RESUMEN
OBJECTIVE: To investigate the effect of an Enhanced Recovery After Surgery (ERAS) program on complications and length of stay (LOS) after radical cystectomy (RC) and to assess if the number and type of components of ERAS play a key role on the decrease of surgical morbidity. MATERIALS AND METHODS: We analyzed the data of 277 patients prospectively recruited in 11 hospitals undergoing RC initially managed according to local practice (Group I) and later within an ERAS program (Group II). Two main outcomes were defined: 90-day complications rate and LOS. As secondary variables we studied 90-day mortality, 30-day readmission and transfusion rate. RESULTS: Patients in Group II had a higher use of ERAS measures (98.6%) than those in Group I (78.2%) (p < 0.05). Patients in Groups I and II experienced similar complications (70.5% vs. 66%, p = 0.42). LOS was not different between Groups I and II (12.5 and 14 days, respectively, p = 0.59). The risk of having any complication decreases for patients having more than 15 ERAS measures adopted [RR = 0.815; 95% confidence interval (CI) 0.667-0.996; p = 0.045]. Avoidance of transfusion and nasogastric tube, prevention of ileus, early ambulation and a fast uptake of a regular diet are independently associated with the absence of complications. CONCLUSIONS: Complications and LOS after RC were not modified by the introduction of an ERAS program. We hypothesize that at least 15 measures should be applied to maximize the benefit of ERAS.
Asunto(s)
Cistectomía , Recuperación Mejorada Después de la Cirugía , Neoplasias de la Vejiga Urinaria/cirugía , Anciano , Cistectomía/métodos , Femenino , Adhesión a Directriz , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Resultado del TratamientoRESUMEN
Metabolic syndrome (MS) individuals have a higher risk of developing chronic kidney disease through unclear pathogenic mechanisms. MS has been also related with higher nephrolithiasis prevalence. To establish the influence of MS on renal function, we designed a murine model of combined metabolic syndrome and hyperoxaluria. Four groups of male Sprague-Dawley rats were established: (1) control group (n = 10) fed with standard chow; (2) stone former group (SF) (n = 10) fed with standard chow plus 0.75% ethylene glycol administered in the drinking water; (3) metabolic syndrome group (MS) (n = 10), fed with 60% fructose diet; (4) metabolic syndrome + stone former group (MS + SF) (n = 10), 60% fructose diet and 0.75% EG in the drinking water. MS group showed a significant injury to renal function when hyperoxaluria was induced. It was demonstrated by a significant decrease of creatinine clearance (p < 0.001), with higher tubular damage (34.3%, CI 95% 23.9-44.7, p < 0.001), produced by deposition of crystals, and increased tubular synthesis of osteopontin as a response to tubular damage. Induction of hyperoxaluria in rats with MS causes severe morphological alterations with a significant impairment of renal function. This impairment is not produced in rats without MS. Therefore, this model can be useful for the study of the influence of MS in stone formation.
Asunto(s)
Oxalato de Calcio/metabolismo , Hiperoxaluria/metabolismo , Síndrome Metabólico/metabolismo , Nefrolitiasis/metabolismo , Insuficiencia Renal/metabolismo , Animales , Oxalato de Calcio/orina , Creatinina , Dieta de Carga de Carbohidratos/efectos adversos , Modelos Animales de Enfermedad , Glicol de Etileno , Fructosa , Humanos , Hiperoxaluria/sangre , Hiperoxaluria/etiología , Hiperoxaluria/orina , Túbulos Renales/patología , Túbulos Renales/fisiopatología , Masculino , Síndrome Metabólico/sangre , Síndrome Metabólico/etiología , Síndrome Metabólico/orina , Nefrolitiasis/sangre , Nefrolitiasis/inducido químicamente , Nefrolitiasis/orina , Osteopontina/metabolismo , Ratas , Ratas Sprague-Dawley , Insuficiencia Renal/sangre , Insuficiencia Renal/etiología , Insuficiencia Renal/orinaRESUMEN
El trasplante renal es el tratamiento de elección de la insuficiencia renal crónica. España es el país del mundo con un mayor índice de donación, próximo a 33 donantes pmp. Sin embargo, en los últimos 2 años se ha asistido a una estabilización en la tasa de donación. La optimización del sistema de donación, la potenciación de los programas de donantes en asistolia, el incremento de la donación de vivo, especialmente tras el desarrollo de la nefrectomía laparoscópica, y quizá el xenotrasplante en un futuro no inmediato constituyen opciones para aumentar el número de riñones aptos para trasplante. El mejor conocimiento de los mecanismos de preservación, especialmente mediante el uso de máquinas de perfusión, permite rescatar órganos límite por tiempos de isquemia prolongados, evaluar la viabilidad de los mismos y modular farmacológicamente el proceso de preservación. El desarrollo de las nuevas drogas inmunosupresoras: Tacrolimus, Mofetil-Micofenolato, Rapamicina o anticuerpos frente a la cadena alfa del receptor de interleukina-2 (basiliximab, daclizumab) han disminuido la incidencia de rechazo agudo en el post-trasplante inmediato a un 10-15 per cent, aunque su eficacia en la supervivencia del injerto a largo plazo es más controvertida. La incidencia de neoplasias en el paciente inmunosuprimido está aumentada, especialmente a expensas de linfomas, tumores cutáneos y sarcomas de Kaposi. Ello conlleva la necesidad de protocolos de seguimiento estricto para la detección precoz de las mismas y la reducción de la inmunosupresión al mínimo necesario y del modo más específico posible. Finalmente, el xenotrasplante constituye una alternativa conceptualmente atractiva, aunque con dificultades inmunológicas, infecciosas y éticas aún no resueltas (AU)
Asunto(s)
Humanos , España , Trasplante Heterólogo , Trasplante de Riñón , Donadores Vivos , Nefrectomía , Laparoscopía , Preservación de Órganos , Terapia de Inmunosupresión , Supervivencia de Injerto , Predicción , Rechazo de Injerto , NeoplasiasRESUMEN
Renal transplant is the treatment of choice for the patient with end stage renal disease. Spain is the country with the highest donation rate (33 ppm). However, at present this figure is stabilized. The development of non-beating heart programmes, living-donor nephrectomy (specially laparoscopic nephrectomy) programmes, and may be xenotransplantation in a non-immediate future could increase the transplantation activity. The knowledge of preservation mechanisms, specially with the use of perfusion machines allows to rescue for transplantation kidneys with a long warm-ischemia time. Furthermore, these machines are useful for analyzing viability markers. The new immunosuppressive drugs: Tacrolimus, Mycophenolate-Mophetil, Rapamycin and monoclonal antibodies against alpha chain of the interleukine-2 receptor (Basoliximab and Dazcizumab) have reduced the incidence of acute rejection in the immediate renal transplant period. However, its effect in the long-term follow-up period is still a matter of controversy. The incidence of tumour in the renal transplant recipient is increased, specially those of lymphoma, skin cancer and Kaposi sarcoma. Periodical exams for detecting the development of tumours are mandatory in this population. Finally, xenotransplantation is an attractive alternative, although immunological, infective and ethical barriers should previously be resolved.