The role of procalcitonin as a marker of diabetic foot ulcer infection

Foot ulcers are frequent in diabetic patients and are responsible for 85% of amputations, especially in the presence of infection. The diagnosis of diabetic foot ulcer infection is essentially based on clinical evaluation, but laboratory parameters such as erythrocyte sedimentation rate (ESR), white blood count (WBC), C‐reactive protein (CRP) and, more recently, procalcitonin (PCT) could aid the diagnosis, especially when clinical signs are misleading. Fifteen diabetic patients with infected foot ulcers were admitted to our department and were compared with an additional group of patients with non‐infected diabetic foot ulcers (NIDFUs). Blood samples were collected from all patients in order to evaluate laboratory markers. In the current study, the diagnostic accuracy of PCT serum levels was evaluated in comparison with other inflammatory markers such as CRP, ESR and WBC as an indicator to make the distinction between infected diabetic foot ulcers (IDFUs) and NIDFUs. CRP, WBC, ESR and especially PCT measurements represent effective biomarkers in the diagnosis of foot infections in diabetic patients particularly when clinical signs are misleading.     

血清降钙素原与C反应蛋白在感染性开放性骨折诊断中的应用价值

[目的]探讨血清降钙素原(procalcitonin PCT)和C反应蛋白(C-reactive protein,CRP)试验在开放性骨折感染的鉴别诊断作用价值.[方法]对30例开放性骨折感染患者,应用免疫比浊法测定血清中PCT和CRP水平.[结果]感染组与对照组CRP水平无统计学意义,而PCT水平感染组明显高于对照组,有显著性差异(P<0.01).[结论]联合检测血清中PCT和CRP浓度对开放性骨折感染的鉴别诊断有重要临床价值,指导临床医师合理使用抗生素.     

前降钙素在脓毒血症早期诊断中的价值

目的　比较脓毒血症大鼠不同时间血浆中前降钙素 (PCT)和C反应蛋白 (CRP)的变化 ,探讨血浆PCT作为细菌感染早期诊断指标的敏感度和可靠性。方法　采用盲肠末端结扎穿孔的方法制备脓毒血症模型。雄性SD大鼠 30只 ,随机分为脓毒血症组 (PS)、假手术组 (SO)和正常对照组 (NC) ,每组 1 0只。分别于模型制备后 0、1 2、2 4、4 8h和对应时点经股静脉抽血 ,测定PCT和CRP。结果　PS组 1 2、2 4和 4 8h的PCT显著高于NC组和SO组的对应时点 (P <0 0 1 ) ,PS组各时点的PCT也有显著差别 (P <0 0 1 )。各组 0、1 2、2 4h的CRP无差别 ,PS组 4 8h的CRP显著高于NC和SO组 (P <0 0 1 )。结论　PCT在大鼠脓毒血症时 ,升高较早 ,且随炎症的加重而升高。PCT在诊断早期细菌感染和评估感染程度方面优于CRP。     

Value of procalcitonin as a marker of surgical site infection following spinal surgery

Aim

To compare the value of Procalcitonin (PCT) as a marker of surgical site infection to other inflammatory markers, including C-Reactive Protein (CRP), White Cell Count (WCC) and Erythrocyte Sedimentation Rate (ESR) in patients undergoing a number of spinal procedures. This study also aims to describe the biokinetic profile of the above-named markers in patients developing surgical site infection and those remaining infection-free post-operatively.

