[Prototheca Wickerhami peritonitis in patients on peritoneal dialysis]

Prototheca spp exits throughout nature but only infrequently cause infection in humans. Most of the cases of human infection have involved the skin or subcutaneous tissues, but there have been reports of rare cases of protothecosis of the urinary tract, and disseminated disease. The species most commonly isolated is Prototheca wickerhamii. Few cases of peritonitis due to P. wickerhamii in peritoneal dialysis had been reported. We report a successful treatment of Prototheca peritonitis complicating peritoneal dialysis with amphotericin, itraconazole and removal of the catheter.

Congenital aneurysm presenting as peripheral facial paresis

The incidence of intracranial aneurysms in infancy is relatively rare. They are infrequent in children less than 1 year old, and are an exception in the neonatal period. They usually originate in the internal carotid artery bifurcation, posterior circulation and seldom in the territory of the distal middle cerebral artery distribution. Infants often present with nonspecific symptoms: irritability, lethargy, vomiting, seizures and coma. Sometimes, they may present with unexpected clinical symptoms such as peripheral facial palsy. Subarachnoid hemorrhage is the most frequent presentation in this kind of aneurysms. Intracerebral hematoma is unusual. We present the case of a 10-week-old child harboring a middle cerebral artery aneurysm. To our knowledge, this is the first case of an aneurysm presenting as a peripheral facial paresis in a pediatric patient.

Occurrence of foodborne pathogenic bacteria in retail prepackaged portions of marine fish in Spain

AIMS

To survey the presence of indigenous and nonindigenous foodborne bacterial pathogens in displayed prepacked portions of fresh marine fish.

METHODS AND RESULTS

A survey of 50 different samples of fresh marine fish (conger, swordfish, sole, grouper and whiting) was conducted over a period of 5 months. Trays of fillets and steaks were obtained at retail level and tested for foodborne bacterial pathogens. Vibrio cholerae and Salmonella were not detected. Two samples (4%) yielded Vibrio strains carrying a DNA fragment specific for Vibrio parahaemolyticus, but resulted negative to PCR amplification of the virulence-related tdh gene. Levels of motile Aeromonas ranging from 2.29 to 7.20 log CFU g(-1) were found in 31 (62%) samples. All fish portions were positive for the Aeromonas hlyA gene and 38 for both aerA and hlyA genes, which may contribute to diarrhoea-related virulence. The incidence of Listeria monocytogenes was 10%. Levels of Staphylococcus aureus lower than 2 log CFU g(-1) were found in 15 (30%) samples. Numbers of presumptive Clostridium perfringens ranging from 1.82 +/- 0.22 to 4.26 +/- 1.25 log CFU g(-1) were detected in 42 (84%) samples. Edwardsiella tarda was detected in two samples of grouper fillets.

CONCLUSIONS

Displayed portions of raw fish carried bacteria that can cause foodborne disease. The risk posed by fresh fish when properly cooked is low, but high when destined to be consumed raw, undercooked or very lightly processed.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study revealed that raw fish sold in Spain could be a source of foodborne bacterial pathogens. Improvements in handling and processing are needed to minimize the prevalence of pathogenic bacteria.

Long-term results for liver transplantation from non-heart-beating donors maintained with chest and abdominal compression-decompression

INTRODUCTION

The aim of this study was to evaluate long-term results after liver transplantation from non-heart-beating donors (NHBD) using the method of chest and abdominal compression-decompression to maintain donors.

METHODS

From December 1995 to November 2004, 10 NHBD were identified and maintained by means of the method of chest and abdominal compression-decompression until family and judicial permission were granted. Nine donors were Maastricht type II and one was type IV.

RESULTS

The mean age of donors was 40.5 years and the mean time under cardiopulmonary resuscitation (CPR) was 80 minutes. Orthotopic liver transplantation (OLT) was performed using these 10 liver grafts after a mean cold ischemia time of 561.5 minutes. All patients developed good posttransplant function, except for one patient who presented with primary nonfunction corrected with retransplantation. This complication was directly related to a long CPR time (P < .01). After a mean follow-up of 57 months, only one patient died from a hepatitis C virus (HCV) recurrence. The rest of the patients have maintained good graft function over time.

CONCLUSIONS

NHBD maintained with the method of chest and abdominal compression-decompression are a valid choice to increase the donor pool. Liver transplantation using these grafts has proven good long-term results, comparable to their heart-beating counterparts.

Portal vein thrombosis in patients undergoing orthotopic liver transplantation: intraoperative endovascular radiological procedures

PURPOSE

To evaluate the usefulness of endovascular procedures for portal vein complications during orthotopic liver transplantation (OLT).

