Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 77
Filtrar
1.
Transplant Direct ; 6(10): e602, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33134482

RESUMO

Rates of kidney transplantation vary substantially across dialysis facilities in the United States. Whether distance between the dialysis facility and transplant center associates with variations in transplantation rates has not been examined. Methods: We performed a retrospective study of adults treated with dialysis between 2005 and 2015, according to the US Renal Data System. We examined the association between distance from dialysis facility to transplant center and time to kidney transplantation (primary outcome) and waitlist registration (secondary outcome) using Fine-Gray models. We also performed sensitivity analyses using the distance from each patient's dialysis facility to the nearest transplant center as the predictor so that patients who were never registered on the waitlist (and therefore would not have a transplant center) could be included. Results: In total, 178 885 waitlisted patients were included for our primary analysis. As distance between dialysis facility and transplant center increased, lower hazard of transplantation (subhazard ratio [HR], 0.92; 95% confidence interval [CI], 0.91-0.94, if distance was 10 to <50 miles; sub-HR, 0.90; 95% CI, 0.88-0.92, if distance ≥50 miles compared with <10 miles) was noted. We also found a weak association between longer distance and hazard of waitlist registration (sub-HR, 0.96; 95% CI, 0.94-0.97, if distance was ≥50 miles versus <10 miles). Findings were similar in sensitivity analyses using distance between dialysis facility and the nearest transplant center (N = 1 149 721). Conclusions: Patients receiving dialysis in facilities located further away from transplant centers have lower hazard of kidney transplantation. Developing strategies to address barriers to transplantation in patients receiving dialysis at facilities located far away from a transplant center may help improve disparities in transplantation rates.

2.
PLoS One ; 15(11): e0242784, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33253253

RESUMO

High body mass index is a known barrier to access to kidney transplantation in patients with end-stage kidney disease. The extent to which weight and weight changes affect access to transplantation among obese candidates differentially by race/ethnicity has received little attention. We included 10 221 obese patients waitlisted for kidney transplantation prior to end-stage kidney disease onset between 1995-2015. We used multinomial logistic regression models to examine the association between race/ethnicity and annualized change in body mass index (defined as stable [-2 to 2 kg/m2/year], loss [>2 kg/m2/year] or gain [>2 kg/m2/year]). We then used Fine-Gray models to examine the association between weight changes and access to living or deceased donor transplantation by race/ethnicity, accounting for the competing risk of death. Overall, 29% of the cohort lost weight and 7% gained weight; 46% received a transplant. Non-Hispanic blacks had a 24% (95% CI 1.12-1.38) higher odds of weight loss and 22% lower odds of weight gain (95% CI 0.64-0.95) compared with non-Hispanic whites. Hispanics did not differ from whites in their odds of weight loss or weight gain. Overall, weight gain was associated with lower access to transplantation (HR 0.88 [95% CI 0.79-0.99]) compared with maintenance of stable weight, but weight loss was not associated with better access to transplantation (HR 0.96 [95% CI 0.90-1.02]), although this relation differed by baseline body mass index and for recipients of living versus deceased donor organs. For example, weight loss was associated with improved access to living donor transplantation (HR 1.24 [95% CI 1.07-1.44]) in whites but not in blacks or Hispanics. In a cohort of obese patients waitlisted before dialysis, blacks were more likely to lose weight and less likely to gain weight compared with whites. Weight loss was only associated with improved access to living donor transplantation among whites. Further studies are needed to understand the reasons for the observed associations.

