Justyna Domienik-Karłowicz

Electrocardiographic criteria of left ventricular hypertrophy in patients with morbid obesity.

Background: Obesity is frequently accompanied by systemic hypertension complicated by left ventricular hypertrophy (LVH). Standard electrocardiography (ECG) is generally accepted screening tool for LVH in systemic hypertension. The aim was to assess currently used ECG criteria in the diagnosis of LVH in morbidly obese patients.

Bariatric surgery as a bridge for kidney transplantation in obese subjects. Case report

BACKGROUND The epidemiological studies indicate that the problem of obesity and associated metabolic syndrome affects the steadily increasing population. The obesity also applies to the patients with the end-stage renal failure requiring renal replacement therapy. Morbid obesity is a contraindication to renal transplantation procedure. A significant excess weight greatly increases the waiting time for transplantation, increases the risk of surgical complications, including complications due to cardiovascular and metabolic disorders. The combination of these risk factors with the immunosuppressive therapy may worsen the symptoms associated with the renal failure, contribute to the deterioration of graft function, shorten the survival, and increase the risk of patient death. CASE REPORT In this paper we described the first Polish case of kidney transplantation, in a patient after bariatric surgery. The patient was disqualified from kidney transplantation because of obesity and referred to our department for metabolic surgery and weight reduction before potential kidney transplantation. 10 months post the bariatric surgery patient was selected as a kidney transplant recipient from a deceased donor. Both procedures have been performed in this same center. CONCLUSIONS Bariatric surgery procedures are safe and effective in patients with end-stage renal disease. Bariatric procedures may be considered as a procedural bridge for a group of morbidly obese patients with renal failure, allowing them to be qualified for transplantation.

Improvement of Graft Function following Roux-en-Y Gastric Bypass Surgery in a Morbidly Obese Kidney Recipient: A Case Report and Literature Review

BACKGROUND Transplantation is the best and approved method of renal replacement therapy. Graft function depends not only on proper regulation of immune processes but also on the optimal control of chronic diseases. The obesity epidemic involves the healthy population and organ recipients equally. Obesity and metabolic syndrome lead to a number of disorders exerting adverse effects on the transplanted organ. CASE REPORT We report a case of a kidney recipient, 12 years after transplantation, with chronic graft failure (serum creatinine level 2.1 mg/dl, GFR 31 ml/min/1.73 m(2)), morbid obesity (weight 139.8 kg, BMI 46.2 kg/m(2), excess body mass 73.1 kg), hypertension, poorly controlled type 1 diabetes (HbA1c 8.8%), and ischemic heart disease. The cause of chronic kidney disease was diabetic nephropathy. The patient was the first Polish kidney recipient referred for bariatric gastric bypass surgery (GB). Directly after surgery, transient creatinine elevation (4.7 mg/dl) was noted. There was no reduction in diuresis. Desired weight loss was achieved within 12 months after surgery (body mass 81.9, BMI 27.1 kg/m(2), percentage loss of excess weight 86.9%) with improved graft function (serum creatinine level 1.3 mg/dl, GFR 45.1 ml/min/1.73 m(2)) and reduction of daily insulin requirement from 74 to 40 units. The severity of hypertension and ischemic heart disease diminished as well. CONCLUSIONS Metabolic surgery is the best treatment of obesity and may contribute to post-transplantation care if weight gain is observed, as a result of the interaction of many factors leading to deterioration of renal graft function.

