Graft intolerance syndrome requiring graft nephrectomy after late kidney graft failure: can it be predicted? A retrospective cohort study

Graft nephrectomy is recommended in case of early graft failure. When the graft fails more than 3–6 months after transplantation, it is current practice to follow a wait‐and‐see policy. A common indication for graft removal is the graft intolerance syndrome. We aimed to create a risk prediction model for the occurrence of graft intolerance resulting in graft nephrectomy. We collected data of kidney transplantations performed in our center between 1980 and 2010 that failed at least 6 months after transplantation. We evaluated the association between baseline characteristics and the occurrence of graft nephrectomy because of graft intolerance using a competing risk regression model. Prognostic factors were included in a multivariate prediction model. In‐ and exclusion criteria were met in 288 cases. In 48 patients, the graft was removed because of graft intolerance. Donor age, the number of rejections, and shorter graft survival were predictive factors for graft nephrectomy because of the graft intolerance syndrome. These factors were included in a prediction rule. Using donor age, graft survival, and the number of rejections, clinicians can predict the need for graft nephrectomy with a reasonable accuracy.     

Age and mortality after injury: is the association linear?

Introduction

Multiple studies have demonstrated a linear association between advancing age and mortality after injury. An inflection point, or an age at which outcomes begin to differ, has not been previously described. We hypothesized that the relationship between age and mortality after injury is non-linear and an inflection point exists.

Methods

We performed a retrospective cohort analysis at our urban level I center from 2007 through 2009. All patients aged 65 years and older with the admission diagnosis of injury were included. Non-parametric logistic regression was used to identify the functional form between mortality and age. Multivariate logistic regression was utilized to explore the association between age and mortality. Age 65 years was used as the reference. Significance was defined as p < 0.05.

Results

A total of 1,107 patients were included in the analysis. One-third required intensive care unit (ICU) admission and 48 % had traumatic brain injury. 229 patients (20.6 %) were 84 years of age or older. The overall mortality was 7.2 %. Our model indicates that mortality is a quadratic function of age. After controlling for confounders, age is associated with mortality with a regression coefficient of 1.08 for the linear term (p = 0.02) and a regression coefficient of ?0.006 for the quadratic term (p = 0.03). The model identified 84.4 years of age as the inflection point at which mortality rates begin to decline.

Conclusions

The risk of death after injury varies linearly with age until 84 years. After 84 years of age, the mortality rates decline. These findings may reflect the varying severity of comorbidities and differences in baseline functional status in elderly trauma patients. Specifically, a proportion of our injured patient population less than 84 years old may be more frail, contributing to increased mortality after trauma, whereas a larger proportion of our injured patients over 84 years old, by virtue of reaching this advanced age, may, in fact, be less frail, contributing to less risk of death.     

Does prophylactic inhaled nitric oxide reduce morbidity and mortality after lung transplantation?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was does prophylactic inhaled nitric oxide (NO) reduce morbidity and mortality after lung transplantation? Altogether 232 papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Primary graft dysfunction and failure are serious complications in the first few days following lung transplantation. These phenomena are characterised by bilateral infiltrates on chest radiographs, reduced lung compliance and increased FiO(2) requirements and alveolar-arterial gradients; thus necessitating prolonged mechanical ventilation and often leading to significant mortality. The process known as ischaemic-reperfusion injury is thought to underlie primary graft failure. The studies conducted examining the role of inhaled NO in preventing morbidity and mortality after orthotropic lung transplant tend to focus on potential reductions in the incidence of ischaemic-reperfusion injury as the determinant of clinical outcomes. The majority of these are unfortunately non-randomised and/or uncontrolled studies. All the studies discussed, including the two prospective randomised controlled trials, suffer from small sample sizes. Nonetheless, despite their limitations, there are currently, no randomised controlled studies that demonstrate a reduction in morbidity [time to extubation, length of intensive care unit (ICU) or hospital stay] or mortality. As such it is difficult to currently, recommend the routine use of prophylactic inhaled NO in lung transplant surgery. Further studies may outline a benefit in certain types of surgeries, e.g. single-lung transplants or double-lung requiring cardiopulmonary bypass.     

Closed suction or penrose drainage after partial nephrectomy: does it matter?