3.
Hepatology ; 2020 Sep 14.
Artigo em Inglês | MEDLINE | ID: mdl-32926749

RESUMO

Organs from HCV-viremic donors have been used in HCV-uninfected recipients (D+/R-) but the optimal treatment approach has not been defined. We evaluated the kinetics of HCV infection post-transplant in D+/R- kidney (KT) and liver transplant (LT) recipients when a preemptive antiviral strategy was used. Six U.S. transplant programs prospectively treated D+/R- primary LT and KT recipients with sofosbuvir-velpastasvir for 12 weeks starting once viremia was confirmed post-transplant and the patient judged to be clinically stable including eGFR >30 ml/min. Primary endpoints were sustained virologic response at 12 weeks post-transplant (SVR12) and safety (assessed by proportion of treatment-related adverse and serious adverse events). Of 24 patients transplanted (13 liver of whom 2 had prior treated HCV infection, 11 kidney), 23 became viremic post-transplant. The median (IQR) time from transplant to start of antiviral therapy was 7.0 (6.0,12.0) vs. 16.5 (9.8,24.5) days and the median (IQR) HCV RNA level 3 days after transplant was 6.5 (3.9,7.1) vs. 3.6 (2.9,4.0) log10 IU/mL in LT vs. KT recipients, respectively. By week four of treatment, 10/13 (77%) LT, but only 2/10 (20%) KT had undetectable HCV RNA (p=0.01). At the end of treatment, all LT recipients were HCV RNA undetectable, while three (30%) of the kidney recipients still had detectable, but not quantifiable, viremia. All achieved SVR12 (lower 95% CI bound 85%). Serious adverse events considered possibly related to treatment were antibody-mediated rejection, biliary sclerosis, cardiomyopathy and graft-versus-host-disease, with the latter associated with multiorgan failure, premature treatment discontinuation and death. We conclude that despite differing kinetics of early HCV infection in liver versus non-liver recipients, a preemptive antiviral strategy is effective. Vigilance for adverse immunologic events is warranted.

4.
Nat Commun ; 11(1): 4289, 2020 08 27.
Artigo em Inglês | MEDLINE | ID: mdl-32855397

RESUMO

Older organs represent an untapped potential to close the gap between demand and supply in organ transplantation but are associated with age-specific responses to injury and increased immunogenicity, thereby aggravating transplant outcomes. Here we show that cell-free mitochondrial DNA (cf-mt-DNA) released by senescent cells accumulates with aging and augments immunogenicity. Ischemia reperfusion injury induces a systemic increase of cf-mt-DNA that promotes dendritic cell-mediated, age-specific inflammatory responses. Comparable events are observed clinically, with the levels of cf-mt-DNA elevated in older deceased organ donors, and with the isolated cf-mt-DNA capable of activating human dendritic cells. In experimental models, treatment of old donor animals with senolytics clear senescent cells and diminish cf-mt-DNA release, thereby dampening age-specific immune responses and prolonging the survival of old cardiac allografts comparable to young donor organs. Collectively, we identify accumulating cf-mt-DNA as a key factor in inflamm-aging and present senolytics as a potential approach to improve transplant outcomes and availability.


Assuntos
DNA Mitocondrial/efeitos adversos , Dasatinibe/farmacologia , Inflamação/prevenção & controle , Transplante de Órgãos/métodos , Quercetina/farmacologia , Adulto , Envelhecimento/fisiologia , Animais , Diferenciação Celular , Ácidos Nucleicos Livres , Senescência Celular/efeitos dos fármacos , Senescência Celular/fisiologia , Citocinas/metabolismo , DNA Mitocondrial/metabolismo , Células Dendríticas/imunologia , Células Dendríticas/fisiologia , Transplante de Coração/efeitos adversos , Transplante de Coração/métodos , Humanos , Inflamação/etiologia , Masculino , Camundongos Endogâmicos C57BL , Camundongos Endogâmicos DBA , Pessoa de Meia-Idade , Transplante de Órgãos/efeitos adversos , Traumatismo por Reperfusão/genética , Traumatismo por Reperfusão/imunologia , Doadores de Tecidos
5.
J Am Coll Surg ; 231(3): 351-360.e5, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32562768

