Chloride-liberal fluids are associated with acute kidney injury after liver transplantation

Introduction

Acute kidney injury (AKI) occurs frequently after liver transplantation and is associated with significant morbidity and mortality. Recent evidence has linked the predominant usage of ‘chloride-liberal’ intravenous fluids, such as 0.9% saline to the development of renal dysfunction in general critically ill patients. We compared the effects of perioperative fluid types on AKI in liver transplant recipients.

Methods

An observational analysis of liver transplant recipients over a 33-month period, between January 2010 and September 2013, was performed. Intensive care unit database and patient records were analyzed for determinants of early postoperative AKI. Univariate and multivariate regression analysis was carried out using a two-tailed P value less than 0.05 to establish significance. The institutional Research Ethics Committee approved the study methodology (RAC no. 2131 073).

Results

One hundred and fifty-eight liver transplants were performed, AKI developed in 57 (36.1%) patients: 39 (68.4%) fully recovered, 13 (22.8%) developed chronic renal failure and 10 (17.5%) required long-term hemodialysis. On univariate regression analysis, AKI was significantly associated with greater than 3,200 ml of chloride-liberal fluids infused within the first postoperative day (HR 5.9, 95% CI 2.64, 13.2, P <0.001), greater than 1,500 ml colloids received in the operating room (hazard ratio (HR) 1.97, 95% CI 1.01, 3.8, P = 0.046), vasopressor requirement for 48 hours posttransplant (HR 3.34, 95% CI 1.55, 7.21, P = 0.002), hyperchloremia at day 2 (HR 1.09, 95% CI 1.01, 1.18, P = 0.015) and preoperative model for end-stage liver disease (MELD) score (HR 1.08, 95% CI 1.03, 1.13, P <0.001).After stepwise multivariate regression, infusion of greater than 3,200 ml of chloride-liberal fluids (HR 6.25, 95% CI 2.69, 14.5, P <0.000) and preoperative MELD score (HR 1.08, 95% CI 1.02, 1.15, P = 0.004) remained significant predictors for AKI.

Conclusions

In a sample of liver transplant recipients, infusion of higher volumes of chloride-liberal fluids and preoperative status was associated with an increased risk for postoperative AKI.     

Novel variants in the stem cell niche factor WNT2B define the disease phenotype as a congenital enteropathy with ocular dysgenesis

WNT2B is a member of the Wnt family, a group of signal transduction proteins involved in embryologic development and stem cell renewal and maintenance. We recently reported homozygous nonsense variants in WNT2B in three individuals with severe, neonatal-onset diarrhea, and intestinal failure. Here we present a fourth case, from a separate family, with neonatal diarrhea associated with novel compound heterozygous WNT2B variants. One of the two variants was a frameshift variant (c.423del [p.Phe141fs]), while the other was a missense change (c.722 G > A [p.G241D]) that we predict through homology modeling to be deleterious, disrupting post-translational acylation. This patient presented as a neonate with severe diet-induced (osmotic) diarrhea and growth failure resulting in dependence on parenteral nutrition. Her gastrointestinal histology revealed abnormal cellular architecture particularly in the stomach and colon, including oxyntic atrophy, abnormal distribution of enteroendocrine cells, and a paucity of colonic crypt glands. In addition to her gastrointestinal findings, she had bilateral corneal clouding and atypical genital development later identified as a testicular 46,XX difference/disorder of sexual development. Upon review of the previously reported cases, two others also had anterior segment ocular anomalies though none had atypical genital development. This growing case series suggests that variants in WNT2B are associated with an oculo-intestinal (and possibly gonadal) syndrome, due to the protein’s putative involvement in multiple developmental and stem cell maintenance pathways.Subject terms: Disease genetics, Diarrhoea     

Eating habits are associated with subjective sleep quality outcomes among university students: findings of a cross-sectional study

Sleep and Breathing - This study investigated the relationships between eating habits and sleep quality among university students. In a cross-sectional study, university students completed a...     

Surface treatment: a potential approach for enhancement of solid-state photostability

The potentials of a simple surface treatment technique aiming at modifying solid-state properties with emphasis on photostability were investigated using methyldopa (MD), a photosensitive drug substance. MD was treated with a preselected solvent by stirring a drug suspension in the solvent in a predetermined solid/solvent ratio under controlled conditions. At the end of the solvent treatment period, MD powder was separated, dried and screened. Changes in the solid-state properties of surface-treated MD were monitored using flowability measurements, scanning electron microscopy, thermal analysis and dissolution rate. Further, photostability testing, according to the ICH guidelines, was conducted using compressed disks of MD treated with solvents in the absence and presence of antioxidants, namely ascorbic acid, butylated hydroxytoluene (BHT) and cysteine HCl. The color change (DeltaE) was determined according to the CIELAB system. Surface treatment of MD drug substance with ethanol, methanol and isopropanol resulted in a marked improvement in flowability which was associated with morphological crystalline changes. Treatment of MD with methanol provided free flowing spherical agglomerates. Disks of solvent-treated MD showed improved photostability which was further potentiated by the inclusion of antioxidants, although only traces of the antioxidant were retained in the treated powder. Tablets containing MD surface treated with methanol containing a mixture of 2% ascorbic acid and 0.2% BHT were prepared by direct compression using a simple formula. The tablets conformed to official requirements.     