Usefulness of hepatobiliary scintigraphy for the evaluation of living related liver transplant recipients in the early postoperative period

AIM: The aim of this study was to investigate the usefulness of hepatobiliary scintigraphy for the evaluation of liver grafts in the early postoperative period in patients receiving liver transplants from living related donors. MATERIALS AND METHODS: Fifty-six liver transplant recipients who received grafts from living related donors were included in the study. We examined the hepatobiliary scintigraphies of all patients, which were performed 7 to 10 days after the transplantation. The scintigraphic images were evaluated visually in terms of hepatic parenchymal function and biliary and vascular complications. RESULTS: In 44/56 recipients, hepatobiliary scintigraphy was completely normal in the early postoperative period. However, in 6/56 cases, scintigraphy was interpreted to show parenchymal dysfunction. In these patients, histopathologic confirmation by biopsies revealed four cases of hepatocellular damage/cholestasis, one acute rejection, and one cholangitis. In 3/56 patients, hepatobiliary scintigraphy demonstrated a hypoactive area in the liver graft; however, the other areas showed normal function. When the abdominal computed tomography (CT) and CT angiography were evaluated, these hypoactive areas were discovered to be related to minor vascular problems. In 3/56 liver graft recipients whose grafts showed normal parenchymal function scintigraphically, images were interpreted to indicate bile leak because accumulation of tracer was seen at an abnormal physiological site. CONCLUSION: Hepatobiliary scintigraphy, which is a noninvasive and objective method, is useful to assess grafts in the early postoperative period among patients who received liver transplants from living related donors.     

Physiologic impact of low-dose dopamine on renal function in the early post renal transplant period

BACKGROUND: Low-dose dopamine (LDD) (< or =5.0 microg/kg/min) is often used in the early postrenal transplant period for its perceived improvements in renal function parameters. However, there is little published evidence to support its use. The aim of this study was to evaluate the effects of LDD on the physiologic parameters of the transplanted kidney. METHODS: With local ethics approval, 20 consecutive adult patients (age range, 27-74 years), who underwent cadaveric renal transplantation with cyclosporine immunosuppression, were randomized into two study groups, each with 10 patients. The study period was over 9 hrs on the first postoperative day. This 9-hr block was divided into three 3-hr periods. Patient group 1 received a dopamine infusion over the second 3-hr period only, and patient group 2 received a dopamine infusion over both the first and third 3-hr periods. During these periods, urine flow rate (UFR), effective renal plasma flow (ERPF), creatinine clearance (CC), and total urinary sodium excretion rate (tUNa) were measured. RESULTS: In both groups, there were significant (P<0.05, Wilcoxon rank sum test) increases in ERPF, UFR, CC, and tUNa during LDD infusion periods compared with periods of no LDD infusion. No changes in heart rate or mean arterial blood pressure were seen with LDD administration. CONCLUSIONS: LDD significantly increases ERPF, UFR, CC, and tUNa in the transplanted allograft kidney treated with cyclosporine immunosuppression in the early posttransplant period.     

Human herpesvirus 6 infection in adult living related liver transplant recipients.

To analyze human herpesvirus 6 (HHV-6) infection in adult living related liver transplantation, we performed a virological analysis, including viral isolation, serological assay, and real-time polymerase chain reaction, of serially collected blood samples from 67 recipients. In addition, cytokine levels were measured to determine their role in viral reactivation. HHV-6 was isolated from only 4 recipients (6.0%), and viral DNA was detected in 15 (22.4%) of the 67 recipients. A significant increase in HHV-6 immunoglobulin G antibody titers was observed in 19 (28.4%) of the 67 recipients. Finally, 26 recipients (38.8%) had HHV-6 reactivation 2-6 weeks after transplantation. HHV-6 associated clinical features were analyzed in the 17 recipients presenting with either viremia or DNAemia. Two recipients with viremia and 3 recipients with DNAemia had unexplained fever at the time of viral infection. An increase in aminotransferase levels was observed in 2 recipients with viremia and 3 recipients with DNAemia. Recipients with liver cirrhosis caused by hepatitis B virus or hepatitis C virus infection as the underlying disease were more likely to have HHV-6 infection (P = 0.025). Mortality at the last follow-up in recipients with HHV-6 reactivation was significantly higher than in those without viral reactivation (P = 0.0118). Plasma interleukin-6 levels were significantly higher in the recipients with HHV-6 viremia than in the recipients without viremia at 4 weeks post-transplant (P = 0.0411). Moreover, tumor necrosis factor alpha levels were also higher in recipients with HHV-6 viremia (P < 0.0001) or reactivation (P = 0.0011) than in recipients without viremia or reactivation 4 weeks post-transplant.     

Enzymuria and low molecular weight protein excretion as the differentiating marker of complications in the early post kidney transplantation period

Renal function in the early post-transplantation period depends largely on factors affecting the kidney prior to implantation. Function of the graft may be also disturbed by the most common complications of the early post-operative period such as acute graft rejection (AGR), acute tubular necrosis (ATN) and may be modified by nephrotoxic action of cyclosporine A (CsA). Evaluation of excretion of enzymes and low molecular weight proteins (LMWP) may help in the differentiation of these complications. Aim Comparison of the urinary excretion of markers of tubular injury in patients with AGR, ATN, or patients with stable graft function (SGF) was made and differences between groups and correlations between markers and cold ischemia time (CIT), warm ischemia time (WIT) and blood trough level of cyclosporine A (CsA₀) were determined. Material and methods In 60 cadaveric renal allograft recipients in the early post-transplantation period urinary excretion of N-acetyl-β-d-glucosaminidase (NAG) and B isoenzyme (NAG-B), alanylaminopeptidase (AAP), γ-glutamyltransferase (GGT), α and π isoenzymes of glutathione S-transferase (α-GST, π-GST), retinol binding protein (RBP) and β2- microglobulin (β2M), were analyzed. Results NAG and NAB-B activities were higher in ATN (P<0.05, P<0.01) and in AGR (P<0.005, P<0.02) than in SGF. Excretion of π-GST was higher in AGR than in SGF (P<0.0002) or ATN (P<0.007). CIT and WIT in patients with ATN were higher (P<0.05) than in SGF group. In ATN patients, correlations of CIT with RBP (P<0.05) and π-GST (P<0.05), and WIT with RBP (P<0.05), and π-GST (P<0.001) were found. Conclusions High urinary NAG and NAG B excretion characterizes ATN and AGR patients. Evaluating urinary excretion of π-GST may be helpful in differentiating AGR from ATN. However, taking into account ischemia time is necessary in interpreting the π-GST value in early post transplant period.     

Clostridial infection in a liver transplant recipient

Clostridium perfringens infection in a liver transplant recipient is a rare complication. We report a case of a liver allograft gas gangrene. The case illustrates the fulminant and rapidly devastating course of this complication.     

Pharmacokinetics of tacrolimus in living donor liver transplant and deceased donor liver transplant recipients

INTRODUCTION: Hepatic dysfunction is an important determinant of the clearance of tacrolimus; however, the impact of reduced hepatic mass in living donor liver transplant (LDLT) patients on the drug exposure and clearance of tacrolimus is not known. AIM.: The aim of the present study is to compare the dosage, concentration and pharmacokinetics parameters of tacrolimus between LDLT and deceased donor liver transplant (DDLT) recipients. PATIENTS AND METHODS: Daily doses used and trough concentrations measured were compared in 12 LDLT and 12 DDLT patients. Multiple blood samples were taken over one dosing interval after oral tacrolimus administration, and pharmacokinetics differences were compared. RESULTS: The mean tacrolimus dosage in first 14 postoperative days was (0.06 mg/kg/day) for LDLT and (0.09 mg/kg/day) for DDLT (P=0.0001). Despite the lower doses used, mean trough concentration was significantly greater in LDLT as compared with DDLT (8.8+/-2.5 ng/mL vs. 6.79+/-1.5 ng/mL, respectively, P=0.013). On the day of the pharmacokinetic study, minimum Concentration (Cmin), 12-hr postdose concentration (Clast), and average concentration (Cavg) were significantly greater in LDLT as compared with DDLT (LDLT: 6.6+/-2.4 ng/mL, 7.2+/-1.8 ng/mL, 8.9+/-3.0 ng/mL; DDLT: 4.3+/-1.0 ng/mL, 4.9+/-1.6 ng/mL, 5.9+/-1.4 ng/mL, P=0.02, 0.04, and 0.02, respectively). Dose normalized AUC was 37.7% greater and clearance, 47.5% lower in LDLT as compared with DDLT. CONCLUSION: Although not statistically significant, the dose normalized AUC was 37.7% greater and clearance 47.5% lower in LDLT as compared with DDLT. An initial tacrolimus dose reduction of about 30-40% may be prudent in LDLT compared with DDLT recipients.     

Evaluation of soluble CD30 as an immunologic marker in heart transplant recipients

CD30 is an immunologic molecule that belongs to the TNF-R superfamily. CD30 serves as a T-cell signal transducing molecule that is expressed by a subset of activated T lymphocytes, CD45RO+ memory T cells. Augmentation of soluble CD30 during kidney transplant rejection has been reported. Our study sought to determine whether the level of sCD30 prior to heart transplant could categorize patients into high versus low immunologic risk for a poor outcome. A significant correlation was observed between high levels of soluble CD30 and a reduced incidence of infection. None of the 35 patients with high pretransplant levels of sCD30 level (>90 U/mL) developed infections posttransplantation. However, 9 of 65 patients who had low levels of sCD30 (<90 U/mL) developed infections posttransplantation (P < .02). No remarkable differences were noted among the other clinical parameters. The results also showed that the high-definition flow-bead (HDB) assay detected both weak and strong class I and class II HLA antibodies, some of which (weak class II HLA Abs) were undetectable by the anti-human globulin cytotoxicity method. In addition, more antibody specificities were detected by HDB. In conclusion, we have observed that high levels of sCD30 prior to heart transplant may be associated with greater immunologic ability and therefore produce a protective effect on the development of infection post heart transplant. We have also shown that the HDB assay is superior to the visual cytotoxicity method to detect HLA antibodies, especially those to class II HLA antigens.     

Weaning of immunosuppression in living donor liver transplant recipients

BACKGROUND: Some reported studies have indicated the possibility of immunosuppression withdrawal in cadaveric liver transplantation. The aim of this study was to evaluate the possibility and feasibility of weaning living donor liver transplant recipients from immunosuppression. METHODS: From June of 1990 to October of 1999, 63 patients were considered to be weaned from immunosuppression. They consisted of 26 electively weaned patients and 37 either forcibly or incidentally weaned patients (nonelective weaning) due to various causes but mainly due to infection. Regarding elective weaning, we gradually reduced the frequency of tacrolimus administration for patients who survived more than 2 years after transplantation, maintained a good graft function, and had no rejection episodes in the preceding 12 months. The frequency of administration was reduced from the conventional b.i.d. until the start of weaning to q.d., 4 times a week, 3 times a week, twice a week, once a week, twice a month, once a month, and finally, the patients were completely weaned off with each weaning period lasting from 3 to 6 months. The reduction method of nonelective weaning depended on the clinical course of each individual case. When the patients were clinically diagnosed to develop rejection during weaning, then such patients were treated by a reintroduction of tacrolimus or an additional steroid bolus when indicated. RESULTS: Twenty-four patients (38.1%) achieved a complete withdrawal of tacrolimus with a median drug-free period of 23.5 months (range, 3-69 months). Twenty-three patients (36.5%) are still being weaned at various stages. Sixteen patients (25.4%) encountered rejection while weaning at median period of 9.5 months (range, 1-63 months) from the start of weaning. All 16 were easily treated with the reintroduction of tacrolimus or additional steroid bolus therapy. CONCLUSIONS: We were able to achieve a complete withdrawal of immunosuppression in some selected patients. Although the mechanism of graft acceptance in these patients has yet to be elucidated, we believe that a majority of long-term patients undergoing living donor liver transplantation may, thus, be potential candidates to be successfully weaned from immunosuppression.     

The risk factors for early infection in adult living donor liver transplantation recipients

Objective

The high rate of early major infections in liver transplantation recipients is due to their compromised immune-system. We examined the risk factors of early major infection in living donor liver transplantation (LDLT).

Materials and methods

From January 2004 to December 2010, 242 patients undergoing LDLT were enrolled in the prospective cohort. We prospectively collected their clinical and demographic variables, operative details, and posttransplant complications.

Result

One hundred thirty-nine patients (57.7%) experienced 252 episodes of early infection posttransplantation: bloodstream septicemia (n = 46, 18.3%), urinary tract (n = 34; 14.1%), pneumonia (n = 64; 25.4%), peritonitis (n = 62; 25.7%), and catheter related (n = 46; 19%). The most frequent Gram-positive bacteria were coagulase-negative staphylococci (n = 52; 16.9%), followed by Staphylococcus aureus (n = 32; 10.4%). The most common Gram-negative bacteria were Escherichia coli (n = 27; 8.8%); Acinetobacter baumannii (n = 29; 9.4%), Pseudomonas aureos (n = 18; 5.8%), and Sternotrophomonas maltophilia (n = 18; 5.8%). Upon multivariate logistic regression analysis, the risk factors for early major infection were a high creatinine level (odds ratio = 1.481), a long anhepatic arterial phase (1.01), a reoperation (6.417), young age (1.040), and non-hepatocellular carcinoma recipient (2.141).

Conclusion

Early major infection after LDLT was high with Gram-positive bacteria, the most common etiologies. Prolonged anhepatic arterial phase, renal insufficiency, and reoperation were risk factors for an early major infection.     

Attitude of hospital personnel faced with living liver donation in a Spanish center with a living donor liver transplant program.

In Spain, despite its high rate of cadaveric donation, death while on the liver transplant waiting list is high. For this reason, living liver donation is being encouraged despite of the risk of morbidity for the donor. The objective of this study was to analyze attitudes toward living liver donation among hospital personnel in a hospital with a recently authorized living donor liver transplantation program. A random sample was taken and was stratified by type of service and job category (n = 1,262). Attitude was evaluated by means of a validated psychosocial questionnaire. The questionnaire was completed anonymously and was self-administered. Statistical analysis included the Student t test, the chi(2) test, and logistical regression analysis. The questionnaire completion rate was 93% (n = 1,168). Only 15% (n = 170) of respondents were in favor of living liver donation if it were unrelated. An additional 65% (n = 766) were in favor if this donation, but only for relatives. Of the rest, 9% (n = 107) did not agree with living liver donation, and the remaining 11% (n = 125) were undecided. The variables related to this attitude were age (P = 0.044); job category (P = 0.002); type of service (according to whether it is related to organ donation and transplantation) (P = 0.044); participation in prosocial activities (P = 0.026); attitude toward cadaveric organ donation (P <0.001); attitude of a respondent's partner toward organ donation (P = 0.010); a respondent's belief that in the future, he or she may need a transplant (P < 0.001); and a willingness to receive a donated living liver organ if one were needed (P < 0.001). There is also a close relationship between attitude toward living kidney donation and living liver donation (P < 0.001). In the multivariate analysis, the only common independent variable from the bivariate analysis was a willingness to receive a living donor liver transplant if one were needed (odds ratio = 9.3). Attitude toward living liver donation among hospital personnel in a hospital with a solid organ transplant program is favorable and is affected by factors related to cadaveric donation, altruistic activity, and feelings of reciprocity. Physicians and the youngest hospital workers are those who are most in favor, which leads us to think that there is a promising future for living liver transplantation, which is essential given the cadaveric organ deficit and the high mortality rate while on the waiting list.