RESUMO

BACKGROUND: Current risk-adjusted models used to predict donor heart use and cardiac graft survival from organ donors after brain death (DBDs) do not include bedside critical care data. We sought to identify novel independent predictors of heart use and graft survival to better understand the relationship between donor management and transplantation outcomes. STUDY DESIGN: We conducted a prospective observational study of DBDs managed from 2008 to 2013 by 10 organ procurement organizations. Demographic data, critical care parameters, and treatments were recorded at 3 standardized time points during donor management. The primary outcomes measures were donor heart use and cardiac graft survival. RESULTS: From 3,433 DBDs, 1,134 hearts (33%) were transplanted and 969 cardiac grafts (85%) survived after 684 ± 392 days of follow-up. After multivariable analysis, independent positive predictors of heart use included standard criteria donor status (odds ratio [OR] 3.93), male sex (OR 1.68), ejection fraction > 50% (OR 1.64), and partial pressure of oxygen to fraction of inspired oxygen ratio > 300 (OR 1.31). Independent negative predictors of heart use included donor age (OR 0.94), BMI > 30 kg/m2 (OR 0.78), serum creatinine (OR 0.83), and use of thyroid hormone (OR 0.78). As for graft survival, after controlling for known recipient risk factors, thyroid hormone dose was the only independent predictor (OR 1.04 per µg/h). CONCLUSIONS: Modifiable critical care parameters and treatments predict donor heart use and cardiac graft survival. The discordant relationship between thyroid hormone and donor heart use (negative predictor) vs cardiac graft survival (positive predictor) warrants additional investigation.

6.
Transplantation ; 104(11): e308-e316, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32467477

RESUMO

BACKGROUND: Acute kidney injury (AKI) after liver transplantation is associated with increased morbidity and mortality. It remains controversial whether the choice of vena cava reconstruction technique impacts AKI. METHODS: This is a single-center retrospective cohort of 897 liver transplants performed between June 2009 and September 2018 using either the vena cava preserving piggyback technique or caval replacement technique without veno-venous bypass or shunts. The association between vena cava reconstruction technique and stage of postoperative AKI was assessed using multivariable ordinal logistic regression. Causal mediation analysis was used to evaluate warm ischemia time as a potential mediator of this association. RESULTS: The incidence of AKI (AKI stage ≥2) within 48 h after transplant was lower in the piggyback group (40.3%) compared to the caval replacement group (51.8%, P < 0.001). Piggyback technique was associated with a reduced risk of developing a higher stage of postoperative AKI (odds ratio, 0.49; 95% confidence interval, 0.37-0.65, P < 0.001). Warm ischemia time was shorter in the piggyback group and identified as potential mediator of this effect. There was no difference in renal function (estimated glomerular filtration rate and the number of patients alive without dialysis) 1 y after transplant. CONCLUSIONS: Piggyback technique, compared with caval replacement, was associated with a reduced incidence of AKI after liver transplantation. There was no difference in long-term renal outcomes between the 2 groups.

7.
J Trauma Acute Care Surg ; 88(6): 783-788, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32459446

RESUMO

BACKGROUND: Delayed graft function (DGF), the need for dialysis in the first week following kidney transplant, affects approximately one quarter of deceased-donor kidney transplant recipients. Donor demographics, donor serum creatinine, and graft cold ischemia time are associated with DGF. However, there is no consensus on the optimal management of hemodynamic instability in organ donors after brain death (DBDs). Our objective was to determine the relationship between vasopressor selection during donor management and the development of DGF. METHODS: Prospective observational data, including demographic and critical care parameters, were collected for all DBDs managed by 17 organ procurement organizations from nine Organ Procurement and Transplantation Network Regions between 2012 and 2018. Recipient outcome data were linked with donor data through donor identification numbers. Donor critical care parameters, including type of vasopressor and doses, were recorded at three standardized time points during donor management. The analysis included only donors who received at least one vasopressor at all three time points. Vasopressor doses were converted to norepinephrine equivalent doses and analyzed as continuous variables. Univariate analyses were conducted to determine the association between donor variables and DGF. Results were adjusted for known predictors of DGF using binary logistic regression. RESULTS: Complete data were available for 5,554 kidney transplant recipients and 2,985 DBDs. On univariate analysis, donor serum creatinine, donor age, donor subtype, kidney donor profile index, graft cold ischemia time, phenylephrine dose, and dopamine dose were associated with DGF. After multivariable analysis, increased donor serum creatinine, donor age, kidney donor profile index, graft cold ischemia time, and phenylephrine dose remained independent predictors of DGF. CONCLUSION: Higher doses of phenylephrine were an independent predictor of DGF. With the exception of phenylephrine, the selection and dose of vasopressor during donor management did not predict the development of DGF. LEVEL OF EVIDENCE: Prognostic study, Level III.