Cost-effectiveness analysis of core decompression

Core decompression is widely used to treat the early stages of osteonecrosis of the hip. The purpose of this analysis is to assist orthopedic surgeons in judging whether currently available data support the use of core decompression as cost-effective. A decision model was created for the treatment of osteonecrosis of the femoral head. Literature review was used to identify possible outcomes and their probability after initial treatment with either observation or core decompression. This model demonstrates core decompression must delay the need for total hip arthroplasty for a minimum of 5 years to maintain an incremental cost-effectiveness ratio lower than 50,000 dollars per quality-adjusted life year gained. Treatment options with ratios higher than 50,000 dollars per quality-adjusted life year are generally considered to have limited cost-effectiveness. This study demonstrates that core decompression has the potential to be a highly cost-effective alternative if it is leads to a delay in the need for total hip arthroplasty of 5 years or longer.     

An in-vitro study of microleakage around class V cavities bonded with a self-etching material versus a conventional two-bottle system.

OBJECTIVE: To evaluate the microleakage around class V restorations restored with either a self-etching adhesive system or a conventional two-bottle adhesive system used with "total etch" technique, and their recommended resin-based composites (RBC).METHODS: Two types of adhesive systems were used. A self-etching adhesive, Etch and Prime 3.0 (Degussa AG, Hanau, Germany), and a conventional two-bottle adhesive, Gluma Solid Bond (Heraeus Kulzer, Dormagen, Germany). The bonding systems were used in strict accordance with the manufacturers' instructions, except that, with the two-bottle adhesive system, the cavities were filled with either a "wet" or a "dry" bonding technique, subsequent to acid-etching with 20% phosphoric acid. Etch & Prime 3.0 was used in conjunction with Degufill Mineral (Degussa, Hanau, Germany) RBC and Gluma Solid Bond with Flow Line RBC (Heraeus Kulzer, Dormagen, Germany). Standardised bucco-cervical cavities were prepared on the buccal and lingual surfaces of 15 extracted maxillary first premolar teeth; all cavity margins were in enamel. Ten of the resulting cavities (Group A) were restored using Etch & Prime 3.0 and Degufill Mineral, ten (Group B) using Gluma Solid Bond (Wet Bond), and ten (Group C) using Gluma Solid Bond (Dry Bond). Leakage scores at occlusal and gingival margins were calculated after thermocycling 500 times between baths, held at 5 degrees C and 55 degrees C, respectively, with 30 seconds dwell time in both. Data were analysed by the Fisher Exact Test.RESULTS: There was no statistically significant difference between the self-etching adhesive and conventional two-bottle adhesive systems at either the occlusal or the gingival margins. With the self-etching adhesive, there was no statistically significant difference in leakage scores between occlusal and gingival margins. There was a statistically significant difference between the occlusal and the gingival margins when a "wet" or "dry" bonding technique was used with the conventional two-bottle adhesive system.CONCLUSIONS: The results suggest that the application of a conventional two-bottle bonding system used with a "total etch" technique is better than that of a self-etching adhesive system. With the former, the use of a "wet" bonding does not give better results than a "dry" bonding technique.     

Application of indocyanine green in surgery: A review of current evidence and implementation in trauma patients

Background: Modern surgical medicine strives to manage trauma while improving outcomes using functional imaging. Identification of viable tissues is crucial for the surgical management of polytrauma and burn patients presenting with soft tissue and hollow viscus injuries. Bowel anastomosis after trauma-related resection is associated with a high rate of leakage. The ability of the surgeon’s bare eye to determine bowel viability remains limited, and the need for a more standardized objective assessment has not yet been fulfilled. Hence, there is a need for more precise diagnostic tools to enhance surgical evaluation and visualization to aid early diagnosis and timely management to minimize trauma-associated complications. Indocyanine green (ICG) coupled with fluorescence angiography is a potential solution for this problem. ICG is a fluorescent dye that responds to near-infrared irradiation. Methods: We conducted a narrative review to address the utility of ICG in the surgical management of patients with trauma as well as elective surgery. Discussion: ICG has many applications in different medical fields and has recently become an important clinical indicator for surgical guidance. However, there is a paucity of information regarding the use of this technology to treat traumas. Recently, angiography with ICG has been introduced in clinical practice to visualize and quantify organ perfusion under several conditions, leading to fewer cases of anastomotic insufficiency. This has great potential to bridge this gap and enhance the clinical outcomes of surgery and patient safety. However, there is no consensus on the ideal dose, time, and manner of administration nor the indications that ICG provides a genuine advantage through greater safety in trauma surgical settings. Conclusions: There is a scarcity of publications describing the use of ICG in trauma patients as a potentially useful strategy to facilitate intraoperative decisions and to limit the extent of surgical resection. This review will improve our understanding of the utility of intraoperative ICG fluorescence in guiding and assisting trauma surgeons to deal with the intraoperative challenges and thus improve the patients’ operative care and safety in the field of trauma surgery.     

Guillain-Barré syndrome in immunocompromised patients: A report of three patients and review of the literature

Both humoral and cell-mediated autoimmune mechanisms have been implicated in the pathogenesis of Guillain-Barré syndrome (GBS). Therefore, its occurrence in severely immunocompromised patients is not expected. We identified 3 severely immunocompromised patients who developed GBS. Two of the 3 patients had acquired immunodeficiency syndrome with CD4 counts of 5 and 4 cells/mm³, respectively. One post-cardiac transplant patient was taking azathioprine and cyclosporine at the time of onset of GBS. In all 3 patients, immunocompromise was induced by infectious or chemotherapeutic agents which preferentially suppress T-lymphocyte responses. All 3 had severe lymphocytopenia and incomplete recovery. We conclude that GBS can occur in patients with severe t-cell suppression. Although no conclusion regarding prognosis can be drawn from our small group of patients, their incomplete recovery is consistent with the idea that T-cells are important for recovery. © 1997 John Wiley & Sons, Inc. Muscle Nerve 20: 1002–1007, 1997