Pulmonary complications in heart transplant recipients

BACKGROUND: Heart transplantation is an important therapeutic option for patients with end-stage disease, but is associated with major pulmonary complications. PATIENTS AND METHODS: We retrospectively reviewed the posttransplant follow-up of 34 orthotopic heart transplant recipients. RESULTS: Two of the 34 patients died of cardiac failure in the early postoperative period. Among the surviving patients, 10 (31.3%) developed pulmonary complications, all within the first 6 months: hospital-acquired bacterial pneumonia in five, fungal pneumonia in three, posttransplant lymphoproliferative disease in one, and community-acquired pneumonia in one patient. None of the patients developed transplantation-related malignancy. The overall mortality was 35.3%. Pneumonia-related mortality rate of 14.7% was due to early-onset nosocomial pneumonias, which were caused by bacterial and opportunistic microorganisms. Extrapulmonary causes of mortality were cardiac failure, meningitis, septicemia, and acute rejection. Cytomegalovirus antigenemia in the first month was associated with a poor prognosis. The frequency of pulmonary complications was higher among older patients and those who developed moderate rejection in the first month (P=.014 and P=.036, respectively). CONCLUSION: Pulmonary infections after heart transplantation occurred more frequently during the first 6 months posttransplantation, accounting for a significant portion of the posttransplantation mortality.     

肝移植术后胆道并发症的诊断与治疗

目的 探讨肝移植术后胆道并发症的诊断与治疗.方法 分析2007-2009年肝移植术后不同类型胆道并发症的患者的临床资料,评价胴道并发症的类型,处理方式及术后恢复情况.结果 肝移植术后胆道并发症患者23例,包括胆漏患者12例,计胆管吻合口漏7例,肝断面胆管漏3例,胆囊管漏1例,迷走胆管漏1例;移植术后胆管狭窄患者11例,其中吻合口狭窄4例,非吻合口性狭窄7例.7例吻合口漏患者中,胆管重建2例(Roux-en-Y吻合和胆肠襻式Warren吻合);胆道吻合口修补1例;单纯依靠外引流管引流1例,活体双供肝肝移植的患者剖腹探查纠正胆漏失败后行再次肝移植1例;行经内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)植入支架2例.肝断面胆管漏3例中,行肝断面胆管缝扎1例,ERCP联合B超引导下穿刺引流2例,引流2个月后胆漏闭合,拔除引流管,但是随后又出现胆道狭窄,ERCP术后,病情好转.胆囊管漏1例,行胆囊管缝扎.迷走胆管漏1例,行胆囊床缝扎.吻合口狭窄的患者4例,3例经ERCP治愈,1例行胆肠吻合重建胆道后治愈.非吻合口性狭窄的7例,行ERCP治疗3例,ERCP失败后,行经皮肝穿刺胆管引流(percutaneous transhepatic cholangiographic drainage,PTCD)1例;再次肝移植3例,2例患者术后恢复良好,1例死于严重感染.结论 肝移植术后胆道并发症危害大,关键在于预防.     

Cytomegalovirus infections in cardiac transplant patients: an experience at a clinical hospital, university of Chile

BACKGROUND: Since cytomegalovirus (CMV) infects between 20% and 50% of heart transplant patients, we reviewed our experience in 7 cases of this infection. METHODS: A prospective analysis of CMV infection was performed in heart transplant patients who received cyclosporine, azathioprine, or mycophenolate mofetil, and prednisone. An elevated creatinine de novo was managed with antibody induction. RESULTS: Between August 2001 and December 2005, we performed 22 heart transplants and 1 heart plus kidney transplant. Twenty-two patients were positive for CMV before transplantation. One patient died early because of graft failure. Immunosuppression included cyclosporine and prednisone (100%), azathioprine (52%), or mycophenolate (47%). Two recipients were induced with thymoglobulin and 13 with Daclizumab, while 8 did not receive any antibody. Nineteen patients received prophylaxis for CMV. Seven patients (30%) showed CMV infection, 6 of whom had received prophylaxis. Symptoms started at an average of 107 days posttransplantation in patients with prophylaxis. Three patients had gastritis, 2 pneumonia, and 1 colitis. One patient had concomitant lung aspergillosis. The two patients who received ATG developed CMV infections; 3 of the 12 with Daclizumab; and 2 who did not receive antibody. Of the CMV-infected subjects, 5 were on azathioprine and 2 on mycophenolate. All patients were treated with gancyclovir. The 1 patient with concomitant aspergillosis died. CONCLUSIONS: The incidence of infection by CMV was 30%. Prophylaxis seemed to delay infection. Daclizumab induction did not increase the risk for CMV.     

