The effect of metallic tracheal stents on radiation dose in the airway and surrounding tissues

Background

Metallic airway stents are often used in the management of central airway malignancies. The presence of a metallic foreign body may affect radiation dose in tissue. We studied the effect of a metallic airway stent on radiation dose delivery in a phantom and an in vivo porcine model.

Methods

A metallic tracheal stent was fitted onto a support in a water phantom. Point dosimeters were positioned in the phantom around the support and the stent. Irradiation was then performed on a linear accelerator with and without the stent. Metallic tracheal stents were deployed in the trachea of three pigs. Dosimeters were implanted in the tissues near (Group 1) and away (Group 2) from the stent. The pigs were then irradiated, and the dose perturbation factor was calculated by comparing the actual dose detected by the dosimeters versus the planned dose.

Results

The difference in the dose detected by the dosimeters and the planned dose ranged from 1.8% to 6.1% for the phantom with the stent and 0%–5.3% for the phantom without the stent. These values were largely within the manufacturer's specified error of 5%. No significant difference was observed in the dose perturbation factor for Group 1 and Group 2 dosimeters (0.836 ± 0.058 versus 0.877 ± 0.088, P = 0.220) in all the three pigs.

Conclusions

Metallic airway stents do not significantly affect radiation dose in the airway and surrounding tissues in a phantom and porcine model. Radiation treatment planning systems can account for the presence of the stent. External beam radiation can be delivered without concern for significant dose perturbation.     

Clinical Outcome of Internal Stent for Biliary Anastomosis in Liver Transplantation

Background

This study analyzed the incidence and management of biliary complications after liver transplantation (LT) with or without internal stent.

Methods

The medical record of all patients who underwent LT and were hospitalized from December 2009 to March 2013 were reviewed. Patients were grouped into 2 groups (internal stent group vs no stent group).

Results

There were 29 deceased-donor liver transplantations (58%) and 21 living-donor liver transplantations (42%). There were 2 perioperative mortalities, and those 2 patients were excluded from this study. The overall biliary complication rate was 6.45% in the internal stent group and 17.65% in the no stent group. The rate of anastomotic stricture was 3.23% (n = 1) in the stent group and 11.76% (n = 2) in the no stent group. The rate of bile leak was 3.23% (n = 1) in the stent group and 0% in the no stent group. The rate of biliary obstruction was 0% in the stent group and 5.88% (n = 1) in the no stent group.

Conclusions

The overall rate of biliary complications in the internal stent group was lower than in the no stent group, and most of the biliary complications could be treated successfully with endoscopic or radiologic intervention.     

Endobronchial metallic stent placement for airway complications after lung transplantation: longitudinal results

Background

In lung transplant recipients, bronchial stenosis (SB) and bronchomalacia (MB) result in obstructive airway disease and allograft dysfunction due to pulmonary infection. We hypothesized that endobronchial metallic stent placement for SB and MB would result in long-term improvement in respiratory function and rates of pulmonary infection.

Methods

We studied symptomatic lung transplant recipients with bronchoscopic evidence of proximal airway complications (SB or MB) and a synchronous decline in forced expiratory volume in 1 second (FEV₁) of at least 10% in the 6-month period before intervention. Stent placement was the primary intervention for SB and all focal MB lesions and for recurrent or refractory SB lesions failing a single initial attempt at balloon dilation. FEV₁ and rates of pulmonary infection were assessed in the 12-month interval before and after stent placement. Spirometric evaluation was performed at 3-month intervals and compared with spirometry at the time of stent placement. The rates of pulmonary infection, determined by the number of antibiotics prescribed, was determined before and after endobronchial correction.

Results

Thirty recipients underwent a total of 75 procedures (50 stent insertions and 25 balloon dilations). FEV₁ improved significantly after stent placement compared with base line (1.29 ± 0.43 L) as follows: 3 months, 1.45 ± 0.50 L, p = 0.014; 6 months, 1.59 ± 0.57 L, p = 0.002; 12 months 1.59 ± 0.53 L, p = 0.006. The infection rate decreased from the 12-month period preceding stent insertion to the corresponding period after stent insertion (6.97/100 days ± 6.33 versus 5.74/100 days ± 7.76, p = 0.018). Recurrent SB occurred in 17.3%. No life-threatening complications occurred after stent placement and no deaths were attributed to stent malfunction or malposition.

