Is “Intra–operating Room” Thromboelastometry Useful in Liver Transplantation? A Case-Control Study in 303 Patients

Coagulation monitoring during liver transplantation (LT) is, even today, fundamental to reduce blood loss during surgery. Thromboelastometry (TEM) is a proven technique for controlling the various parameters that influence coagulation. However, there are no studies linking “intra–operating room” TEM (orTEM) with LT outcomes. We describe a case-control study in 303 liver graft recipients analyzing variables associated with operative complications and long-term LT outcomes. The results showed that orTEM reduced the use of blood products in patients with Model for End-Stage Liver Disease scores of ≥21, retransplantation, and high surgical difficulty and important intraoperative bleeding. In addition, results in survival and postoperative complications were better when orTEM was used. In conclusion, we confirm that use of orTEM is associated with less use of blood products and a lower rate of complications after LT.     

Control de la hemostasia durante la nefrectomía parcial laparoscópica sin renorrafia parenquimatosa: la experiencia Vivostat®

ObjectiveTo present our experience using an autologous fibrin sealant prepared with the Vivostat system^® to control haemostasis without any renal parenchymal reconstruction.Material and methodsWe performed 45 laparoscopic partial nephrectomies using this haemostatic agent. The surgical steps were: colon mobilization, identification of ureter, renal vessels and renal tumor, renal artery control with Rummel tourniquet, tumor excision with harmonic scalpel, application of fibrin glue to the resection bed twice (before and after kidney reperfusion). Patients were evaluated for acute or delayed bleeding.ResultsMean age was 63.9 years (33-80); mean tumor size was 2.5 cm (1.5-4); mean operative time was 136.1 min (90-180). Mean warm ischemia time was 19.2 min (10-30). Mean blood loss was 97 ml (50-300). Individual haemostatic stitches were performed before application of the sealant if acute bleeding was observed (14 cases). We did not achieve any case of postoperative bleeding from resection bed or renal failure. 1 patient required transfusion due to an abdominal wall haematoma. 65% were clear cell carcinoma, 10% were papillary carcinoma, 20% were oncocitoma. Free margin rate was 100%. Mean hospital stay was 4 days (2-6). Mean follow-up was 14 months (5-45).ConclusionsExcluding renorrhaphy during laparoscopic partial nephrectomy is feasible and safe. Our initial experience with the vivostat system in laparoscopic partial nephrectomy has been encouraging, but longer follow-up is needed to determine the real benefit of this surgical technique in laparoscopic partial nephrectomy     

Brachial-ankle pulse wave velocity and systolic time intervals in risk stratification for progression of renal function decline

BackgroundCardiovascular dysfunction was associated with progression of renal function decline. This study was to assess whether combination of brachial-ankle pulse wave velocity (baPWV) and the ratio of brachial pre-ejection period (bPEP) to brachial ejection time (bET) was independently associated with progression of renal function decline.MethodsWe included 363 patients and classified them into four groups according to median values of bPEP/bET and baPWV. Groups 1, 2, 3, and 4 were patients with bPEP/bET and baPWV below the median, bPEP/bET above but baPWV below the median, bPET/bET below but baPWV above the median, and bPET/bET and baPWV above the median, respectively. The decline in renal function was assessed by the estimated glomerular filtration rate (eGFR) slope and the renal end points were defined as commencement of dialysis or ≥25% decline in eGFR. The relative risk of renal end points was analyzed by Cox regression method.ResultsThe eGFR slope was significantly associated with baPWV, bPEP/bET, and patients in groups 2, 3, and 4 (vs. group 1) (P < 0.006). Multivariate forward Cox regression analysis showed that high baPWV, high bPEP/bET, and patients in groups 2, 3, and 4 (vs. group 1) (P ≤ 0.047) were independent predictors of renal end points.ConclusionsOur results demonstrated higher baPWV and bPEP/bET were associated with faster renal function decline and adverse renal end points. Dividing patients into four groups using these two parameters might be useful in risk stratification for progression of renal function decline.American Journal of Hypertension 2012; doi:10.1038/ajh.2012.77.     

