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Management of post cardiac transplantation immunosuppression and COVID-19: in a situation record.
The ischemic and primary vascular injury of the brainstem (BS) can determine, among other serious conditions, the brain death (BD) of the individual. We present 2 cases of individuals with primary ischemic vascular disease of the BS who evolved to BD and were donors of solid organs and tissues. In both cases, the clinical examination was positive for the diagnosis of BD, and transcranial Doppler did not confirm the pattern of cerebral circulatory arrest that accompanies BD. The magnetic resonance angiography performed on 1 patient confirmed the lesion etiology and the presence of vascular obstruction. Both patients were real and effective organ and tissue donors. In these cases, we suggest not to resort to transcranial Doppler as an auxiliary diagnostic test. BACKGROUND Intraoperative temporary portocaval shunt (TPCS) has been performed during liver transplant to improve hemodynamics and renal function as well as to decrease bleeding during hepatectomy. The aim of this study was to evaluate the impact of TPCS on liver transplant in a long-term single-center study. METHODS From January 2006 to December 2018, all deceased donor transplants were retrospectively evaluated. Patients were divided in 2 groups group 1, including those in whom intraoperative TPCS was performed and group 2, including those without TPCS. read more We analyzed recipient characteristics, survival, mortality, and complication rates in the intraoperative and postoperative periods. RESULTS A total of 999 deceased donor liver transplants were studied, with 509 patients in group 1 and 490 in group 2. There were 156 cases (15.61%) of preoperative portal vein thrombosis in the whole series. Postoperative renal function (P = .029) as well as length of hospital and intensive care unit stay (P = .0001) were better in group 1. Surgery time and warm ischemia time was also shorter in group 1 (P = .0001). Complications with Clavien-Dindo score ≥ 3 were higher in group 2 (P = .006). Multivariate analysis showed important risk with fulminant hepatitis (odds ratio, 2.127; 95% CI, 1.408-3.213; P 29. According to Law 91/1999, art. 18, in Italy, health care professionals and administrative staff involved in the process of organ collection and transplantation are required to ensure anonymity of both the donor and the recipient. Against this backdrop, in 2018, the Italian Committee for Bioethics (ICB) released an official opinion titled "Opinion on the preservation of the anonymity of donor and receiver in the transplantation of organs" that offers a new perspective on the topic, effectively opening the possibility of anonymity ending at certain conditions. The relevance of anonymity within the transplant network is a globally recognized principle with a strong ethical value. In this article, based on the experience of one author directly involved in the ICB opinion drafting, we examine the document and discuss how such a proposal could be implemented at the legislative level. BACKGROUND Calcineurin inhibitors (CNIs), tacrolimus and cyclosporine, undergo pharmacokinetic processes. Enzymes and transport proteins found in various organs are involved. It is possible that genetic polymorphisms of these proteins influence CNIs pharmacokinetics and the generation of CNIs metabolites. CNIs may be nephrotoxic, and it is thought that some CNIs' metabolites may have a similar effect. The study was aimed at the assessment of the relationship between selected gene polymorphisms for enzymes and transport proteins and change of estimated glomerular filtration rate (eGFR) during a 2-year follow-up in kidney transplant (KTX) patients. METHODS The study involved 366 patients after KTX (160 women; 43.7%) receiving tacrolimus (62.57%) and cyclosporine (37.43%). The mean age was 50.1 years, and the median time after KTX was 60.5 months. The study protocol conformed with the Declaration of Helsinki. The percent of difference between eGFR at baseline and at 24 months (ΔeGFR) was calculated. We evaluated selected genetic polymorphisms of CYP3A4, CYP3A5, MDR1, UGT1A9, UGT2B7, UGT1A8, and MRP2. RESULTS In the tacrolimus group, there were no significant differences of ΔeGFR between groups distinguished based on analyzed genotypes. In the cyclosporine group, differences were found for CYP3A4∗22 C/C -12.3 (-26.8 to -1.8) versus C/T 13.2 (12.4 to 13.9), P = .034; MDR1 3435C>T C/T -18.2 (-31.5 to -5.7) versus C/C -1.8 (-17.1 to 6.9) vs T/T -8.1 (-18.4 to 12.4), P = .031; and UGT1A9 2152C>T C/C -9.0 (-25.5 to 2.8) versus C/T -26.8 (-31.9 to -24.1), P = .017. CONCLUSION The study results suggest that in KTX metabolic transformations and transport, especially of cyclosporine, dependence on the genetic variability of CYP3A4, UGT1A9, and MDR1 may contribute to kidney damage. Disorders of homeostasis and an increased incidence of infection in patients undergoing hemodialysis causes frequent appearance of pathologic changes in the oral mucosa. The organ transplant and subsequent pharmacologic immunosuppression may result in systemic disorders manifesting by pathologic oral lesions. METHODS The study was conducted on 18 patients undergoing hemodialysis and 18 patients after renal transplant. The study comprised case taking and physical examination, including detailed intraoral and extraoral examination. RESULTS The intraoral examination revealed gingivitis in 61.1% of patients in both groups. In the renal transplant group compared with the hemodialysis group 55.6% vs 38.9% of patients had gingival recession, 55.6% vs 44.4% had periodontitis, 27.8% vs 22.2% had macroglossia, and 11.1% vs 5.6% had geographic tongue, respectively. In the patients on hemodialysis leukoplakia and pallor or pathologic pigmentation of oral mucosa were more frequently observed lesions. Other significant findings in the renal transplant group were lingual papillary atrophy, aphthae, and erythroplakia. Patients of both group reported xerostomia, halitosis, gum bleeding, dysgeusia in their history. DISCUSSION Both groups of patients after renal transplant and patients undergoing hemodialysis presented pathologic lesions in the oral cavity. The study revealed the differences between type and frequency of these pathologic changes, which shows different effect of the above methods of treatment of end-stage renal failure on the oral cavity.
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