MATERIALS AND METHODS

Between May 1994 and November 2004, we performed 504 OLTs in 464 adults. Seventy-eight patients (16.8%) presented with portal vein thrombosis (PVT). This analysis of patients from May 2000 to September 2004 included 10 patients with PVT, who were treated with endovascular techniques due to low portal flow. We compared this group with patients who were treated surgically with attention to rethrombosis and survival rates. If portal vein problems were due to obstruction, a venoplasty and primary stent placement were performed. We also embolized with coils or surgically ligated remaining competitive portosystemic shunts.

RESULTS

Perfusion problems in the allograft were solved in all cases. We placed seven stents and embolized six competitive shunts. One anastomotic dysfunction was repaired. None of the patients died or rethrombosed during surgery or follow-up.

CONCLUSION

Endovascular techniques during OLT can resolve some liver graft perfusion problems due to PVT and "steal" phenomena, especially with unsatisfactory eversion thromboendovenectomy in patients with grade IV PVT. Although primary permeability of stents has been good, these results need to be confirmed.

Steroid-free immunosuppression for pancreas-after-liver transplantation

Simultaneous pancreas-kidney transplantation is presently a well-accepted procedure for patients with type 1 diabetes mellitus and renal failure. However, experiences with combined pancreas and liver transplantation are scarce, a few data are available about the best immunosuppression for these patients. We report our experience with two patients who received a pancreas after liver transplantation for long-standing insulin-dependent diabetes mellitus, with steroid-free immunosuppression based on daclizumab, tacrolimus, and mycophenolate mofetil. Short- and long-term evolution was uneventful. Currently, both patients are insulin free with appropriate metabolic control after 12 and 6 months follow-up. Considering our preliminary results, we suggest a steroid-free immunosuppressive regimen as an option for pancreas-after-liver transplantation.

[Cardiac troponin I determination in patients with chronic renal failure]

OBJECTIVE

The aim of the study was evaluate cardiac troponin I (cTnI) determination in patients with chronic renal failure (CRF) and compare with creatine kinase-MB isoenzyme (CK-MB and CK-MB/CK).

METHODS

We performed a retrospective study on patients with CRF with MDRD (modification of diet in renal disease study group) < 60 mL/min admitted with suspected myocardial injury by history, physical examination and electrocardiography. cTnI measurement was assessed at admission with the ACCESS analyzer (Beckman).

RESULTS

Acute myocardial injury (AMI) was diagnosed in 10% (47/467) patients with cTnI determination > 0.05 ng/mL, while the diagnostic was angina in 9% (41/467) and in 81% (379/467) we finded other diagnostics. In the AMI group, 49% had chest discomfort, 43% diabetes and the mortality was 45%, while in the angina group were 41%, 32% and 7%, respectively. The sensitivity for cTnI with cut-off value > 0.5 ng/mL was 70% and specificity 92%. The number of false positives was 31% (20 patients).

DISCUSSION

cTnI is the preferred biomarker for myocardial damage in patients with CRF. Other cut-off value could enhance the sensitivity for AMI.

Study on the Efficacy and Safety of Adefovir Dipivoxil Treatment in Post–Liver Transplant Patients With Hepatitis B Virus Infection and Lamivudine-Resistant Hepatitis B Virus

Hepatitis B virus (HBV) recurrence and de novo HBV infection are frequent events in liver transplantation recipients. Treatment with lamivudine is initially efficient in both infections but the incidence of lamivudine-resistant HBV emergence increases over time. Adefovir appears to be promising in post-liver transplantation patients with recurrent HBV infection and lamivudine-resistant HBV. This study analyzed adefovir treatment in 42 post-liver transplantation patients who developed recurrent HBV or de novo HBV infection with lamivudine-resistant HBV (54.8% HCV-coinfected). Patients received 10 mg of oral adefovir once daily for a mean period of time of 21.5 months (range from 12 to 31 months). In 62.9% of patients, ALT levels decreased significantly. Serum HBV-DNA was undetectable in 64% of the cases. Twenty percent of patients lost HBeAg marker and 13.3% of them developed anti-HBe. In 9.5% of recipients, HBsAg became negative. There was no significant change in serum creatinine levels. In only one patient was worsening of the renal function detected, making dose adjustment necessary. No other side effects were reported. Our results confirm the efficacy and safety of adefovir treatment in post-liver transplantation patients with lamivudine-resistant HBV, neither were adefovir-resistant mutations identified in patients after 21 months of therapy, nor were there adverse events, especially renal toxicity.