Low incidence of thromboembolism in relapsed/refractory myeloma patients treated with thalidomide without thromboprophylaxis in Taiwan

Thromboembolism (TE) is a common complication in patients with multiple myeloma (MM). Immunomodulatory agents, e.g., thalidomide, have expanded the therapeutic options for treating myeloma; however, Western countries report a high incidence of thrombosis in thalidomide-treated MM patients who lack thromboprophylaxis. A Korean trial reported low TE incidence in thalidomide-treated myeloma patients (39?% were given aspirin prophylactically). We aimed to elucidate the TE frequency in MM patients in Taiwan who were treated with thalidomide without TE prophylaxis. We retrospectively collected the records of MM patients who had used thalidomide from a single institute between 2004 and 2010, combined these records with two other Taiwanese studies, and compared all three with the Korean trial. In the current Taiwanese series, five of 144 patients (3.5?%) developed TE as follows: three (2.1?%) were venous and two (1.3?%) were arterial. Only 6.1?% of the patients had undergone TE prophylaxis, which is less than in the Korean trial (38.9?%, p?<?0.05). Of the patients in the relapsed/refractory cohort (n?=?114) who were given thalidomide alone, none (0/52) developed venous TE (VTE); however, two patients (2/35, 5.7?%) who were given thalidomide–dexamethasone as a salvage treatment developed VTE. In the thrombosis cohort, four patients (80?%) were treated with thalidomide plus dexamethasone. In conclusion, the frequency of thalidomide-related TE in myeloma patients without effective TE prophylaxis was low in Taiwan. In relapsed/refractory myeloma patients, the VTE frequency was slightly lower compared with Western patients irrespective of treatment with thalidomide alone or combined with dexamethasone. Even in low TE incidence areas, thalidomide combined with dexamethasone was more thrombogenic compared with others.     

不同低氧方式对大鼠血清和组织局部肾素血管紧张素系统的影响

目的 研究慢性间歇低氧(CIH)与持续低氧(CH)对大鼠血清及组织器官局部的肾素血管紧张素(RAS)系统的影响,以探讨CIH相关性高血压及低氧性肺动脉高压的发生机制.方法 18只SD雄性大鼠按随机数字表法分为CIH组、CH组和对照组共3组,每组6只.CIH组大鼠循环给予氮气和压缩空气(每循环180 s,舱内最低氧浓度达6％～8％,维持20～25 s,然后恢复至21％,7 h/d),CH组持续给予氮气(舱内氧浓度保持8％～12％,7 h/d),对照组大鼠常规饲养.结果 第6周时CIH大鼠收缩压(SBP)显著高于CH组、对照组(P＜0.05)和实验前水平(P＜0.01).CIH分别与CH和对照组比较:肾小动脉和肺小动脉中ACE及ACE2水平差异有统计学意义(P＜0.05);血清和肾组织中AngⅡ显著增高(P＜0.05),Ang-(1-7)则明显降低(P＜0.05).CH组肺组织AngⅡ较CIH及对照组增高(P＜0.05),Ang-(1-7)降低(P ＜0.05);SBP与血清及肾AngⅡ水平呈正相关;与Ans-( 1-7)水平呈负相关.CIH组肾小动脉及CH组肺小动脉管壁厚度、壁厚度占外径或内径的百分比(WT％)及管壁面积占血管壁总面积的百分比(WA％)分别与其他两组比较均有明显差异(P＜0.05).肺及肾的小动脉管壁厚度与其相应组织局部的AngⅡ呈正相关(r=0.386、0.414,均P＜0.05),与Ang-( 1-7)呈负相关(r=-0.401,-0.394,均P＜0.05).结论 CIH与CH两种低氧方式对大鼠血清及各组织局部的RAS系统影响程度及结果存在差异性,CIH主要影响大鼠肾组织及肾小动脉及体循环RAS系统,与血压增高密切相关;CH主要影响肺组织及肺小动脉RAS系统,可能与肺动脉重塑及肺动脉高压有关.     

间歇性完全性左束支阻滞13例分析

目的分析间歇性完全左束支阻滞(CLBBB)病例的临床特点。方法回顾分析13例12导联动态心电图检出间歇性完全左束支阻滞患者的病因、动态心电图、超声心动图、冠状动脉造影结果。结果 60岁以上患者12例,占92%。病因以冠心病、高血压、扩张型心肌病多见。本组冠脉造影及冠状动脉螺旋CT血管成像的7例间歇性完全性左束支阻滞患者中确诊为冠心病者3例。超声心动图结果:53.8%患者心房增大或心房心室同时增大。动态心电图检查可见间歇完全左束支阻滞常合并各种类型心律失常。结论间歇完全性左束支阻滞常发生在老年患者,常见于器质性心脏病,尤其是冠心病、高血压、扩张型心肌病。