Assuntos
Morte Encefálica/fisiopatologia , Cuidados Críticos/estatística & dados numéricos , Função Retardada do Enxerto/epidemiologia , Transplante de Rim/efeitos adversos , Rim/efeitos dos fármacos , Vasoconstritores/efeitos adversos , Adulto , Fatores Etários , Isquemia Fria/efeitos adversos , Cuidados Críticos/métodos , Função Retardada do Enxerto/etiologia , Função Retardada do Enxerto/prevenção & controle , Relação Dose-Resposta a Droga , Feminino , Humanos , Rim/irrigação sanguínea , Rim/fisiopatologia , Transplante de Rim/métodos , Transplante de Rim/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Fenilefrina/administração & dosagem , Fenilefrina/efeitos adversos , Estudos Prospectivos , Medição de Risco , Obtenção de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Vasoconstritores/administração & dosagem , Adulto Jovem
9.
Anesthesiology ; 132(6): 1594, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32217873
10.
Clin Transplant ; 34(5): e13835, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32068301

RESUMO

BACKGROUND: No standard exists for the use of deceased donor liver biopsy during procurement. We sought to evaluate liver biopsy and the impact of findings on outcomes and graft utilization. METHODS: A prospective observational study of donors after neurologic determination of death was conducted from 02/2012-08/2017 (16 OPOs). Donor data were collected through the UNOS Donor Management Goals Registry Web Portal and linked to the Scientific Registry of Transplant Recipients (SRTR) for recipient outcomes. Recipients of biopsied donor livers (BxDL) were studied and a Cox proportional hazard analysis was used to identify independent predictors of 1-year graft survival. RESULTS: Data from 5449 liver transplant recipients were analyzed, of which 1791(33%) received a BxDL. There was no difference in graft or patient survival between the non-BxDL and BxDL recipient groups. On adjusted analysis of BxDL recipients, macrosteatosis (21%-30%[n = 148] and >30%[n = 92]) was not found to predict 1-year graft survival, whereas increasing donor age (HR1.02), donor Hispanic ethnicity (HR1.62), donor INR (HR1.18), and recipient life support (HR2.29) were. CONCLUSIONS: Excellent graft and patient survival can be achieved in recipients of BxDL grafts. Notably, as demonstrated by the lack of effect of macrosteatosis on survival, donor to recipient matching may contribute to these outcomes.

11.
Transplantation ; 103(11): e365-e368, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31356580

RESUMO

BACKGROUND: In a recent trial, targeted mild hypothermia in brain-dead organ donors significantly reduced the incidence of delayed graft function after kidney transplantation. This trial was stopped early for efficacy. Here, we report long-term graft survival for all organs along with donor critical care end points. METHODS: We assessed graft survival through 1 year of all solid organs transplanted from 370 donors who had been randomly assigned to hypothermia (34-35°C) or normothermia (36.5-37.5°C) before donation. Additionally, changes in standardized critical care end points were compared between donors in each group. RESULTS: Mild hypothermia was associated with a nonsignificant improvement in 1-year kidney transplant survival (95% versus 92%; hazard ratio, 0.61 [0.31-1.20]; P = 0.15). Mild hypothermia was associated with higher 1-year graft survival in the subgroup of standard criteria donors (97% versus 93%; hazard ratio, 0.39 [0.15 to -1.00]; P = 0.05). There were no significant differences in graft survival of extrarenal organs. There were no differences in critical care end points between groups. CONCLUSIONS: Mild hypothermia in the donor safely reduced the rate of delayed graft function in kidney transplant recipients without adversely affecting donor physiology or extrarenal graft survival. Kidneys from standard criteria donors who received targeted mild hypothermia had improved 1-year graft survival.