Impact of urban air pollutants and noise levels over daily hospital admissions in children in Madrid: a time series analysis

OBJECTIVE

The aim of this paper was to analyse the effects of the urban air pollutants and noise levels on daily emergency hospital admissions of children less than 10 years of age in Madrid.

MATERIAL AND METHODS

Poisson Regression Models were used to quantify the associations. Meteorological variables, influenza epidemics, pollen concentrations and trends and periodicities were used as controlling variables.

RESULTS

The main results obtained were the detected relationship (p<0.05) between emergency hospital admissions due to organic diseases and noise levels (AR=2.4%) and for PM(10) concentrations (AR=2.1%). For respiratory diseases statistically significant associations were detected for noise levels (AR=4.7%) and cold temperatures (AR=3.8%). The main association detected for causes of admissions due to bronchitis was for O(3) (AR=36.8%) and for pneumonia was for noise levels (AR=7.7%).

CONCLUSION

The results obtained suggest that noise level particularly is a risk factor for daily emergency hospital admissions for organic and respiratory diseases in children less than 10 years old in Madrid.

Efficacy of Hemobahn® in the Treatment of Superficial Femoral Artery Lesions in Patients with Acute or Critical Ischemia: A Comparative Study with Claudicants

PURPOSE

To assess the results of covered stents in the treatment of superficial femoral artery (SFA) occlusive disease.

METHOD

From July 2000 till June 2003, 32 patients (34 limbs) were scheduled for procedures including Hemobahn deployment in the SFA. Indication for treatment was claudication (group I, N=15 patients and 16 limbs, 31.2% occlusions) or critical and acute ischemia (group II, N=17 patients and 18 limbs, 61.1% occlusions). TASC D SFA lesions were excluded. No limb artery was patent pre-operatively in 19% and 89% of limbs in groups I and II, respectively (p=0.00001).

RESULTS

Outflow procedures were performed simultaneously in one limb in group I and 12 in group II (p=0.0003). The technical, hemodynamic and clinical success rates were 100, 100 and 94.1%, respectively. Mean follow-up was 18.1 months. Primary patency rates at 12 months were 81.3+/-10.6% in group I and 88.6+/-9.0% in group II (p=0.547). At 12 months, the secondary patency and limb salvage rates were, respectively, 87.5+/-8.9 and 100% in group I and 87.5+/-8.93 and 94.45+/-6.71% in group II.

CONCLUSION

Treatment of SFA occlusive lesions (excluding TASC D lesions) with the Hemobahn covered stent yielded good results for both claudicants with good outflow and patients with critical or acute ischemia with bad outflow, if concomitant outflow-improving procedures were performed.

Two-Hour Post-Dose Cyclosporine Levels in Renal Transplantation in Argentina: A Cost-Effective Strategy for Reducing Acute Rejection

Monitoring of cyclosporine (microemulsion CsA) at 2 hours post-dose (C2), a measure of absorption and exposure, appears superior to trough (C0) monitoring for prediction of rejection risk. The purpose of this study was to determine whether C2 was cost-effective compared to C0 in Argentina.

METHODS

A predictive decision model was adapted to Argentina to predict costs associated with C0 and C2 measurements in the first year after transplantation. Patients were treated with microemulsion CsA, steroids and azathioprine or MMF. Parameter estimates for the C0 strategy were based on event rates observed in published clinical trials. The model was adapted to Argentinean health system through local protocols and expert opinions; costs were valued in Argentinean pesos and converted to US dollars (1 USD = 2.85 ARS).

RESULTS

Incidence of acute rejection was predicted to be 25.0% at 1-year among patients monitored by C0 and 18.0% by C2. Graft survival was predicted to be 1.4% lower in the C0 group. No important differences were identified in co-morbidity, C0 and C2 monitoring costs, and in ambulatory-based adverse events between C0 and C2 cohorts. The model predicted an average cost per patient of $16,269 for C0 and $16,343 for C2 testing (year 1). Sensitivity analyses indicated that the average daily dose of microemulsion CsA was the most important parameter leading to the incremental cost per patient.

CONCLUSIONS

C2 is expected to provide a potentially important reduction in the risk of acute rejection without increasing the estimated cost of care in the first year post-transplant.

Disability and social ties: comparative findings of the CLESA study

The associations between prevalence, incidence and recovery from activities of daily living (ADL) disability and social ties among community-dwelling persons over 65 in Finland, The Netherlands and Spain are examined. Data were harmonized in the CLESA study. The baseline sample was composed of 3,648 subjects between 65 and 85 years old, living in Finland, The Netherlands and Spain. Disability in four activities of daily living was determined at baseline and at follow-up. Social participation, number of family ties and presence of friends were added to obtain a social ties index. Logistic regressions were fitted to the prevalence, incidence and recovery data to estimate the associations between disability and social ties, adjusting for education, co-morbidity and self-rated health. The modifying effects of country, age and sex were tested in all models. For every country, the social ties index, having friends and social participation were negatively associated with ADL disability prevalence. ADL incidence was negatively related to the number of family ties, with a stronger relationship in Spain than in The Netherlands or Finland. ADL recovery was associated with the social ties index. No age or gender differences in these associations were found. Social ties appear to generate a beneficial effect on the maintenance and restoration of ADL function. While social ties play an important role in maintaining and restoring function in all three countries, family ties appear to generate a stronger effect on protection from disability incidence than does social participation, and the strength of this effect varies by culture.

Open-Label, Multicenter Study on the Safety, Tolerability, and Efficacy of Simulect in Pediatric Renal Transplant Recipients Receiving Triple Therapy With Cyclosporin, Mycophenolate, and Corticosteroids

INTRODUCTION

Basiliximab is a monoclonal antibody directed to the interleukin-2 receptor. Several studies have demonstrated both its efficacy and safety. Even with the use of polyclonal antibodies in renal pediatric transplant recipients, the local incidence of steroid-resistant rejections has been close to 10% of the total incidence of acute rejection episodes (AREs). An open, multicenter prospective study was performed to assess the safety tolerability, and efficacy of induction with basiliximab in renal pediatric transplant patients receiving cyclosporine, mycophenolate, and steroids.

MATERIALS AND METHODS

Eighteen patients (8 boys) of mean age 11.9 +/- 4.5 years and body weight 32 +/- 15 kg received cadaveric (n = 7) or living (n = 11) donor grafts. Simulect was administered on days 0 and 4. Efficacy was assessed by the incidence of biopsy-proven acute rejection (BPAR). Safety assessment consisted of a description of the adverse events (AEs).

RESULTS

Six BPAR (Banff I and II) occurred in 5, (27.7%) children all of which were steroid responsive. Creatinine levels at day 7 and months 3, 6, and 12 were 1.6 +/- 1.5 mg/dL, 1.0 +/- 0.4 mg/dL, 1.0 +/- 0.5 mg/dL, and 1.0 +/- 0.4 mg/dL, respectively. Schwartz calculation at 12 months was 71 +/- 15 mL/1.73 m2 AEs were hypertension (12), anemia (9), abdominal pain (8), metabolic acidosis (8), nausea (7), diarrhea (2), gingival hypertrophy (2), hirsutism (2), lymphocele (2), and infections (15). No deaths, graft losses, PTLDs, or malignancies were observed.

CONCLUSIONS

No steroid-resistant AREs, were observed in this pediatric group using basiliximab. The Schwartz calculation at 12 months was 71 +/- 15 mL/min/1.73 m2.

[Monitoring protocol of native vascular accesses for haemodialysis]

Vascular access failure is an important cause of morbidity and mortality for patients on haemodialysis. We have prospectively studied, with a 5 years follow up, a monitoring protocol of native vascular accesses, using the available methods in every haemodialysis unit. All the native vascular accesses, created from 1- 1998 to XII-2001, with a posterior follow up until XII-2002, were monitored. Monitoring was based on physical examination, dificulty for blood flow greater than 300 ml/min, and in a monthly basis: dynamic venous pressure, urea recirculation and urea kinetic model. Abnormalities suggestive of fistulogram were a priori defined. During the recruitment period, a total of 164 accesses were created in 144 patients. Of these only 3 were grafts, 28 native vascular accesses were never functioning (primary failure rate 17. 1%), and 127 native accesses created in 113 patients (age 63.3 +/- 12.4 years; 18 % diabetics), were monitored (83% cephalic vein). Monitoring findings indicated realization of fistulogram in 35% and percutaneus angioplasty in 25% of the accesses. In order to maintain patency, the surgical intervention rate was 0.03 procedures/patient/year, the radiological 0.10 and the total 0.13. During the 5 years of the study occurred 41 thrombosis episodes in 40 accesses (0.07 thrombosis/patient/year), with percutaneus repermeabilization in 30%. Primary (unassisted) survival was 30.3 months (Confidence Interval 95% 25.6, 35.0) and secondary (assisted) survival 42.8 months (Confidence Interval 95%: 38.7, 46.9). Logistic regression analysis showed that presence of a central catheter at the time of creating the vascular access posses a greater risk for thrombosis (Relative Risk 5.6 if in subclavian vein), whereas age, diabetes, time to canulation, number of previous accesses and anatomic type do not increase that risk. In conclusion, in an old haemodialysis population, with an important diabetes prevalence, it is possible to create functioning native vascular accesses in most of them. The monitoring protocol allowed the detection and posterior correction of stenosis in a great number of accesses. The main risk of thrombosis is the presence of a central catheter at the time of creating a vascular access.

[Occult chronic kidney disease (OCKD), and cardiovascular risk factors. Epidemiologic study]

Vascular diseases are the first cause of mortality within the occidental world. In Spain, they represent 35.5% within the total of deceases. Vascular diseases, jointly with Diabetic Nephropaty, are the first cause of inclusion of patients in dialysis. In precocious stages of renal disease, and as a consequence of the inflammatory condition generated already exists vascular damage. But its prevention is difficult, because habitually GFR is evaluated by means of plasmatic creatinin rate impeding the suitable detection of renal disease prevailing.

OBJECTIVE

The purpose of this study is to evaluate the prevailing of Occult Chronic Kidney Disease (OCKD) and its association with conventional vascular risk factors (VRF).

MATERIAL AND METHODS

The epidemiologic study was made in a randomly selected population elder than 18 years. GFR was calculated using Cockcroft-Gault and MDRD methods, and the results were correlated with VRF.

RESULTS

The studied population mean age is 50.49 +/- 16.28 years, hypertension prevailing is 31.5%, diabetes: 7.5%, obesity: 21.9%, dislipènic: 35.62%, anemia: 1.4%. IV degree IRCO rate (GFR: 15-30 ml/min) is 0.7 (MDRD) with 69.43 +/- 12.58 years of age, and 1.5% (C-G) with 76.25 +/- 10.64 years of age. GFR, independently on the method used in its calculation, is significantly correlated with TAS (< 0.0001), pulse pressure (< 0.0001), Hb (0.0001), obesity (< 0.0001), Total Cholesterol (< 0.0001), triglycerides (< 0.0018), c-HDL (< 0.0001), c-LDL (< 0.0001) e hiperuricemic (< 0.0001). GFR disparity depends on the equation used. It could be explained because C-G overestimate by "weigh" and it has higher deviation in lower renal function values. Whereas, using MDRD equation there is an overestimation by "age" and it has lower variability.

CONCLUSIONS

In an aged population, the prevailing of OCKD and the rate of VRF are high conferring high vascular risk. It will be necessary to adopt intervention measures in order to avoid renal disease progress and its high morbid-mortality.

Liver transplantation from maastricht category 2 non-heart-beating donors: a source to increase the donor pool?

INTRODUCTION

The demand for liver transplantation has increasingly exceeded the supply of cadaver donor organs. Non-heart-beating donors (NHBDs) may be an alternative to increase the cadaver donor pool. The outcome of 20 liver transplants from Maastricht category 2 NHBD was compared with that of 40 liver transplants from heart-beating donors (HBDs). After unsuccessful cardiopulmonary resuscitation (CPR), cardiopulmonary support with simultaneous application of chest and abdominal compression (CPS; n = 6) or cardiopulmonary bypass (CPB; n = 14) was used to maintain the donors.

RESULTS

At a minimum follow-up of 2 years, actuarial patient and graft survival rates with livers from Maastricht category 2 NHBD were 80% and 55%, respectively. Transplantation of organs from these donors was associated with a significantly higher incidence of primary nonfunction, biliary complications, and more severe initial liver dysfunction compared with organs from HBDs. The graft survival rates was 83% for livers from NHBDs preserved with CPS and 42% in those maintained with CPB.

Liver transplantation from maastricht category 2 non-heart-beating donors: a source to increase the donor pool?

INTRODUCTION

The demand for liver transplantation has increasingly exceeded the supply of cadaver donor organs. Non-heart-beating donors (NHBDs) may be an alternative to increase the cadaver donor pool. The outcome of 20 liver transplants from Maastricht category 2 NHBD was compared with that of 40 liver transplants from heart-beating donors (HBDs). After unsuccessful cardiopulmonary resuscitation (CPR), cardiopulmonary support with simultaneous application of chest and abdominal compression (CPS; n = 6) or cardiopulmonary bypass (CPB; n = 14) was used to maintain the donors.

RESULTS

At a minimum follow-up of 2 years, actuarial patient and graft survival rates with livers from Maastricht category 2 NHBD were 80% and 55%, respectively. Transplantation of organs from these donors was associated with a significantly higher incidence of primary nonfunction, biliary complications, and more severe initial liver dysfunction compared with organs from HBDs. The graft survival rates was 83% for livers from NHBDs preserved with CPS and 42% in those maintained with CPB.