Pulmonary and blood stream infections in adult living donor and cadaveric liver transplant patients

BACKGROUND: Infectious complications occur in approximately 50% of cadaveric liver transplant (CDLT) recipients. Living-donor liver transplantation (LDLT) is an established alternative to shorten the waiting time. Currently, the incidence of pulmonary infections after LDLT and the microbiologic causes are unknown. In the present cohort study, we compared the incidence and profiles of pulmonary and blood stream infections (BSI) between LDLT and CDLT recipients. We hypothesized a lower incidence in LDLT recipients. METHODS: The clinical course of 55 LDLT recipients consecutively transplanted between January 2003 and December 2006 was analyzed. The 173 CDLT recipients who were transplanted in the same period served as a control group. Patients were treated in a single Intensive Care Unit, applying standardized postoperative care. RESULTS: Mean model for end-stage liver disease score did not differ between LDLT and CDLT recipients (14.2 vs. 13.3). The overall incidence of pulmonary and BSI for both groups was 8% and 24%, respectively. Pulmonary infections were experienced by 18% of LDLT versus 5% of CDLT recipients (P=0.005) and BSI occurred in 33% of LDLT versus 21% of CDLT recipients (P=0.1). CONCLUSIONS: In contrast to our hypothesis, LDLT recipients experienced significantly more pulmonary infections and a trend toward increased higher incidence of BSI. These findings emphasize the need for future research on the causative agents and prevention of infection in LDLT recipients. The observation that patients with pulmonary infection had a significantly reduced 1-year survival rate underscores the importance of our observations.     

心脏移植受者术后感染的防治

通过临床分析３例心脏移植受者在术后不同阶段所发生的各种感染性疾病，主要探讨心脏移植术后感染发生的规律及其防治措施。结果发现在术后１－２个月，细菌性感染及机会性真菌感染较多见，采用敏感的抗生素能够完全控制感染。术后３个月以上的患者，各种感染逐渐减少。提示在移植术后初期，应加强对感染的监测与防治。     

Three cases of cardiac hydatidosis: diagnosis, surgical treatment, and complications

Three cases of cardiac hydatid disease from among the many cases of hydatidosis (>300) in various organs observed by the authors are reported. The sites of the cysts and the complications that arose are described. The first case developed hydatid pulmonary embolism caused by rupture into the right ventricular cavity, the second suffered peripheral hydatid embolism caused by rupture into the left ventricular cavity, and the third, whose diagnosis was fortuitous, had no complications. The first patient died shortly after admission. The other two underwent radical pericystectomy and partial pericystectomy with cardiopulmonary bypass. The best result was obtained in the third case where rupture had not occurred. The second patient recovered but developed hemiparesis. The various diagnostic tools available are discussed, as well as some technical aspects of pericystectomy, which has a high mortality rate. The importance of early diagnosis and treatment of this rare localization of Echinococcus granulosus is emphasized, and echocardiography is recommended even for nonspecific cardiac symptoms in areas where the parasite is endemic.     

Efficacy and limitations of preemptive therapy against cytomegalovirus infections in heart transplant patients

OBJECTIVES: Cytomegalovirus (CMV) disease often represents a serious complication that promotes opportunistic infections in heart transplant recipients. In this study we evaluated the impact of preemptive gancylovir therapy, guided by pp65 antigenemia on the morbidity associated with viral reactivation. PATIENTS AND METHODS: We have performed a CMV infection surveillance program since March 1999, with antigenemia pp65 determinations weekly for the first 2 months biweekly in the third months, and monthly to the sixth month. Patients with pp65 antigenemia value >/= 10 positive cells per 2 x 10(5) polymorphonuclear cells (PMN) were treated with intravenous gancyclovir followed by 1 month of oral gancyclovir. RESULTS: Among the 107 patients who underwent the virological monitoring, 80 were pp65 antigenemia-positive with preemptive therapy administered in 48 cases. Five patients displayed symptomatic CMV disease (4.7% vs 18% rate in the period of 1988 to 1998 before the introduction of virologic monitoring; P <.01). We observed only one case of gancyclovir-resistant pneumonia which was successfully treated with foscarnet. CMV recurrence in 10 patients required a second cycle of gancyclovir treatment. Our experience included 13 opportunistic infections (12.7%) with 11 antigenemia-positive. CONCLUSIONS: Preemptive therapy drastically reduces the incidence of CMV disease and the associated morbidity. Compared to universal prophylaxis, this approach may avoid unnecessary pharmacologic treatment in more than 50% of transplant recipients. Indeed, preemptive therapy does not fully prevent CMV disease, because it may manifest at the first antigenemia determination, and furthermore may select gancyclovir-resistant strains.     