Assuntos
Sobrevivência de Enxerto , Hipotermia Induzida , Transplante de Rim/métodos , Doadores de Tecidos , Adulto , Idoso , Temperatura Corporal , Morte Encefálica , Função Retardada do Enxerto , Seguimentos , Humanos , Rim/patologia , Rim/cirurgia , Pessoa de Meia-Idade , Segurança do Paciente , Perfusão , Modelos de Riscos Proporcionais , Obtenção de Tecidos e Órgãos , Resultado do Tratamento
12.
Clin Transplant ; 33(7): e13626, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31162858

RESUMO

Delayed graft function (DGF) in kidney transplant significantly increases inpatient and outpatient cost. Targeted, mild hypothermia in organ donors after neurologic determination of death significantly reduced the rate of DGF in a recent randomized controlled clinical trial. To assess the potential economic benefit of national implementation of donor hypothermia, rates of reduction DGF were combined with estimates of the impact of DGF on hospital cost and total health expenditure for standard and extended criteria donor organs (SCD and ECD). DGF increases the cost of the transplant episode by $9487 for ECD transplant and $10 342 for SCD transplant. Medicare recipients with DGF incur an additional $18 513 spending for ECD and $14 948 in SCD transplants over the first year. An absolute reduction in DGF rate after kidney transplantation consistent with trial results (ECD 25%, SCD 7%) has the potential to lower annual hospital cost for kidney transplant by $13 178 746 and annual Medicare spending by $20 970 706 compared to standard donor management practice using static cold storage. Targeted mild hypothermia improves care of renal transplant patients by safely reducing DGF rates in both ECD and SCD transplant. Broader application of this safe, effective, and low-cost intervention could reduce healthcare expenditures for providers and insurers.


Assuntos
Morte Encefálica , Função Retardada do Enxerto/economia , Hipotermia , Transplante de Rim/economia , Transplante de Rim/métodos , Doadores de Tecidos/provisão & distribução , Obtenção de Tecidos e Órgãos/economia , Função Retardada do Enxerto/prevenção & controle , Feminino , Seguimentos , Gastos em Saúde , Humanos , Masculino , Modelos Econômicos , Prognóstico , Recuperação de Função Fisiológica , Obtenção de Tecidos e Órgãos/normas , Resultado do Tratamento
13.
Clin Transplant ; 33(6): e13571, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31001850

RESUMO

Criteria for organ acceptance in brain-dead organ donors remain inconsistent, especially when concerning pancreatic transplants. We sought to examine donor-specific predictors of pancreatic graft use and survival to better guide the selection and management of potential donors. A prospective observational study of all donors from ten organ procurement organizations was conducted from March 2012 to January 2015. Critical care endpoints were collected at 4 standardized time points. Data associated with pancreatic transplantation and graft survival rates were first determined using univariate analyses, and then logistic regression was used to identify independent predictors of these two outcomes. From 1819 donors, 238 (13.1%) pancreata were transplanted, and at a mean follow-up of 192 days, 218 (91.6%) grafts had survived. After regression analysis, donor age (OR = 0.89), HgbA1C (OR = 0.07), and achieving the donor management goal (DMG) for ejection fraction at allocation of ≥50% (OR = 3.29) remained as independent predictors of pancreatic utilization. On regression analysis, graft survival was independently predicted by lower donor age (OR = 0.93) and achieving the DMGs for mean arterial pressure (60-110 mm Hg) and glucose (≤180 mg/dL) at separate time points. These results may help guide the management and selection of potential pancreatic donors after brain death.


Assuntos
Morte Encefálica , Seleção do Doador/métodos , Transplante de Pâncreas/mortalidade , Doadores de Tecidos/provisão & distribução , Obtenção de Tecidos e Órgãos/normas , Adulto , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Taxa de Sobrevida
15.
Transplantation ; 102(11): e466-e471, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30048397