E-selectin and sICAM-1, biomarkers of endothelial function, predict recurrence of venous thromboembolism

BACKGROUND Risk factors for atherosclerosis and venous thromboembolism (VTE) overlap and are mostly associated with endothelial dysfunction (ED). We hypothesized that ED is present in patients after the first episode of acute pulmonary embolism (APE) and predicts the risk of VTE recurrence. DESIGN AND METHODS Patients, at least 6months after the first episode of symptomatic, confirmed APE were included in this case-control study. The exclusion criteria were risk factors for cardiovascular diseases and other conditions associated with endothelial dysfunction. Eighty two patients (aged 38±11years; 44 M; 38 F) were enrolled in the study, 39 after provoked APE, 43 after unprovoked APE, and 30 controls (C) (aged 38±12years; 15 M, 15 F). In order to evaluate the endothelial function in patients with a history of APE flow-mediated dilation (FMD) of the brachial artery and biomarkers of endothelial dysfunction (sVCAM-1, sICAM-1, ADMA, E-selectin) were measured. Subsequently all patients were followed up in an outpatient clinic for VTE recurrence. RESULTS FMD was more often impaired in APE patients than in controls (5.3% (0.8-20.3) vs. 13.8% (4.1-24.3); p<0.0001). Biomarker levels differed between APE and C groups: sVCAM-1 (631ng/ml (105-2382) vs. 495ng/ml (348-934); p=0.04) and sICAM-1 (679ng/ml (279-1006) vs. 600ng/ml (394-766); p=0.002). There were 19 recurrences of VTE during the at least 12-month follow-up (15 with history of unprovoked-APE and 4 after provoked-APE). E-selectin ≥39ng/ml and sICAM-1≤655ng/ml indicated the group without recurrence of VTE. In a group of 43 unprovoked APE patients both E-selectin<39ng/ml and sICAM-1>655ng/ml were found in 17 subjects. Eleven of them (65%) were diagnosed with recurrent VTE. CONCLUSIONS Endothelial function is significantly impaired in patients after an episode of APE as indicated by FMD assessment and biomarker levels. Low concentrations of E-selectin and high levels of sICAM-1 are associated with a high risk of recurrent thromboembolism.

The use of anticoagulants in morbidly obese patients.

Due to its constantly growing incidence, obesity is an increasingly serious social and medical problem. Available data on the use of novel oral anticoagulants in morbidly obese and obese patients are very limited. However, we tried to summarize the available knowledge on the use of anticoagulants in this subpopulation of patients in everyday clinical practice. Studies on the clinical use of anticoagulants provide a poor basis for any adjustment of doses in obese patients as compared to patients with normal body weight. In our opinion, further studies are required in this particular population.

The First Polish Liver Transplantation after Roux-en-Y Gastric Bypass Surgery for Morbid Obesity: A Case Report and Literature Review

BACKGROUND Morbid obesity is associated with liver pathology, most commonly non-alcoholic steatohepatitis (NASH) leading to cirrhosis. However, the morbid obesity impedes qualification for organ transplantation. CASE REPORT We present a case report of a 56-year-old woman who underwent bariatric procedure followed by liver transplantation (LTx). Her initial weight was 130.2 kg (BMI 50.9 kg/m2). The patient had a history of arterial hypertension, diabetes, gonarthrosis, and obstructive sleep apnea syndrome and no history of alcohol abuse. She underwent Roux-en-Y gastric bypass (RYGB) procedure. The routine intraoperative liver biopsy revealed fibrosis (III°), steatosis (II°), and intra-acinar inflammation. The operation led to a substantial loss of weight. Two years after the surgery the patient was referred to the Transplantation Clinic of Department of General Surgery and Transplantology with suspicion of liver failure due to advanced cirrhosis, which could be a result of previously diagnosed NASH and, probably, excessive alcohol use after bariatric surgery. The patient was qualified for elective LTx, which was performed 3 years after the RYGB. Immediately before LTx, the patients weight was 65 kg (BMI 25.4 kg/m²). The postoperative period was complicated by bleeding into the peritoneal cavity, which required reoperation. She also had renal failure, requiring renal replacement therapy. One year after LTx, she showed stable liver function with normal transaminases activity and bilirubin concentration, remission of diabetes, and good renal function. CONCLUSIONS Steatohepatitis in morbidly obese patients may lead to cirrhosis. Bariatric procedure can be a bridge to liver transplantation for morbidly obese patients with advanced liver fibrosis.

