Improving graft survival for patients undergoing liver transplantation

Dickson RC, Pungpapong S, Keaveny AP, Taner BC, Ghabril M, Aranda‐Michel J, Satyanarayana R, Bonatti H, Kramer DJ, Nguyen JH. Improving graft survival for patients undergoing liver transplantation.
Clin Transplant 2011: 25: E345–E355. © 2011 John Wiley & Sons A/S. Abstract: Liver transplant (LT) outcomes are reported to be improving in non‐HCV recipients but not for those infected with HCV. Our aim was to evaluate graft survival and predictors of outcome in HCV and non‐HCV patients before and after 2003. Patients with primary LT between February 1, 1998, and December 31, 2005, were included. Patients were divided into Era 1 (1998–2002) and Era 2 (2003–2005) with follow‐up through May 31, 2009. Graft survival was compared for HCV, non‐HCV, and all patients. There was significant improvement in graft survival in Era 2 for HCV patients. Graft survival in Era 2 of HCV patients was equivalent to non‐HCV patients. The most significant improvement between eras was in outcomes of grafts from donors ≥60 yr with three‐yr graft survival 58.6 (51.3–65.9) vs. 75.4 (68.9–81.9), p = 0.002. The use of donors ≥60 did not change between eras: 31% vs. 34%; however, utilization in HCV recipients decreased from 36% to 3% (p < 0.001). In conclusion, graft survival of HCV patients has improved significantly since 2003 and was comparable to non‐HCV patients up to three yr. The change in management of donor organs into HCV and non‐HCV patients likely contributed to this outcome.     

Does a longer delay in fixation of talus fractures cause osteonecrosis?

This retrospective study investigated active duty soldiers with delayed definitive fixation of combat-related talus fractures. The authors predicted a longer delay to internal fixation and a correlation between the timing of fixation and development of osteonecrosis and posttraumatic arthritis. The Joint Theater Trauma Registry was queried by ICD-9 codes for talus fractures. Soldiers, ages 18 to 40, with talus fracture between 2001 and 2008 were included. Radiographs identified the injury type, Hawkins sign, osteonecrosis, and posttraumatic arthritis. Mean time to fixation was 12.9 days. Hawkins sign was observed in 59% of fractures at a mean of 7 weeks. No correlation was found between osteonecrosis or posttraumatic arthritis and open fractures, comminuted fractures, or timing of fixation. Average follow-up was 16 months. This case series has the longest mean time to fixation by more than threefold. There was no correlation of delayed timing of fixation and development of osteonecrosis or posttraumatic arthritis.     

Barriers to achieving optimal glycemic control in a multi-ethnic society: a US focus

The increasing prevalence of diabetes is particularly apparent in certain ethnic groups, such as African and Hispanic Americans. These groups generally also have poorer glycemic control and outcomes. To better understand the issues surrounding these problems and possible methods to overcome them we performed a literature review from the past 15 years on barriers to glycemic control with a focus on US data. The literature reveals that barriers may be inherent (eg, genetic, cultural, and language/communication) or acquired (eg, those associated with changes in lifestyle and socioeconomic factors). Healthcare interventions that take into consideration cultural and population-specific characteristics can reduce the prevalence and severity of diabetes and its resulting complications. Implementing such strategies will require suitable education for patients and providers, the availability of culturally-sensitive, patient-centered healthcare teams, the creation of collaborative relationships between providers and patients, better use of community resources, and assistance for patients to make informed decisions about available treatment options. There is also evidence suggesting that at the same level of glucose control Hispanics and African Americans have the same degree of complications as whites; therefore, good control is essential for the future well-being of all patients. Addressing these issues may help to decrease the ethnic disparities that currently exist in diabetes care.     

A 57 year old man with chronic renal failure and cardiac tamponade who developed ischemic hepatitis

Ischemic hepatitis is an infrequent entity, usually associated with low cardiac out put. We present a case of a 57 year-old man with chronic renal failure and cardiac tamponade who developed elevation of serum alanine transferase level of 5,054 U/L, aspartate transferase level of 8,747 U/L and lactate dehydrogenasa level of 15,220 U/L. The patient developed hepatic encephalopathy and hypoglycemia. Liver Doppler ultrasound was normal. He was seronegative for HBV and HCV, drugs list was scrutinized for the names of known hepatotoxins. Ischemic hepatitis was diagnosed. The hypoglycemia and encephalopathy were solved and the patient was discharged with normal transaminase levels. Ischemic hepatitis is typically preceded by hypotension, hypoxemia, or both. As one would expect, the most common cause of sustained systemic hypotension is cardiovascular disease. Liver biopsy is usually not necessary. The best treatment is support measures and correct the underlying condition.     