RESUMO

BACKGROUND: In liver transplantation, both cold and warm ischemia times are known to impact early graft function. The extraction time is a period during the initial phase of organ cooling which occurs during deceased donor procurement. During this time, the organ is at risk of suboptimal cooling. Whether donor extraction time, the time from donor aortic cross-clamp to removal of the donor organ from the body cavity has an effect on early graft function is not known. METHODS: We investigated the effect of donor extraction time on early graft function in 292 recipients of liver grafts procured locally and transplanted at our center between June 2012 and December 2016. Early graft function was assessed using the model of early allograft function score in a multivariable regression model including donor extraction time, cold ischemia time, warm ischemia time, donor risk index, and terminal donor sodium. RESULTS: Donor extraction time had an independent effect on early graft function measured by the model of early allograft function score (coefficient, 0.021; 95% confidence interval, 0.007-0.035; P < 0.01; for each minute increase of donor extraction time). Besides donor extraction time, cold ischemia time, warm ischemia time, and donor risk index had a significant effect on early graft function. CONCLUSIONS: We demonstrate an independent effect of donor extraction time on graft function after liver transplantation. Efforts to minimize donor extraction time could improve early graft function in liver transplantation.


Assuntos
Isquemia Fria , Hepatectomia , Transplante de Fígado/métodos , Duração da Cirurgia , Doadores de Tecidos , Coleta de Tecidos e Órgãos/métodos , Isquemia Quente , Adulto , Isquemia Fria/efeitos adversos , Técnicas de Apoio para a Decisão , Feminino , Sobrevivência de Enxerto , Hepatectomia/efeitos adversos , Humanos , Testes de Função Hepática , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Disfunção Primária do Enxerto/diagnóstico , Disfunção Primária do Enxerto/etiologia , Medição de Risco , Fatores de Risco , Fatores de Tempo , Coleta de Tecidos e Órgãos/efeitos adversos , Resultado do Tratamento , Isquemia Quente/efeitos adversos
16.
Clin Transplant ; 32(5): e13238, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29526051

RESUMO

BACKGROUND: During kidney transplantation, intraoperative fluid management can affect post-transplant graft function. It is unclear whether or not central venous pressure (CVP) monitoring is required to guide fluid therapy during kidney transplantation. METHODS: We compared post-transplant graft function in recipients of living donor kidney transplants between August 2006 and March 2009 based on the use or absence of intraoperative CVP monitoring. Graft function, assessed using the creatinine reduction ratio on postoperative day 2 (CCR2), was evaluated by multivariable linear regression analysis and in a propensity-matched cohort. RESULTS: Two hundred and ninety patients were included in the analysis. Central venous pressure was monitored in 84 patients (29%). There was no difference in post-transplant graft function, as measured by CCR2, between patients with and without CVP monitoring in both unadjusted and multivariable-adjusted analyses. There were also no statistically significant differences in CCR2, delayed graft function, or 3-month renal function between those monitored with CVP and those without, in the propensity-matched cohort. CONCLUSIONS: In this single-center analysis, immediate post-transplant renal function was not associated with the use of intraoperative CVP monitoring.


Assuntos
Pressão Venosa Central/fisiologia , Função Retardada do Enxerto/diagnóstico , Sobrevivência de Enxerto , Falência Renal Crônica/cirurgia , Transplante de Rim/métodos , Doadores Vivos , Monitorização Fisiológica , Estudos de Coortes , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Rim/fisiologia , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória , Prognóstico , Pontuação de Propensão , Fatores de Risco , Transplantados
17.
Transplantation ; 102(5): e229-e235, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29470352

RESUMO

BACKGROUND: Renal failure is common among patients undergoing liver transplantation. Liver allocation based on the model for end-stage liver disease score has increased the number of recipients who require perioperative renal replacement therapy (RRT). Although RRT can be continued intraoperatively, the risks and benefits of intraoperative RRT are not well defined. The aim of this study is to report the intraoperative management of patients with pretransplant renal failure at a transplant center with extremely infrequent utilization of intraoperative RRT. MATERIALS AND METHODS: We performed a retrospective analysis of all adult patients undergoing orthotopic liver or simultaneous liver-kidney (SLK) transplantation between June 2009 and December 2015. Patients were divided into 2 groups based on their need for pretransplant RRT. RESULTS: A total of 785 patients underwent liver or SLK transplant during the study period. One hundred and seventy-four patients (22.2%) required preoperative dialysis. Only 2 patients required intraoperative RRT. There was no difference in the incidence of acidosis or hyperkalemia between patients who required preoperative dialysis and those who did not. CONCLUSIONS: We describe the successful management of patients undergoing liver or SLK transplantation almost entirely without the need for intraoperative RRT.


