refractory heart failure (one postoperative), and recurrent liver disease (HCV-induced severe recurrence) during follow-up one). Actuarial survival (calculated for those who survived the postoperative period) was 80%, 71%, and 60% at 12, 36, and 60 months. Actuarial mean survival time was 60 months (95%IC:47-78). Neither the sex, the UNOS status, the etiology of liver disease, the etiology of renal failure, the type of hepatectomy (piggy back vs others) or the type of immunosuppression (P=.83) were related to long-term survival according to the log-rank test. A control group of 48 patients was constructed with subjects who underwent liver transplantation immediately before or after the combined transplant. A total (two cases after the CLKT and one case prior to). There were no differences in survival. CONCLUSION: Combined liver-kidney transplant represents a proper therapeutic option for patients with simultaneously failing organs based on long- and short-term outcomes.

The link between excitotoxic oligodendroglial death and demyelinating diseases.

Oligodendrocytes, the myelinating cells of CNS axons, are highly vulnerable to excitotoxic signals mediated by glutamate receptors of the AMPA and kainate classes. Receptors in these cells are commonly activated by glutamate that is released from axons and glial cells. In addition, oligodendrocytes contribute to the control of extracellular glutamate levels by means of their own transporters. However, acute and chronic alterations in glutamate homeostasis can result in overactivation of AMPA and kainate receptors and subsequent excitotoxic oligodendroglial death. Furthermore, demyelinating lesions caused by excitotoxins can be similar to those observed in multiple sclerosis. This, together with the effect of AMPA and kainate receptor antagonists in ameliorating the neurological score of animals with experimental autoimmune encephalomyelitis (an animal model of multiple sclerosis), indicates that oligodendrocyte excitotoxicity could be involved in the pathogenesis of demyelinating disorders.

KA1-like kainate receptor subunit immunoreactivity in neurons and glia using a novel anti-peptide antibody.

Functional kainate receptors can be formed by various combinations of subunits with low (GluR5, GluR6 and GluR7) or high affinity (KA1 and KA2) for kainate. The precise contribution of each subunit to native receptors, as well as their distribution within the central nervous system (CNS) is still unclear. Here, we describe the presence of KA1-like immunoreactivity in both neurons and glial cells of the CNS, using a newly developed antiserum to a specific carboxy terminus epitope of the KA1 subunit. Intense immunoreactivity was observed in the CA3 area of the rat hippocampus. Electron microscopy revealed that immunostaining was present in dendritic structures postsynaptic to commissural-associational fibers, rather than in those contacted by mossy fiber terminals. We also observed immunostaining of CA1 pyramidal cell apical dendrites. In the cerebral cortex, KA1-like immunostaining was observed in many pyramidal neuron somata, mainly in layer V, and along their apical dendrites. A subset of gamma-amino-butyric acidic cells were also intensely stained. In the cerebellum, the antiserum selectively stained Purkinje cell somata and their dendrites as well as Bergmann glial processes. Other types of macroglia were also labeled by the KA1 antiserum. Thus, optic nerve oligodendrocytes both in vitro and in situ and cultured astrocytes were densely stained. Our results indicate that KA1-type subunits are more widely distributed throughout the CNS than previously thought. This newly developed antiserum may help to clarify the properties of kainate receptors containing KA1 or KA1-type subunits within the normal and pathological brain.

Excitotoxicidad oligodendroglial y desmielinización en el nervio óptico

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Postnatal development of perisomatic GABAergic axon terminals on neurons projecting from area 17 to area 18 of the cat visual cortex.

We have studied the postnatal development of presumptive axon terminals (puncta) which were recognized by antibodies to the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) and were located on the somata of area 17 neurons projecting to the ipsilateral area 18 of the visual cortex in cats ranging from 7 days of age to adulthood. Projection neurons were retrogradely labeled by injection of horseradish peroxidase conjugated to wheat germ agglutinin into the ipsilateral area 18. These neurons were mainly pyramidal in shape at all the developmental stages examined and the adult distribution of labeled cells was reached by 21 days. Subsequent GABA postembedding immunohistochemistry using high-resolution light microscopy was carried out to study the development of GABAergic terminals on cell bodies of identified projecting neurons in layers II-III. At all ages examined, we found perisomatic GABAergic puncta on these cells. Their density showed a significant increase from postnatal days 7 to 45, and then remained largely constant through adulthood. Since GABAergic puncta are considered the light-microscopic correlate of GABAergic synaptic terminals, our results support the idea of a developmentally regulated increase in the inhibitory activity of local interneurons on area 17 pyramidal neurons projecting to area 18 in the cat visual cortex which occurs within the same time frame as that of the acquisition of the mature operation of these cells.