Assessment of Left Ventricular Systolic Synchronization in Patients with Chronic Kidney Disease and Narrow QRS Complexes

Objective: The evidence of structural and functional cardiac abnormalities has been demonstrated by echocardiography in patients with chronic kidney disease (CKD). This study investigated whether left ventricular (LV) asynchrony is present in patients with CKD and normal QRS duration. Methods: Tissue synchronization imaging (TSI) was performed in 25 (56 ± 14 years) patients with CKD and narrow QRS complexes and 25 (51 ± 12 years) control subjects. LV asynchrony was identified on TSI images and the time to regional peak systolic velocity (Ts) in LV was measured by the six-basal–six-midsegmental model. Four TSI parameters of systolic asynchrony were computed when Ts was measured in ejection phase. Results: The standard deviation of Ts of 12 LV segments (33.6 ± 17.8 vs 16.7 ± 10 ms, P = 0.0001), standard deviation of Ts of the six basal LV segments (30 ± 20 vs 17.6 ± 9.6 ms, P = 0.008), maximal difference in Ts between any two of the 12 LV segments (102 ± 45 vs 54 ± 32 ms, P = 0.0001), and maximal difference in Ts between any two of the six basal LV segments (78 ± 50 vs 46 ± 22 ms, P = 0.007) were prolonged in patients with CKD compared with controls. The prevalence of LV systolic asynchrony was significantly higher in patients with CKD compared with controls (44% vs 12%, P = 0.01). The standard deviation of Ts of 12 LV segments were significantly associated with LV diameters, LV volumes, LV mass, blood pressure levels, and renal functions in univariate analysis. Conclusion: The results of this study indicate that LV systolic asynchrony may develop in patients with CKD.     

Rheological properties of blood in patients with chronic liver disease

We analyzed rheologic parameters, including erythrocyte rigidity (ER), whole blood and plasma viscosity, erythrocyte and platelet count, hemoglobin, hematocrit, mean corpuscular volume (MCV), fibrinogen, erythrocyte sedimentation rate (ESR), cholesterol, triglyceride, high-density lipoprotein (HDL), low-density lipoprotein (LDL), very-low density lipoprotein (VLDL), and gamma globulin levels in 18 patients with chronic liver disease and 20 healthy volunteers. Fifteen patients had cryptogenic cirrhosis while 3 had chronic active hepatitis. ER and MCV was significantly higher in the patient group than the control group while whole blood and plasma viscosities were significantly lower. There were significant correlations between ER and blood and plasma viscosity, ER and MCV, plasma and blood viscosity, HDL and plasma viscosity and a negative correlation between ER and ESR. Our results demonstrate that erythrocytes become more rigid in chronic liver disease. We suggest that erythrocytes with increased rigidity can impair hepatic microvascular circulation and thus contribute to liver dysfunction.     

Medical management of porto-pulmonary hypertension and right heart failure prior to living-related liver transplantation

Porto-pulmonary hypertension and right heart failure are relatively prevalent complications of end-stage liver disease and may increase mortality of patients undergoing cadaveric orthotopic liver transplantation. Even with extensive pre-transplant evaluation, these complications are frequently diagnosed unexpectedly in the operating room and transplant procedure may need to be aborted due to high perioperative mortality from both right and left ventricular failure. Living-related liver transplantation is a new surgical alternative to cadaveric liver transplantation, but presence of porto-pulmonary hypertension increases its postoperative mortality as well. Due to inherent elective nature, however, living-related liver transplantation may allow for preoperative hemodynamic optimization and treatment of right ventricular failure. To the authors' knowledge, this is the first reported case of an adult patient with porto-pulmonary hypertension who underwent successful living-related liver transplantation. Favorable transplantation outcome was obtained in this case through good hemodynamic control with long-term IV epoprostenol therapy, preoperative right heart calcification, and perioperative administration of pulmonary vasodilators and inotropic agents.     

Recent advances in pediatric liver transplantation

Pediatric liver transplantation has matured into a wellestablished, highly successful treatment for advanced pediatric liver disease. Recent 1-year success rates range from 85% to 95%. This unprecedented achievement is the result of careful selection criteria and optimal timing of transplantation, technical advances in surgical technique, and improved treatment following transplant. This report highlights many recent published findings representing advances that have led to current successful approaches.     

A prospective, comparative study of the immune response to inactivated influenza vaccine in pediatric liver transplant recipients and their healthy siblings.

BACKGROUND: Annual influenza vaccination is routinely recommended for pediatric solid organ transplant recipients. However, there are limited data defining the immune response to the inactivated vaccine in this population. METHODS: This prospective study compared the humoral and cell-mediated immune responses to the trivalent subvirion influenza vaccine in pediatric liver transplant recipients with those in their healthy siblings. All subjects received inactivated influenza vaccine. Hemagglutination inhibition and interferon-gamma (IFN-gamma) enzyme-linked immunosorbent spot assays for New Caledonia and Shanghai strains were performed at baseline, after each vaccine dose, and 3 months after the series. Seroconversion was defined as a 4-fold increase in antibody titers; seroprotection was defined as an antibody titer > or =1:40. An increase in the number of T cells secreting IFN-gamma was considered to be a positive enzyme-linked immunosorbent spot response. RESULTS: After 1 dose of vaccine, transplant recipients achieved rates of antibody seroprotection and seroconversion that were similar to those achieved by their healthy siblings. However, for both influenza strains, IFN-gamma responses by enzyme-linked immunosorbent spot were significantly attenuated in transplant recipients after 2 doses of vaccine. No cases of influenza or vaccine-related serious adverse events were documented in the study. CONCLUSIONS: The diminished cell-mediated immune response to influenza vaccination that was observed in pediatric liver transplant recipients suggests that the current vaccine strategy may not provide optimal protection. Because of concerns regarding potential emergence of more virulent influenza strains, further studies are warranted to determine if IFN-gamma responses are predictive of efficacy and to identify the optimal vaccination strategy to protect populations with a high risk of infection.     