Hemodynamic effects of levosimendan compared with dobutamine in patients with low cardiac output after cardiac surgery

INTRODUCTION AND OBJECTIVES: Levosimendan is an inotropic agent that is effective in the treatment of heart failure. However, experience with levosimendan in patients with reduced cardiac output following cardiopulmonary bypass is limited. The objective of this study was to compare the short-term hemodynamic effects of levosimendan with those of dobutamine in managing low cardiac output after cardiac surgery. METHODS: Forty-one patients who had low cardiac output after cardiopulmonary bypass were randomly assigned to dobutamine (n=20), 24-hour infusion of 7.5 microg/kg per min, or levosimendan (n=21), at a loading dose of 12 microg/kg followed by 24-hour infusion of 0.2 microg/kg per min. The following parameters were determined during a 48-hour observation period: arterial, central venous, pulmonary arterial and pulmonary capillary wedge pressure, cardiac index, heart rate, stroke volume, and systemic and pulmonary vascular resistance. RESULTS: Although both dobutamine and levosimendan improved the cardiac index, the increase was significantly greater with levosimendan (2.4 [0.2] l/min per m2 vs 2.9 [0.3] l/min per m2, respectively, at 24 h; P<.05). Moreover, levosimendan significantly reduced systemic and pulmonary vascular resistance, and significantly decreased systemic arterial, pulmonary arterial, pulmonary capillary wedge, and central venous pressure. CONCLUSIONS: Both dobutamine and levosimendan are effective in managing postoperative low cardiac output. However, levosimendan induces non-specific systemic, venous and pulmonary vasodilation which can result in hypotension as a adverse event. In these patients, it is advisable to omit or reduce the loading dose.     

Improvement of survival in infants with congenital diaphragmatic hernia in recent years: effect of ECMO availability and associated factors

Background/Purpose

Survival of patients with congenital diaphragmatic hernia (CDH) depends both on non-modifiable congenital conditions and on modifiable pre and postnatal management. ECMO improves survival up to 80% in neonates with CDH in the best ECMO centers worldwide. The first Neonatal ECMO Program in Chile was started in our University in 2003. Our objective is to determine the impact of a Neonatal ECMO Program in a level III NICU on newborns with CDH.

Methods

Data of all newborns with CDH admitted to our NICU was separated into two groups: pre ECMO (1996–2003) and ECMO (2003–2007). Crude and adjusted odds ratios for 24 months survival were estimated by logistic regression.

Results

Data of 46 newborns with CDH was analysed, 20 in the pre ECMO and 26 in the ECMO period. Patient characteristics were similar in both groups; however, 24-month survival increased significantly from 25% (5/20) in the pre ECMO period to 77% (20/26) in the ECMO period (P = 0.001). Adjusted odds ratios for 24-month survival were 26.98 for OI ≤ 40, 7.58 for 5 min Apgar ≥ 7 and 17.5 for ECMO availability.

Conclusions

The establishment of an ECMO program was associated with a significant increase in long-term survival for infants with CDH.     

The inflammatory bases of hepatic encephalopathy

A hypothesis about the inflammatory etiopathogeny mediated by astroglia of hepatic encephalopathy is being proposed. Three evolutive phases are considered in chronic hepatic encephalopathy: an immediate or nervous phase with ischemia-reperfusion, which is associated with reperfusion injury, edema and oxidative stress; an intermediate or immune phase with microglia hyperactivity, which produces cytotoxic cytokines and chemokines and is involved in enzyme hyperproduction and phagocytosis; and a late or endocrine phase, in which neuroglial remodeling, with an alteration of angiogenesis and neurogenesis, stands out. The increasingly complex trophic meaning that the metabolic alterations have in the successive phases making up this chronic inflammation could explain the metabolic regression produced in acute and acute-on-chronic hepatic encephalopathy. In these two types of hepatic encephalopathy, characterized by edema, neuronal nutrition by diffusion would guarantee an appropriate support of substrates, in accordance with the reduced metabolic needs of the cerebral tissue.