PURPOSE: Prospective studies in the general surgery literature have shown fewer wound related complications with closed suction drainage than with open passive drainage. Nevertheless, some urologists avoid closed suction drains after partial nephrectomy mainly because of a theoretical increased risk of a prolonged urinary leak or delayed hemorrhage. MATERIALS AND METHODS: We reviewed the records of 184 patients who underwent 197 consecutive partial nephrectomies at our institution. Closed suction or open passive (Penrose) drainage was used based on surgeon preference. Drain type was compared with duration of use and the incidence of relevant complications. RESULTS: A Penrose drain was used in 37.6% (74 of 197) of partial nephrectomies and a closed suction drain was used in 62.4% (123). Clinical characteristics were equivalent between both groups, including age, body mass index, tumor size (mean 3.1 cm), number of renal tumors excised, estimated blood loss and operative time. There was no statistically significant difference in the duration of drainage between the Penrose group (mean 7.1 days) and the closed suction group (7.8 days). While we found variation in the incidence of relevant complications by drain type, none of these differences was statistically significant. Complications included prolonged urinary drainage in 7.6% of cases (8.9% closed suction, 5.4% Penrose), wound infection or perinephric abscess in 3.6% (2.4% closed suction, 5.4% Penrose) and delayed hemorrhage in 1.5% (2.4% closed suction, 0 Penrose). CONCLUSIONS: No statistically significant differences in postoperative morbidity were observed between the use of closed suction or Penrose retroperitoneal drains after partial nephrectomy.     

Tuberculosis of the ilium: is it really so rare?

Tuberculosis of the ilium is a rare identity, accounting for less than 1% of all skeletal tuberculosis. We report two such lesions in immunocompetent individuals. Tuberculosis remains an important differential diagnosis when faced with unusual or chronic bony lesions, especially in endemic areas, even in non-immunocompromised individuals. It can involve any site and affect people of any age.     

Inflammatory response after out-of-hospital cardiac arrest—Impact on outcome and organ failure development

Background

Post-cardiac arrest syndrome that occurs in out-of-hospital cardiac arrest (OHCA) patients is characterized by inflammatory response. We conducted a scoping review of current evidence regarding several inflammatory markers' usefulness for assessment of patient outcome and illness severity. We also discuss the proposed underlying mechanisms leading to inflammatory response after OHCA.

Methods

We searched the MEDLINE, PubMed Central, Cochrane CENTRAL and Web of Science Core Collection databases with the following search terms: (“inflammation” OR “cytokines”) AND “out-of-hospital cardiac arrest.” Each inflammatory marker found was combined with “out-of-hospital cardiac arrest” using “AND” to find further relevant studies. We included original studies measuring inflammatory markers in adult OHCA patients that assessed their prognostic capabilities for mortality, neurological outcome, or organ failure severity.

Results

Fifty-nine studies met the inclusion criteria, covering in total 65 different markers. Interleukin-6 (IL-6), procalcitonin (PCT) and C-reactive protein (CRP) were the most studied markers, and they were associated with poor outcomes in 13/15, 13/14 and 11/17 studies, respectively. Based on area under the receiver operating characteristic curve (AUC) value, the time point of best discriminatory capacity for poor outcome was ICU admission for IL-6 (median AUC 0.78, range 0.71–0.98) and day one after OHCA for PCT (median AUC 0.84, range 0.61–0.98). Seven studies reported AUCs for CRP (range 0.52–0.76) with no measurement time point being superior to others. The association of IL-6 and PCT with outcome appeared stronger in studies with more severely ill patients. Studies reported conflicting results regarding each marker's association with organ failure severity.

Conclusion

Inflammatory markers are potentially useful for early risk stratification after OHCA. PCT and IL-6 have moderate prognostic value during the first 24 h of the ICU stay. Predictive accuracy appears to be associated with the study overall event rate.     

Use of the radial artery graft after transradial catheterization: is it suitable as a bypass conduit?

BACKGROUND: The suitability of the radial artery after transradial catheterization as a bypass conduit has been of great concern to surgeons. METHODS: A total of 67 patients underwent isolated coronary artery bypass grafting using the radial artery: 22 patients received preoperative transradial catheterization (group 1) and 45 patients did not receive transradial catheterization (group 2). Those patients were retrospectively reviewed. RESULTS: Patient characteristics, operative procedures, and early clinical outcome were not different between groups. The stenosis-free graft patency rates in groups 1 and 2 were 88% (16 of 18 patients) and 90% (38 of 42 patients) in the left internal thoracic artery (p = 0.87); 77% (17 of 22 patients) and 98% (48 of 49 patients) in the radial artery (p = 0.017); and 87% (13 of 15 patients) and 84% (21 of 25 patients) in the saphenous vein (p = 0.42), respectively. Intimal hyperplasia of the radial artery was observed in 68% (11 of 16 patients) in group 1 and in 39% (14 of 34 patients) in group 2 (p = 0.046). CONCLUSIONS: Transradial catheterization reduced early graft patency and caused intimal hyperplasia, although it did not affect early clinical outcomes. We suggest that the use of the radial artery as a bypass conduit after transradial catheterization should be undertaken cautiously.