Conclusions

In lung transplant recipients with SB and MB, maintenance of airway patency by stent placement is safe and resulted in improvements in lung function and reduced pulmonary infection rates for up to 1 year after their insertion.     

Do we need to cool the lung graft after ex vivo lung perfusion? A preliminary study

Background

After normothermic ex vivo lung perfusion (EVLP), pulmonary grafts are usually flush-cooled and stored on ice until implantation although evidence for this practice lacks. We compared outcomes between 2 post-EVLP preservation strategies in a porcine left single-lung transplantation model.

Material and methods

After cold flush and 2-h EVLP, donor lungs were prepared and split. In [C], (n = 5) lungs cooled on device to 15°C were preserved in ice-water; in [W] (n = 5), lungs were disconnected from EVLP at 37°C and kept at room temperature. The left lung was transplanted in a recipient animal. Posttransplant, 6 h-monitoring included hourly assessment of pulmonary vascular resistance, pulmonary artery pressure, plateau airway pressure, compliance, and oxygenation before and after exclusion of the right lung. Lung biopsies and bronchoscopy with bronchoalveolar lavage (BAL) were performed at retrieval, at the end of EVLP (R lung), and 1 and 6 h after reperfusion (L lung).

Results

Lungs in [W] showed the highest compliance (P < 0.05) and the lowest plateau airway pressure (not statistically significant) throughout the whole reperfusion period. Oxygenation and pulmonary artery pressure were similar between groups. Pulmonary vascular resistance was stable in [C], but rose after reperfusion in [W]. Histologic signs of lung injury and BAL neutrophilia were more pronounced in [C] at 1 h (not statistically significant and P < 0.05, respectively). BAL cytokine levels and lung tissue expression of intercellular adhesion molecule 1 did not differ between groups.

Conclusions

Normothermic preparation after EVLP results in similar graft performances compared with lung cooling after EVLP.     

Traitements antifongiques en réanimation au cours des infections fongiques invasives documentées ou suspectées

Objective

Describe systemic antifungal therapy in non-neutropenic adult patients in intensive care unit (ICU).

Patients and method

A prospective, observational study was conducted during the first half of 2010 in the 7 ICU in a hospital with medical consultant on antimicrobial therapy. All non-neutropenic consecutive adult patients receiving systemic antifungal therapy for documented or suspected invasive fungal infection (IFI) apart from aspergillosis were included.

Results

Out of 1502 patients admitted in ICU, 104 (7 %) underwent systemic antifungal therapy, including 30 (29 %) for a documented IFI and 74 (71 %) for a suspected IFI. Candida albicans was identified in 23 (77 %) of the IFI and 45/52 (86 %) of the broncho-pulmonary and/or urinary colonizations in suspected IFI. Echinocandin was significantly more prescribed in patients with a documented infection (19/30 patients) and fluconazole in patients with a suspected infection (48/74 patients). The first line therapy was primarily stopped after recovery (11/30 patients) or de-escalation (9/30 patients) in documented infections, and for lack of indication (34/74 patients) or due to recovery (21/74 patients) in suspected infections after on average of 7 days of treatment.

Conclusion

For ICU non-neutropenic adult patients in our center, antifungal therapy is prescribed two times out of three for suspected, unproved infections, in most cases with fluconazole. Documented infections were more often treated by echinocandin with secondary de-escalation. An interventional prospective study to assess the role of antifungal pre-emptive or empirical therapy is necessary.     

Percutaneous valved stent implantation in the ascending aorta for the treatment of very high-risk aortic regurgitation: an animal study

Purpose

We investigated the effects of percutaneous valved stent implantation in the ascending aorta as an alternative treatment for aortic regurgitation in a canine model.

Materials and methods

A total of 16 healthy dogs weighing an average of 18.3 ± 2.1 kg were used for the establishment of animal models of chronic aortic regurgitation by percutaneous aortic valve perforation and balloon dilation. At 2 mo after successful model establishment, all experimental animals underwent valved stent implantation in the ascending aorta and then were followed up for 3 mo.

Results

Experimental models of chronic aortic regurgitation were successfully established in 10 dogs. Surviving dogs underwent successful valved stent implantation in the ascending aorta and were subsequently followed up for 3 mo. The level of instantaneous aortic regurgitation at 3-mo follow-up was significantly reduced compared with that before valved stent implantation (2.4 ± 0.9 versus 10.6 ± 2.1 mL/s, P < 0.05). The left ventricular ejection fraction was significantly increased (53.8 ± 4.2% versus 37.8 ± 3.7%, P < 0.05), and the left ventricular end-diastolic volume was also significantly reduced (30.3 ± 2.2 versus 40.1 ± 3.6 mL, P < 0.05). No paravalvular leak, stroke, atrioventricular block, or other complications occurred in dogs undergoing valved stent implantation.

Conclusions

Percutaneous valved stent implantation in the ascending aorta is feasible, effective, and safe as an alternative treatment for very high-risk aortic regurgitation in a canine model.     

Effect of Age on Native Kidney Function after Adult Intestinal Transplants on Long-Term Follow-up

Background

Kidney function usually deteriorates after intestinal transplant, with prevalence of renal failure almost 20% after 5 years. We report our results on adults from single institution over >10 years.

Methods

Forty-six patients were transplanted with 22 survivors; we divided them in 2 groups: Group 1, recipients with creatinine >1.2 mg/dL (normal, 0.50–1.2) and Group 2, normal creatinine. Group 1 included 12 patients (9 males) with a mean age of 42.8 years; all lived at home, with normal creatinine at transplant (apart from 1 patient with a creatinine of 1.6 mg/dL), and were mainly transplanted for short bowel syndrome. One underwent retransplantation. Immunosuppression was based on alemtuzumab (8 recipients) plus tacrolimus (FK). Group 2 included 10 patients (6 males) with a mean age of 34.7 years; all lived at home, had normal creatinine at transplantation, and were mainly transplanted for short bowel syndrome. Immunosuppression was mainly based on alemtuzumab (8 recipients) plus FK.

Results

There were no relevant differences between the 2 groups regarding number of recipients, sex, baseline creatinine at transplant, reason for transplantation, retransplantation, immunosuppression, antifungal or antiviral therapy, hospitalization, total parenteral nutrition (or fluids), or stoma. The only relevant difference was age (P = .04); patients with deteriorated kidney function or altered creatinine were found to be older.     

Effect of Donor–Recipient Age Gradient on Graft Outcomes in Deceased Donor Liver Transplantation

Purpose

Donor age is a well-known factor influencing graft function after deceased donor liver transplantation (DDLT). However, the effect of donors older than recipients on graft outcomes remains unclear. This study investigated the relationship between the donor–recipient age gradient (DRAG) and posttransplant outcomes after DDLT.

Methods

We included 164 adult recipients who underwent DDLT between May 1996 and April 2011. Patients were divided into 2 groups according to the value of DRAG: Negative (DRAG −20 to −1; n = 99) versus positive (DRAG 0–20; n = 65). Medical records were reviewed and laboratory data were retrospectively collected.

Results

The median age of donors and recipients was 43 (range, 10–80) and 46 (range, 19–67) years, respectively. The mean follow-up time was 57.4 months. A positive DRAG had a negative effect on levels of alkaline phosphatase until 2 weeks after transplantation. However, the positive group showed a lower incidence of hepatitis B viral disease recurrence. The 1-, 3-, and 5-year graft survival rates were 80.4%, 76.8%, and 71.4% in the negative group, and 65.8%, 58.4%, and 56.3% in the positive group, respectively. The positive DRAG group showed significantly inferior graft survival compared with the negative DRAG group (P = .036).

Conclusion

This study demonstrated that donors older than recipients had a deleterious effect on graft outcomes. DRAG could be a meaningful determinant of graft survival among DDLT recipients.     

Ureteral Obstruction: Is the Full Metallic Double-Pigtail Stent the Way to Go?

Background

The Resonance metallic ureteral stent (Cook Medical, Bloomington, Indiana, USA) has been introduced for the management of extrinsic-etiology ureteral obstruction for time periods up to 12 mo.

Objective

The current study aims to determine short- and medium-term effectiveness of the Resonance stent in malignant and benign ureteral obstruction.

Design, setting, and participants

In total, 50 patients with extrinsic malignant obstruction (n = 25), benign ureteral obstruction (n = 18), and previously obstructed mesh metal stents (n = 7) were prospectively evaluated.

Intervention

All patients were treated by Resonance stent insertion. Twenty stents were inserted in antegrade fashion, and the remaining stents were inserted in a retrograde approach. No patient dropped out of the study. The follow-up evaluation included biochemical and imaging modalities.

Measurements

We evaluated the technical success rate, stricture patency rate, complications, and the presence and type of encrustation.

Results and limitations

The technical success rate of transversal and stenting of the strictures was 100%. In 19 patients, balloon dilatation was performed prior to stenting. The mean follow-up period was 8.5 mo. The stricture patency rate in patients with extrinsic malignant ureteral obstruction was 100% and in patients with benign ureteral obstruction 44%. Failure of Resonance stents in all cases of obstructed metal stents was observed shortly after the procedure (2–12 d). In nine cases, stent exchange was demanding. Encrustation was present in 12 out of 54 stents.

Conclusions

The Resonance stent provides safe and sufficient management of malignant extrinsic ureteral obstruction. Resonance stent use in benign disease needs further evaluation, considering the untoward results of the present study.     

Renal Allograft Outcome in Recipients of Positive-Crossmatch Combined Liver-Kidney Transplantation

Background

Successful kidney transplantation despite positive crossmatch (+CXM) before transplantation is well recognized in combined liver-kidney transplant (CLKT) recipients. This is probably due to immunologic protection of the renal allograft (RA) conferred by the liver allograft. However, occurrences of antibody-mediated rejection and poor long-term RA outcome is also documented with +CXM CLKT recipients, suggesting that such immunologic protection may not be universal.

Methods

A total of 1,401 CLKT recipients with known status of pre-transplantation CXM were identified from the United Network for Organ Sharing registry from January 1, 1986, to December 31, 2006. Univariate analysis for significant differences in clinical variables and Kaplan-Meier estimate for patient and graft survivals were performed. The results were compared between positive and negative CXM groups.

Results

Pre-transplantation +CXM was seen in 17.3% (242/1401) of CLKT recipients studied. The demographic and clinical characteristics were similar between the groups, except for higher panel reactive antibody level and CXM positivity in female recipients. Outcome analysis showed higher RA rejection (19.3% vs 10.8%; P = .026) and increased hospital length of stay (37.3 ± 46.0 vs 28.8 ± 33.2 days; P = .028) in the +CXM group. RA survivals at 1, 3, and 5 years were 8%, 7%, and 6% lower in the +CXM group. The patient and liver allograft survivals were not different between the groups.

Conclusions

In CLKT recipients with pre-transplantation +CXM, the immunologic protection of RA conferred by the liver allograft is less robust than previously perceived and may lead to higher rejection rate and poor RA outcome. This can be mitigated with routine pre-transplantation CXM.     

Progression of Metabolic Syndrome in Renal Transplant Recipients

Background

Metabolic syndrome, which is closely related to insulin resistance, is highly prevalent in renal transplant recipients.

Purpose

We aimed to investigate prevalence, risk factors, and progression of metabolic syndrome in renal transplant recipients.

Methods

One hundred fifty-eight renal transplant recipients who had been on transplantation for more than 1 year and 79 age-sex matched healthy controls were included in the cross-sectional phase of the study. We measured baseline characteristics, blood pressure, fasting blood glucose, and lipid profiles and we defined metabolic syndrome using the National Cholesterol Education Program Adult Treatment Panel III criteria. One hundred twenty-four renal transplant recipients were eligible for the second evaluation after 22.9 ± 3.8 months. Metabolic syndrome prevalence and homeostasis model assessment insulin resistance levels were evaluated during the follow-up period.

Results

Overall, metabolic syndrome was present in 34.2% of the patients and 12.7% of the controls at the cross-sectional phase of the study (P = .000). Only the hypertension component of metabolic syndrome was significantly increased in patients compared to controls (P = .000). Pretransplantation weight and body mass index were significantly higher in patients who had metabolic syndrome (P = .000). During the follow-up period, prevalence of metabolic syndrome did not change (P = .510); however, body mass index and blood pressure increased and the high density lipoprotein cholesterol component of metabolic syndrome decreased (P = .001). We did not find any significant difference in glomerular filtration rate change among patients with and without metabolic syndrome (−2.2 ± 11.36 vs −6.14 ± 13.19; P = .091). Glucose metabolism parameters including hemoglobin A1c, insulin, and homeostasis model assessment insulin resistance were disturbed in patients with metabolic syndrome (P = .000, P = .001, P = .002, respectively).

Conclusion

Metabolic syndrome is highly prevalent in renal transplant recipients and closely associated with insulin resistance. The prominent criterion of metabolic syndrome in patients seems to be hypertension, especially high systolic blood pressure. The identification of metabolic syndrome as a risk factor may yield new treatment modalities to prevent it.     

Factors Associated With Consciousness Recovery Time After Liver Transplantation in Recipients With Hepatic Encephalopathy

Background

Hepatic encephalopathy (HE) occurs as a result of liver failure and is often considered to be a clinical indication for liver transplantation (LT). An assessment of post-transplantation consciousness level in recipients with HE is crucial, because recovery of consciousness implies reestablishment of transplant liver function and lack of perioperative brain damage. The purpose of this study is to evaluate factors associated with consciousness recovery time after LT in recipients with HE.

Methods

Out of 633 adult recipients who underwent LT, recipients who exhibited HE at the time of LT were analyzed retrospectively. The time between graft reperfusion and postoperative consciousness recovery was determined, and recipients were divided into 2 groups: group E with recovery of consciousness early (≤48 hours), and group L with recovery of consciousness late (>48 hours). Analyzed variables included recipient sex, age, graft type, Model for End-Stage Liver Disease score, HE history/duration/type/grade, and preoperative laboratory values, including blood ammonia concentration.

Results

HE was present at the time of LT in 69 (10.9%) of 633 recipients. Among the 69 recipients, 11 recipients who died or underwent reoperation before consciousness recovery were excluded, and 58 recipients (group E: n = 32; group L: n = 26) were enrolled into analysis. Multivariate analysis showed that HE duration >5 days (odds ratio [OR], 15.58; 95% confidence interval [CI], 1.35–179.56; P = .028) and HE type C (OR, 30.90; 95% CI, 1.67–573.48; P = .021) were the independent factors associated with late recovery from HE after LT.

Conclusions

We suggest that recipients with long-duration or type C HE should be carefully managed during the post-transplantation period to prevent deterioration of HE.     

Ureteral stenting in laparoscopic colorectal surgery

Background

Few studies have examined the current status of ureteral stent use or the indications for stenting, particularly in laparoscopic colorectal surgery. This study examines current national trends and predictors of ureteral stenting in patients undergoing major colorectal operations and the subsequent effects on perioperative outcomes.

Methods

The 2005–2011 National Surgical Quality Improvement participant user files were used to identify patients undergoing laparoscopic segmental colectomy, low anterior resection, or proctectomy. Trends in stent use were assessed across procedure types. To estimate the predictors of stent utilization, a forward-stepwise logistic regression model was used. A 3:1 nearest neighbor propensity match with subsequent multivariable adjustment was then used to estimate the impact of stents.

Results

A total of 42,311 cases were identified, of which 1795 (4.2%) underwent ureteral stent placement. Predictors of stent utilization included diverticular disease, need for radical resection (versus segmental colectomy), recent radiotherapy, and more recent calendar year. After adjustment, ureteral stenting appeared to be associated with a small increase in median operative time (44 min) and a trivial increase in length of stay (5.4%, P < 0.001). However, there were no significant differences in morbidity or mortality.

Conclusions

We describe the clinical predictors of ureteral stent usage in this patient population and report that while stenting adds to operative time, it is not associated with significantly increased morbidity or mortality after adjusting for diagnosis and comorbidities. Focused institutional studies are necessary in the future to address the utility of ureteral stents in the identification and possible prevention of iatrogenic injury.     

New method of stent-facilitated arterial reconstruction for orthotopic mouse liver transplantation

Background

Arterialized orthotopic liver transplantation (OLT) in the mouse mimics human liver transplantation physiologically and clinically. The present method of sutured anastomosis for reconstruction of the hepatic artery is complex and is associated with high incidence of complications and failure. This makes the endpoint assessment of using this complex model difficult because of the many variables of the technical aspect.

Methods

A total of 14 pairs of donors and recipients from syngeneic male mice were used for arterialized OLT. The grafts were stored in University of Wisconsin solution at 4°C for less than 4 h, and the recipients underwent OLT using a two-cuff technique. The arterial reconstruction was facilitated by the use of a single stent connecting the donor liver artery segment to the recipient common hepatic artery.

Results

All 14 recipients survived with the time for arterial reconstruction ranging from 4–10 min. Patency of the artery was confirmed by transecting the artery near the graft 2 and 14 d after transplantation. At day 2, five of the six arteries transected were patent and at day 14, seven of the remaining eight were patent for an overall patency rate of 85.7%.

Conclusions

The stent-facilitated arterial reconstruction can be done quickly with a high patency rate. This model expands the translational research efforts to address marginal livers such as steatotic livers.     

Effect of Aspergillus fumigatus and Candida albicans on pro-inflammatory response in cystic fibrosis epithelium

Background

The identification of filamentous fungi and/or yeasts in the airway secretions of individuals with cystic fibrosis (CF) is becoming increasingly prevalent; yet the importance of these organisms in relation to underlying inflammation is poorly defined.

Methods

Cystic fibrosis bronchial epithelial cells (CFBE) and human bronchial epithelial cells (HBE) were co-incubated with Candida albicans whole cells or Aspergillus fumigatus conidia for 24 h prior to the measurement of pro-inflammatory cytokines IL-6 and IL-8 by ELISA.

Results

Treatment of HBE or CFBE with C. albicans whole cells did not alter cytokine secretion. However treatment of CFBE with A. fumigatus conidia resulted in a 1.45-fold increase in IL-6 and a 1.65-fold increase in IL-8 secretion in comparison to basal levels; in contrast there was far less secretion from HBE cells.

Conclusion

Our data indicate that A. fumigatus infection modulates a pro-inflammatory response in CF epithelial cells while C. albicans does not.     

Atrial Fibrillation in Patients Undergoing Liver Transplantation—A Single-Center Experience

Background

As the prevalence of atrial fibrillation rises with age and older patients increasingly receive transplants, the perioperative management of this common arrhythmia and its impact on outcomes in liver transplantation is of relevance.

Methods

Retrospective review of 757 recipients of liver transplantation from January 2002 through December 2011.

Results

Nineteen recipients (2.5%) had documented pre-transplantation atrial fibrillation. Sixteen patients underwent liver and 3 a combined liver-kidney transplantation. Three patients died within 30 days (84.2% 1-month survival) and another 3 within 1 year of transplantation (68.4% 1-year survival). Compared with patients without atrial fibrillation, the relative risk of death in the atrial fibrillation group was 5.29 at 1 month (P = .0034; 95% confidence interval [CI], 1.73–16.18) and 3.28 at 1 year (P = .0008; 95% CI, 1.63–6.59). Time to extubation and intensive care unit (ICU) and hospital readmissions were not different from the control cohort. Rapid ventricular response requiring treatment occurred in 4 patients during surgery and 7 after surgery, resulting in 3 ICU and 3 hospital readmissions.

Conclusions

The results suggest that patients with atrial fibrillation may be at increased risk of mortality after liver transplantation. Optimization of medical therapy may decrease ICU and hospital readmission due to rapid ventricular response.     

Transplantation Is a Risk Factor for Acute Kidney Injury in Patients Undergoing Total Hip Replacement Arthroplasty for Avascular Necrosis: An Observational Study

Background

The increased number of patients undergoing transplantation has increased the number of transplant recipients undergoing total hip replacement arthroplasty (THRA). We have evaluated the association between transplantation and acute kidney injury (AKI) in patients undergoing THRA.

Methods

Patients who underwent THRA from May 2004 to February 2012 were retrospectively assessed. Their demographic and clinical characteristics, the results of perioperative laboratory tests, the amounts of fluids transfused during surgery, and anesthesia time were evaluated. Patients were divided into 2 groups: transplant (n = 222) and nontransplant (n = 2,044) patients. With use of the maximal Acute Kidney Injury Network criteria, AKI was evaluated by changes in creatinine concentration within 48 hours of THRA. Propensity analyses and logistic regression were performed to evaluate the association between transplantation and postoperative AKI.

Results

Postoperative AKI was significantly associated with transplantation (P < .0001), and transplantation was an independent factor predictive of postoperative AKI (P < .0001).

Conclusions

Transplant recipients are at risk for AKI following THRA. The mechanism by which organ transplantation enhances postoperative AKI warrants further evaluation.     

Elevated Preoperative Recipient Neutrophil-Lymphocyte Ratio Is Associated With Delayed Graft Function Following Kidney Transplantation

Introduction

The neutrophil-lymphocyte ratio (NLR) is an indicator of inflammatory status. We studied the effect of preoperative elevated NLR in the recipient in relation to the risk of developing delayed graft function (DGF) after kidney transplantation.

Methods

We retrospectively analysed the preoperative white blood cell count of renal transplant recipients between 2003 and 2005. An NLR >3.5 was considered elevated. There were 398 kidney transplant recipients of whom 249 received organs from donors after brain death (DBD), 61 from donors after circulatory death (DCD), and 88 from living donors.

Results

One hundred three patients (26%) developed DGF, of which 67 (65%) had NLRs >3.5. Of 295 recipients with primary graft function, only 44 (15%) had elevated NLR. Univariate analysis revealed three factors that significantly influenced graft function: NLR >3.5, cold ischemic time (CIT) >15 hours, and donor type. On multivariate analysis, both donor type (DCD: hazard ratio [HR] = 2.421, confidence interval [CI] = 1.195–4.905, P = .014; LD: HR = 0.289, CI = 0.099–0.846, P = .024) and NLR (HR = 10.673, CI = 6.151–18.518, P < .0001) remained significant.

Conclusions

Elevated recipient preoperative NLR could contribute to increase the risk of developing DGF, which appears to be more pronounced in patients receiving grafts from living donors.     

Association Between Serum C-Reactive Protein and Albumin Levels and Psychiatric Comorbidities in Liver Transplant Recipients

Background

Orthotopic liver transplantation (OLT) is the definitive treatment for patients with end-stage liver disease. Many post-OLT patients have psychiatric comorbidities. The relationship between psychiatric comorbidities and biological factors, such as C-reactive protein (CRP) and albumin levels, in OLT recipients has seldom been investigated.

Methods

We analyzed medical charts of all patients aged over 18 who underwent orthotopic OLT at a tertiary medical center between September 2008 and July 2010 for serum CRP and albumin levels before and 1 month after OLT. Data for baseline characteristics, such as gender, age, and body mass index (BMI), were also collected. Patients who had a psychiatric consultation or took psychotropic medications during the hospitalization were categorized as “with psychiatric comorbidities.”

Results

Psychiatric comorbidities existed in 51 (33.8%) of 151 OLT recipients. By analysis of covariance adjusted for age and BMI, post-OLT CRP levels in patients with psychiatric comorbidities were significantly higher than those without psychiatric comorbidities (P = .015). For patients with psychiatric comorbidities, the paired t test showed significantly increased CRP levels at 1 month after when compared to the pre-OLT baseline levels (P = .044). Patients without psychiatric comorbidities had significantly decreased CRP levels at 1 month after when compared with the pre-OLT baseline levels (P = .009).

Conclusions

Elevated CRP levels may indicate activation of a systemic inflammatory process caused by psychiatric comorbidities in OLT recipients.