Postconditioning attenuates acute intestinal ischemia–reperfusion injury

The aim of this study was to test the hypothesis that postconditioning (POC) would reduce the detrimental effects of the acute intestinal ischemia–reperfusion (I/R) compared to those of the abrupt onset of reperfusion. POC has a protective effect on intestinal I/R injury by inhibiting events in the early minutes of reperfusion in rats. Twenty-four Wistar–Albino rats were subjected to the occlusion of superior mesenteric artery for 30 minutes, then reperfused for 120 minutes, and randomized to the four different modalities of POC: (1) control (no intervention); (2) POC-3 (three cycles of 10 seconds of reperfusion–reocclusion, 1 minute total intervention); (3) POC-6 (six cycles of 10 seconds of reperfusion–reocclusion, 2 minutes total intervention); and (4) sham operation (laparotomy only). The arterial blood samples [0.3 mL total creatine kinase (CK) and 0.6 mL malondialdehyde (MDA)] and the intestinal mucosal MDA were collected from each after reperfusion. POC, especially POC-6, was effective in attenuating postischemic pathology by decreasing the intestinal tissue MDA levels, serum total CK activity, inflammation, and total histopathological injury scores. POC exerted a protective effect on the intestinal mucosa by reducing the mesenteric oxidant generation, lipid peroxidation, and neutrophil accumulation. The six-cycle algorithm demonstrated the best protection.     

Loss of speech after orthotopic liver transplantation

Alteration of speech is a rare but distressing complication of orthotopic liver transplantation (OLT). We describe a characteristic speech disorder identified in a large series of consecutive patients undergoing OLT. Between 1988 and 1993, 525 adults underwent OLT. For all recipients with neurologic complications, we reviewed clinical findings, imaging and electrophysiologic test results, and perioperative laboratory data. Five patients (ages 23–52; UNOS status 3–4) exhibited a characteristic pattern of stuttering dysarthria, leading to complete loss of speech production, occasionally with elements of aphasia. In four of the five patients, right-sided focal seizures were subsequently noted. All cases presented within the first 10 postoperative days and improved within 1 month of cessation of cyclosporin (CyA), although halting, monotonous speech was evident to some degree in all five for up to 1 year. There was no correlation between onset of symptoms and CyA levels. None of the patients had clinical or radiologic findings suggestive of central pontine myelinolysis or akinetic mutism. EEGs and Spect scan results were consistent with dysfunction in the left frontotemporoparietal regions of the brain. A characteristic speech disorder, which may be described as cortical dysarthria or speech apraxia, occurs in approximately 1% of adults undergoing OLT. Prompt recognition of this syndrome and temporary cessation of CyA therapy may favorably affect the course.     

Impact of donor age on survival and fibrosis progression in patients with hepatitis C undergoing liver transplantation using HCV+ allografts.

Studies have suggested that the use of hepatitis C virus (HCV)-positive (HCV+) donor allografts has no impact on survival. However, no studies have examined the effect that HCV+ donor histology has upon recipient and graft survival. We evaluated the clinical outcome and impact of histological features in HCV patients transplanted using HCV+ livers. We reviewed all patients transplanted for HCV at our institution from 1988 to 2004; 39 received HCV+ allografts and 580 received HCV-negative (HCV-) allografts. Survival curves compared graft and patient survival. Each HCV+ allograft was stringently matched to a control of HCV- graft recipients. No significant difference in survival was noted between recipients of HCV+ livers and controls. Patients receiving HCV+ allografts from older donors (age > or =50 yr) had higher rates of graft failure (hazard ratio, 2.74) and death rates (hazard ratio, 2.63) compared to HCV- allograft recipients receiving similarly-aged older donor livers. Matched case-control analysis revealed that recipients of HCV+ allografts had more severe fibrosis post-liver transplantation than recipients of HCV- livers (P = 0.008). More advanced fibrosis was observed in HCV+ grafts from older donors compared to HCV+ grafts from younger donors (P = 0.012). In conclusion, recipients of HCV+ grafts from older donors have higher rates of death and graft failure, and develop more extensive fibrosis than HCV- graft recipients from older donors. Recipients of HCV+ grafts, regardless of donor age, develop more advanced liver fibrosis than recipients of HCV- grafts.     

Erythrocytosis in a patient on hemodialysis for thirteen years

Most hemodialysis patients exhibit renal anemia mainly due to erythropoietin deficiency as a result of impaired erythropoetin production in the kidney. However, erythrocytosis in patients with renal failure requiring hemodialysis is extremely rare. We report the development of erythrocytosis in a patient with a polycystic kidney disease on hemodialysis for 13 years. She had erythrocytosis with increased serum erythropoietin levels despite severe secondary hyperparathyroidism, which is known to depress erythrocytosis. Since neither renal disease (renal cell carcinoma) nor extrarenal diseases (hypoxia, hepatoma, cerebellar diseases) linked with erythropoietin production could be proven, this case might be one with inappropriate idiopathic erythropoietin production after 13 years of hemodialysis, the longest duration of dialysis in the literature before erythrocytosis was observed.