Single-anastomosis duodeno-ileal – new revision procedure in a patient with insufficient weight loss after sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is one of the most popular and effective bariatric surgical procedures worldwide. The effect of LSG is mostly dependent on the restrictive mechanism, which makes it more vulnerable to failure. Failing of bariatric procedure is not uncommon and occurs in 6% to 23%. In case of weight loss failure, there are no hard recommendations on the choice of the redo procedure. One of the most novel options, introduced in 2007, relatively simple to perform following LSG is single-anastomosis duodenoileal bypass. Herein we describe surgical technique and history of a patient with inadequate weight loss after laparoscopic sleeve gastrectomy, who underwent single-anastomosis duodenoileal bypass.

Questionable validity of left ventricular hypertrophy cutoff values in morbidly and super-morbidly obese patients

Current diagnostic ECG criteria of left ventricular hypertrophy in obese patients are still lacking.

Response to Letter to the Editor from Anthanont Pimjai: Emerging Markers of Atherosclerosis Before and After Bariatric Surgery

Dear Dr. Anthanont Pimjai, We have carefully read with great interest your letter to the Editor with comments and concerns about the results of our study [1]. We would like to make some remarks. All women included in our study, both in the study and in the control group, were Caucasian [2]. Therefore, the study group was homogeneous in terms of ethnicity, so no ethnic variations could be observed. However, we agree with you that the available data on the potential influence of adiponectin on cardiovascular disease is rather equivocal. Aung et al. in their meta-analysis (14,063 CVD patients enrolled) showed a strong positive association of adiponectin with cardiovascular mortality (n = 11 studies, overall pooled effect estimate = 1.69 [1.35–2.10]) [3]. That was in accordance with a study by Schondorf et al. as well as our research [2, 4]. Furthermore, it is worth noticing that some studies have suggested that high-molecular-weight adiponectin is a stronger risk factor for cardiovascular diseases than total adiponectin level [5]. In another study, serum adiponectin levels were found to be inversely correlated with intima-media thickness as a marker of carotid atherosclerosis [6]. As Dr Pimjai mentioned before, other adequately powered studies failed to identify adiponectin as a cardiovascular risk factor. Some researchers claim that these contradictory results in this field might be caused by confounding factors, sex and age of the analyzed subjects, different oligomers of adiponectin tested, other methodological issues (various assays: radioimmunoassays or ELISAs), or handling of laboratory samples.[7] We agree with Dr Pimjai that further, well-designed studies are needed to clarify the full relationship between adiponectin and the risk of cardiovascular disease.

Right atrial myxoma with pulmonary embolism

We present a rare case of a patient with giant right atrial myxoma and simultaneous pulmonary embolism, with good results after surgical removal of the tumour. A 62-year-old woman was admitted to the hospital due to fatigue increasing for several weeks before admission. She complained of progressive exertional dyspnoea and had a medical history of three-months anaemia. On admission she was in a good general condition without clinical signs of heart failure. Transthoracic and transoesophageal echocardiography revealed a mobile mass about 7 cm in length attached to the posterior wall of the right atrium (Figs. 1–3). It prolapsed through the tricuspid valve into the right ventricular outflow tract during diastole. Examinations did not reveal any pathological structures in the main veins draining into the right atrium. Computer tomography (CT) of the chest showed a solid, heterogeneously-hypodense mass, poorly delimited in the right atrium and ventricle, and with dimensions 80 × 45 mm. The lower limb compression venous Doppler ultrasonography showed no signs of thrombosis. Moreover, the pulmonary embolism was confirmed by angio-CT. It revealed the multiple emboli in lobar and segmental pulmonary arteries. The patient was urgently qualified for cardiac surgery and underwent it without complications. The tumour was completely removed (Fig. 4). Histological examination of the tumour confirmed myxoma. Primary tumours of the heart coexisting with a pulmonary embolism are rare. Right atrial myxoma is observed only in 15–20% of myxoma cases with high potential of pulmonary embolism. Immediate surgical treatment is indicated on account of the high risk of pulmonary embolism or sudden cardiac death.