Assuntos
Doença Hepática Terminal/cirurgia , Cuidados Intraoperatórios/métodos , Transplante de Rim/métodos , Transplante de Fígado/métodos , Diálise Renal , Insuficiência Renal/terapia , Acidose/etiologia , Doença Hepática Terminal/complicações , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/fisiopatologia , Feminino , Humanos , Hiperpotassemia/etiologia , Cuidados Intraoperatórios/efeitos adversos , Transplante de Rim/efeitos adversos , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Diálise Renal/efeitos adversos , Insuficiência Renal/complicações , Insuficiência Renal/diagnóstico , Insuficiência Renal/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
18.
Semin Cardiothorac Vasc Anesth ; 22(2): 211-222, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29276852

RESUMO

Worldwide 715 482 patients have received a lifesaving organ transplant since 1988. During this time, there have been advances in donor management and in the perioperative care of the organ transplant recipient, resulting in marked improvements in long-term survival. Although the number of organs recovered has increased year after year, a greater demand has produced a critical organ shortage. The majority of organs are from deceased donors; however, some are not suitable for transplantation. Some of this loss is due to management of the donor. Improved donor care may increase the number of available organs and help close the existing gap in supply and demand. In order to address this concern, The Organ Donation and Transplantation Alliance, the Association of Organ Procurement Organizations, and the Transplant and Critical Care Committees of the American Society of Anesthesiologists have formulated evidence-based guidelines, which include a call for greater involvement and oversight by anesthesiologists and critical care specialists, as well as uniform reporting of data during organ procurement and recovery.


Assuntos
Anestesia/métodos , Morte Encefálica , Consenso , Doadores de Tecidos , Obtenção de Tecidos e Órgãos , Cuidados Críticos , Hidratação , Humanos , Ressuscitação
20.
J Hepatol ; 68(4): 798-813, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29133246

RESUMO

Liver transplantation has emerged as a highly efficient treatment for a variety of acute and chronic liver diseases. However, organ shortage is becoming an increasing problem globally, limiting the applicability of liver transplantation. In addition, potential recipients are becoming sicker, thereby increasing the risk of losing the graft during transplantation or in the initial postoperative period after liver transplantation (three months). This trend is challenging the model for end-stage liver disease allocation system, where the sickest candidates are prioritised and no delisting criteria are given. The weighting of the deontological demand for "equity", trying to save every patient, regardless of the overall utility; and "efficiency", rooted in utilitarianism, trying to save as many patients as possible and increase the overall quality of life of patients facing the same problem, has to be reconsidered. In this article we are aiming to overcome the widespread concept of futility in liver transplantation, providing a definition of potentially inappropriate liver transplantation and giving guidance on situations where it is best not to proceed with liver transplantation, to decrease the mortality rate in the first three months after transplantation. We propose "absolute" and "relative" conditions, where early post-transplant mortality is highly probable, which are not usually captured in risk scores predicting post-transplant survival. Withholding liver transplantation for listed patients in cases where liver transplant is not deemed clearly futile, but is potentially inappropriate, is a far-reaching decision. Until now, this decision had to be discussed extensively on an individual basis, applying explicit communication and conflict resolution processes, since the model for end-stage liver disease score and most international allocation systems do not include explicit delisting criteria to support a fair delisting process. More work is needed to better identify cases where transplantation is potentially inappropriate and to integrate and discuss these delisting criteria in allocation systems, following a societal debate on what we owe to all liver transplant candidates.


Assuntos
Transplante de Fígado , Obtenção de Tecidos e Órgãos , Doença Hepática Terminal/cirurgia , Humanos , Hipertensão Pulmonar/diagnóstico , Falência Hepática Aguda/cirurgia , Transplante de Fígado/mortalidade , Índice de Gravidade de Doença , Listas de Espera
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA