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Background: The role that intensive care unit (ICU)-acquired pneumonia plays in the long-term outcomes of cardiac surgery patients is not well known. This study examined the association of pneumonia with in-hospital mortality and long-term mortality after adult cardiac surgery., Methods: A total of 2750 patients admitted to our ICU after cardiac surgery from January 2003 to December 2009 are the basis for this observational study. Patients who developed ICU-acquired pneumonia were matched with patients without it in a 1:2 ratio. The matching criteria were age, urgent or scheduled surgery, surgical procedure, and the propensity score for pneumonia. Multiple regression analysis was used to find predictors of hospital mortality. The relationship between pneumonia and long-term survival was analyzed with Kaplan-Meier survival estimates and a risk-adjusted Cox proportional regression model for patients discharged alive from hospital., Results: Pneumonia was diagnosed in 32 (1.2%) patients and there were 19 cases per 1000 days of mechanical ventilation. Patients with pneumonia had a significantly higher hospital mortality rate (28% vs 6.2%, P = .003) and a higher mortality at the end of follow-up (53% vs 19%, P < .0001) than those without it. Regression analysis showed that pneumonia was a strong predictor of hospital mortality. Five-year survival was as follows: pneumonia, 62%; control, 81%; and cohort patients, 91%. The Cox model showed that, after adjusting for confounding factors, patients with pneumonia (hazard ratio = 3.96, 95% confidence interval [CI]: 1.41-11.14) had poorer long-term survival., Conclusion: Pneumonia remains a serious complication in patients operated for cardiac surgery and is associated with increased hospital mortality and reduced long-term survival., (© The Author(s) 2014.)

The aim of this study was to evaluate the impact of a steroid-free regimen with tacrolimus and mycophenolate mofetil (modified therapy) vs. a standard regimen of tacrolimus and steroids on the cardiovascular risk score of liver transplant recipients. Patients who received a liver transplant were randomized to a modified therapy (n = 58) or a standard regimen (n = 59). Both groups were balanced at baseline, except for a higher prevalence of diabetes mellitus (DM) (p < 0.01) and a higher serum creatinine concentration (p < 0.05) in the modified therapy group. After 12 months, the prevalence of new-onset DM, arterial hypertension, hypercholesterolemia, hypertriglyceridemia, and changes in cardiovascular risk factors was similar in both groups. The increase in serum creatinine (mg/dL) compared to baseline at one yr post-transplantation was numerically lower in the modified therapy group (0.22 ± 0.42) than in the standard regimen group (0.41 ± 0.67) (p = 0.068). Although estimated cardiovascular risk score did not vary significantly compared to baseline in either group, there was a slight reduction in the modified regimen (-0.27 ± 2.87) vs. a mild increase (0.17 ± 2.94) in the standard regimen (p = 0.566). In conclusion, a steroid-free regimen with tacrolimus and mycophenolate mofetil was associated with a trend toward better preservation of kidney function and reduction of cardiovascular risk score., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: To evaluate the safety and patency of self-expanding stents to treat hepatic venous outflow obstruction after orthotopic liver transplantation. To evaluate differences in the response between patients with early obstruction and patients with late obstruction., Material and Methods: This is a retrospective analysis of 16 patients with hepatic venous outflow obstruction after liver transplantation treated with stents (1996-2011). Follow-up included venography/manometry, ultrasonography, CT, and laboratory tests. We did a descriptive statistical analysis of the survival of patients and stents, technical and clinical success of the procedure, recurrence of obstruction, and complications of the procedure. We also did an inferential statistical analysis of the differences between patients with early and late obstruction., Results: The mean follow-up period was 3.34 years (21-5,331 days). The technical success rate was 93.7%, and the clinical success rate was 81.2%. The rate of complications was 25%. The survival rates were 87.5% for patients and 92.5% for stents. The rate of recurrence was 12.5%. The rate of primary patency was 0.96 (95% CI 0.91-1) at 3 months, 0.96 (95% CI 0.91-1) at 6 months, 0.87 (95% CI 0.73-1) at 12 months, and 0.87 (95% CI 0.73-1) at 60 months. There were no significant differences between patients with early and late obstruction, although there was a trend toward higher rates of primary patency in patients with early obstruction (P=.091)., Conclusions: Treating hepatic venous outflow obstruction after orthotopic transplantation with self-expanding stents is effective, durable, and effective. There are no significant differences between patients with early obstruction and those with late obstruction., (Copyright © 2013 SERAM. Published by Elsevier España, S.L.U. All rights reserved.)

Solid-organ transplant recipients are at increased risk of developing cancer compared with the general population. Tumours can arise de novo, as a recurrence of a preexisting malignancy, or from the donated organ. The ATOS (Aula sobre Trasplantes de Órganos Sólidos; the Solid-Organ Transplantation Working Group) group, integrated by Spanish transplant experts, meets annually to discuss current advances in the field. In 2011, the 11th edition covered a range of new topics on cancer and transplantation. In this review we have highlighted the new concepts and best practices for managing cancer in the pre-transplant and post-transplant settings that were presented at the ATOS meeting. Immunosuppression plays a major role in oncogenesis in the transplant recipient, both through impaired immunosurveillance and through direct oncogenic activity. It is possible to transplant organs obtained from donors with a history of cancer as long as an effective minimization of malignancy transmission strategy is followed. Tumour-specific wait-periods have been proposed for the increased number of transplantation candidates with a history of malignancy; however, the patient's individual risk of death from organ failure must be taken into consideration. It is important to actively prevent tumour recurrence, especially the recurrence of hepatocellular carcinoma in liver transplant recipients. To effectively manage post-transplant malignancies, it is essential to proactively monitor patients, with long-term intensive screening programs showing a reduced incidence of cancer post-transplantation. Proposed management strategies for post-transplantation malignancies include viral monitoring and prophylaxis to decrease infection-related cancer, immunosuppression modulation with lower doses of calcineurin inhibitors, and addition of or conversion to inhibitors of the mammalian target of rapamycin., (Copyright © 2012. Published by Elsevier Inc.)

Without any treatment, the prognosis of hepatitis B in liver transplant recipients is very poor. So, antiviral prophylaxis is very important in patients with hepatitis B who undergo liver transplantation. Before liver transplantation, a suppression of viral replication has to be achieved by nucleos(t)ide analogs. Drugs used in the prophylaxis of post-transplant hepatitis B include immunoglobulin against HBV and nucleos(t)ide analogs. Prophylaxis against graft infection must be based on the individual risk of recurrence. When prophylactic measures have failed and graft infection has occurred, treatment of recurrent hepatitis B may be based on the resistance profile of the virus and previous antiviral exposure. Finally, lamivudine seems to be very effective in the prevention of de novo hepatitis B in patients transplanted with a graft from an anti-HBc positive donor.

1. De novo malignancy is one of the leading causes of late mortality after liver transplantation. 2. The risks of skin cancers and lymphoma are more than 10-fold greater than the risks in an age-matched and sex-matched general population. 3. Some types of neoplasia, such as lung, head and neck, and colorectal cancer, are more frequent in liver transplant recipients than in an age-matched and sex-matched population. The risks of other frequent malignancies, such as prostate and breast cancer, do not seem to be increased. 4. The most important risks for posttransplant malignancy are Epstein-Barr virus seronegativity (for lymphoma), sun exposure (for skin cancer), smoking, and increasing age. 5. Despite the absence of evidence, general recommendations (such as avoidance of overimmunosuppression, sunlight protection, and cessation of smoking) should be given. Screening protocols may help to detect neoplasia at an early stage of disease., ((c) 2009 AASLD.)

Introduction and Objectives: Preoperative anemia as a risk factor of adverse outcomes after coronary surgery has not been well-established. This study has aimed to analyze the association between preoperative anemia and postoperative adverse events and in-hospital mortality in the patients undergoing isolated coronary artery bypass graft surgery in the Son Dureta hospital., Methods: All the patients undergoing isolated coronary artery bypass graft surgery with extracorporeal circulation from November 2002 to June 2007 were included. Preoperative anemia was defined as hemoglobin (Hb)<13g/dL in men and Hb<12g/dL in women. The association between postoperative cardiac and noncardiac adverse events and the presence or absence of preoperative anemia and concomitant surgical risk, assessed by logistic EuroScore, were analyzed., Results: A total of 623 patients were included. The rate of preoperative anemia was 34.5%. Patients with Euroscore > or =4 had higher incidence of preoperative anemia than patients with Euroscore<4 (41% vs. 27%; p=0.0001). There were no statistically significant differences in the rate of postoperative adverse events related to the presence or absence of preoperative anemia. Median ICU and hospital length of stay were longer in patients with preoperative anemia than in patients without preoperative anemia (ICU: 3.2+/-2.5 days vs. 3.7+/-2.8, p=0.004; in-hospital: 17.5+/-11.3 days vs. 14.7+/-10.2, p=0.001). Hospital mortality rate was 0.8% (95% CI 0.3-1.9). There were no differences in the mortality rate of the patients with and without preoperative anemia (0.9% vs 0.7%, p=0.8)., Conclusions: In this study, preoperative anemia in patients undergoing coronary artery bypass graft surgery was not associated with increased hospital morbidity-mortality. However, ICU and hospital length of stay were longer in patients with preoperative anemia. The limitation of the sample size prevents us from confirming whether preoperative anemia is a risk factor after coronary surgery or not.

Immunosuppression increases the risk of posttransplant malignancy and it may increase posttransplant mortality. The finding of factors related to the development of posttransplant malignancy may serve as a guide to avoid those risk factors and to develop strategies of posttransplant surveillance. The incidence and risk factors of malignancy were studied in 187 consecutive liver transplant recipients surviving more than 3 months. None of the 12 patients surviving less than 3 months had de novo neoplasia. The impact of malignancy on survival was studied in a case-control study. After a median follow-up of 65 months, 49 patients developed 63 malignancies: 25 patients had 35 cutaneous neoplasias and 27 patients had 28 noncutaneous malignancies. The 5- and 10-year actuarial rates of cutaneous neoplasia were 14 and 24% and the rates of noncutaneous neoplasia were 11 and 22%, respectively. Risk factors for the development of cutaneous malignancy were older age and Child-Turcotte-Pugh A status. Risk factors for the development of noncutaneous malignancy were older age, alcoholism, and smoking. Cutaneous neoplasia had no effect on survival, whereas patients with noncutaneous malignancy had a significant reduction of survival. The overall relative risk of cutaneous and noncutaneous neoplasia, as compared with the general population were 16.91 (95% confidence interval: 11.78-23.51) and 3.23 (95% confidence interval: 2.15-4.67), respectively. The relative risk of cancer-related mortality (after excluding recurrent malignancy) was 2.93 (95% confidence interval: 1.56-5.02). Multivariate analysis showed that noncutaneous malignancy was an independent risk factor for posttransplant mortality. In conclusion, liver transplant recipients have a higher risk of cancer-related mortality than the general population. This increased risk is due to the development of noncutaneous neoplasia. Older age, alcoholism, and smoking increase the risk of de novo noncutaneous neoplasia.

Herpes zoster is the consequence of the reactivation of latent varicella-zoster infection. Immunosuppression may be a predisposing factor for herpes zoster. We have retrospectively assessed the risk of herpes zoster, the risk factors for its occurrence, and its evolution in a population of 209 consecutive liver transplant recipients. Herpes zoster developed in 25 (12%) of patients. One-, 3-, 5-, and 10-year actuarial rates of herpes zoster were 3%, 10%, 14%, and 18%, respectively. In a case-control study, patients developing herpes zoster were younger, received a higher number of immunosuppressive drugs, and were more frequently receiving mycophenolate mofetil or azathioprine. In multivariate analysis, the only factor related to herpes zoster occurrence was treatment with mycophenolate mofetil or azathioprine. Eight patients (31%) developed postherpetic neuralgia. In conclusion, herpes zoster is a relatively common complication after liver transplantation. It is related to immunosuppressive therapy. Postherpetic neuralgia develops in one third of patients with posttransplant herpes zoster.

Purpose: To assess the efficacy of self-expanding metallic stents in treating inoperable gastric and duodenal stenoses during follow-up and to evaluate the complications encountered., Methods: A total of 31 patients suffering from gastroduodenal obstruction (29 malignant, 2 benign) were treated with a self-expanding metallic stent (Wallstent). In 24 cases insertion was by the peroral route, in seven cases via gastrostomy., Results: All the strictures were successfully negotiated under fluoroscopic guidance without having to resort to endoscopy. A total of 27 patients (87%) were able to resume a regular diet, a soft diet, or a liquid diet orally. Complications included one case of stent malpositioning, one case of leakage of ascitic fluid through the gastrostomy orifice, one case of perforation and fistula to the biliary tree, and two cases of hematemesis. In two patients (6%) additional stents were implanted to improve patency. In all patients follow-up was maintained until death. Recurrence of symptoms immediately before death occurred in seven cases (23%). Mean survival time of patients was 13.3 weeks (SE +/- 4.6)., Conclusions: The deployment of gastroduodenal stents resulted in good palliation of inoperable gastric and duodenal stenoses. Certain technical aspects, e.g., adaptation of stents to bowel morphology, is critical to proper stent function and avoidance of complications.

Background: Some patients develop proteinuria and progressive renal failure after unilateral nephrectomy, although the majority of patients maintain normal renal function. Reasons to explain this different evolution are not known., Methods: A cross-sectional study was performed in 73 patients who had undergone unilateral nephrectomy 13.6 +/- 8.6 years before. Patients with morphologic abnormalities in the remaining kidney, systemic disorders, or abnormal renal function at the time of nephrectomy were excluded. All of the 73 included patients showed normal renal function and negative proteinuria at nephrectomy. The patient's medical records were reviewed, and clinical and analytical data throughout follow-up were obtained., Results: Fifty-three out of the 73 patients (group I) showed a normal renal function and negative proteinuria at the cross-sectional study. The remaining 20 patients (group II) showed proteinuria (3.4 +/- 3.1 g/day). The time elapsed between nephrectomy and proteinuria appearance was 10.1 +/- 6.1 years. Thirteen patients of group II had developed renal insufficiency (serum creatinine at the cross-sectional study of 3.9 + 3.2 mg/dL) in addition to proteinuria. The time elapsed between proteinuria appearance and the onset of renal insufficiency was 4.1 +/- 4.3 years. Renal insufficiency showed a slowly progressive course in most of these patients. There were no significant differences between group I and group II patients in age, gender, renal function, or blood pressure at the time of nephrectomy. In contrast, group II patients showed a body mass index (BMI) that was significantly higher than group I at nephrectomy (31.6 +/- 5.6 vs. 24.3 +/- 3.7 kg/m(2), P < 0.001), at cross-sectional study (33.3 +/- 6.6 vs. 25.1 +/- 3.5 kg/m(2), P < 0.001), and throughout follow-up. Among the 14 obese (BMI > 30 kg/m(2)) patients at the time of nephrectomy, 13 (92%) developed proteinuria/renal insufficiency. In contrast, among the 59 patients with BMI < 30 kg/m(2), only 7 (12%) developed these complications (P < 0.001). Kaplan-Meier estimated probability of negative proteinuria and normal renal function 10 years after nephrectomy was 40 and 70%, respectively, in obese patients at nephrectomy. At 20 years after nephrectomy, these percentages were 8 and 35%, respectively. In contrast, in nonobese patients, the probability of negative proteinuria and normal renal function was 93 and 98%, respectively, at 10 years (P < 0.001) and 77 and 91%, respectively, at 20 years (P < 0.001). Multiple logistic regression analysis showed that the risk of developing renal disease was only statistically correlated with BMI at the time of unilateral nephrectomy (odds ratio 1.34, 1.03 to 1.76 CI)., Conclusions: Obese patients are at risk for developing proteinuria and chronic renal failure after unilateral nephrectomy. Regular and long-term follow-up are recommended in these patients.

Liver transplant recipients have an increased risk for cardiovascular disease because of a high incidence of obesity, arterial hypertension, diabetes mellitus, and hyperlipidemia. Hyperhomocysteinemia has been found to be an important risk factor for cardiovascular disease in large studies. Fasting serum levels of homocysteine were measured in 105 liver transplant recipients, and hyperhomocysteinemia was defined as a fasting serum homocysteine level greater than 13 micromol/L. Patients with versus without hyperhomocysteinemia were compared. The possible association of hyperhomocysteinemia with age, sex, cause of liver disease, time elapsed since liver transplantation, immunosuppressive therapy, folic acid level, liver function test results, renal function, and other cardiovascular risk factors was investigated. Patients with serum homocysteine levels greater than 15 micromol/L were treated with folic acid, 10 mg/d, and serum homocysteine levels were measured again 1 to 3 months later in 10 patients. Hyperhomocysteinemia was detected in 28 patients (27%). In univariate analysis, it was associated with hepatitis C virus infection, treatment with mycophenolate mofetil, and greater serum levels of alkaline phosphatase, gamma-glutamyl transpeptidase, urea, and creatinine. In multivariate analysis, only greater serum levels of creatinine (P =.006) were associated with hyperhomocysteinemia. Treatment with folic acid resulted in a decrease in fasting serum homocysteine levels in 9 of the 10 patients tested (P =.01). Hyperhomocystinemia, associated with renal dysfunction, is a frequent finding in liver transplant recipients. Treatment with folic acid may reduce fasting homocysteine levels.

Objective: The purpose of this retrospective survey was to determine the prevalence and outcome of hepatitis C virus (HCV) infection in cirrhotic patients undergoing liver transplantation (OLT) in Spain in 1992., Methods: Post-OLT HCV infection was defined by anti-HCV (second-generation ELISA) and/or PCR. Patients were divided into groups A (HCV-positive pre-OLT: n = 124, 46%) and B (HCV-negative pre-OLT: n = 145, 54%)., Results: HCV infection was more prevalent in patients originally diagnosed as having non-A non-B cirrhosis (97%) and cryptogenic cirrhosis (79%) than in patients with cholestatic or metabolic diseases. Group A patients were older (53.3+/-7.9 versus 47.6+/-9.7; P< 0.05) and had a higher prevalence of hepatocellular carcinoma (22% versus 4%, P< 0.05). Post-OLT HCV infection was 99% in group A versus 4% in group B (P< 0.05). Histological hepatitis developed in 39% (66% in group A versus 14% in group B, P< 0.05) with similar follow-up. Chronic rejection occurred in 6% (3% in group A versus 8.5% in group B, P= 0.07). Retransplantation rate (overall 8%) and two-year patient survival did not differ between groups (79% versus 72%). Graft survival was higher in group A (74% versus 65% at 2 years, P= 0.04)., Conclusions: HCV-cirrhosis represented the most frequent indication for OLT in Spain in 1992. While HCV recurrence was universal, de novo acquisition was rare. HCV accounted for most post-OLT hepatitis (87%), but was not associated with chronic rejection, nor with a higher retransplantation rate. Patient survival was not different in HCV patients compared to a control group after a follow-up of 2-3 years. Therefore, at present, HCV-cirrhosis is an acceptable indication for OLT.

The purpose of the present retrospective study is to analyse 14 patients harbouring brainstem haematomas and to discuss the early and late prognosis. The patients were divided into two groups: group A (survivors), 8 patients with follow-up duration ranging between 8 months and 12 years; and group B (nonsurvivors), 6 patients. At the time of onset or hospital admission, the former were under 50 years of age and had no important clinical history. Their degree of consciousness was altered only slightly or moderately and their brainstem haemorrhages were focal or only slightly diffuse. Three patients in this group underwent surgical treatment. The members of group B, who died within days of their admission to the hospital, were over 60 years of age, had a number of clinical antecedents and severe alterations of consciousness, while 83% of them presented diffuse brainstem haemorrhages. None of the patients of this group were treated surgically. It was concluded that: 1) the indications for surgery for these lesions were progressive hydrocephalus, increase in the mass effect with progressive symptomatology and suspected "cryptic vascular malformation" with risk of later rebleeding or brain tumour; 2) surgical treatment was necessary to improve the symptomatology in 3 patients in group A, although there were no significant differences between surgically treated and nonsurgically treated patients in the same group with respect to prognosis; 3) age, clinical history, degree of alteration of consciousness and type of haemorrhage are the major factors affecting the early and late prognosis of brainstem haemorrhages.