Pulmonary edema in renal transplant patients

A syndrome heralded by fever, deterioration of graft function, respiratory failure accompanied by pulmonary infiltrates has been termed "transplant lung." We hemodynamically studied eight such patients. At the height of their illness, pulmonary artery wedge pressure (PAWP) was elevated to 19.3 +/- 2.6 mm Hg along with mean pulmonary artery pressure (PAP) of 35.0 +/- 3.8 mm Hg in presence of increased cardiac index (CI) of 4.9 +/- 0.9 L.m2.min. Pathophysiology of pulmonary edema appears to include high left ventricular filling pressures, pulmonary hypertension, alterations of oncotic hydrostatic gradient, and increased cardiac output. A partial reversal of pulmonary hypertension was observed with dialysis or diuresis. Our data suggest incipient renal failure and fluid accumulation as the etiology of hemodynamic pulmonary edema in "transplant lung."     

Increased risk of pneumococcal infections in cardiac transplant recipients

We observed 5 episodes of pneumococcal infection among 129 cardiac transplant patients between March 1985 and December 1987, giving an estimated incidence of 36 cases per 1000 patient-years. Infections occurred a mean of 58 days after transplantation and included bacteremia with empyema, bacteremia alone, and pneumonia. All patients recovered from their infections. There was no correlation between infection and age, sex, immunosuppression, or rejection episodes. We also measured antibody levels to 12 pneumococcal antigens in 6 unvaccinated, uninfected patients before and after cardiac transplantation, to see if baseline antibody levels decreased. Protective levels of antibody were defined as greater than or equal to 300 ng of anticapsular antibody nitrogen per milliliter serum. Before transplantation patients had protective antibody levels to a mean of 8.7 +/- 1.2 pneumococcal serotypes; after transplantation, the number of presumably protective antibody levels decreased to 6.5 +/- 1.4 (P = 0.021). One of these patients subsequently developed pneumococcal pneumonia. Cardiac transplant patients are at increased risk of pneumococcal infections. Vaccinating transplant candidates prior to transplantation may provide protection after transplantation.     

Gastrointestinal complications in heart transplant patients: MITOS study

INTRODUCTION: The most frequent immunosuppressive treatment complications in solid organ transplant recipients are gastrointestinal (GI) disorders. MATERIALS AND METHODS: An observational, cross-sectional study to evaluate the prevalence and management of GI complications in transplanted patients was conducted via a written questionnaire given to doctors at their practice. RESULTS: This study included 1788 patients; 181 corresponded to heart transplant recipients. The mean age for the heart transplant patients was 58.7 +/- 11.8 years. The mean time from the transplantation was 5.2 +/- 4.4 years. GI complications were seen in 38.7% of cases. Regarding the clinical management, in 72.9% of cases patients with GI complications received pharmacologic treatment, 86.3% with gastric protectors, 32.8% reduced the dose of some drug, 8.1% interrupted the drug temporarily, and 10.9% discontinued the drug permanently. The drug that was always discontinued was mycophenolate mofetil (MMF), and in 85.7% of cases in which the dose of an immunosuppressive drug was reduced, the reduced drug was also MMF. CONCLUSIONS: Almost 40% of heart transplant recipients suffered GI complications which affected daily activities in most cases. The most used strategy to manage these complications was based on a treatment with gastric protectors together with dose reduction and/or partial or definitive MMF discontinuation.     

Cytomegalovirus infections in renal transplant patients

The incidence of cytomegalovirus infection in Chinese patients was reviewed in a retrospective study of 99 renal transplant recipients. CMV infection occurred in 18 patients (18.2%). In 4 the infection was considered primary and in 14 it was thought to be reactivation. Of the infections 88.9% occurred within the first 6 months after transplantation, 44.4% were asymptomatic, while the rest had protean manifestations with the commonest combinations of fever, hepatic dysfunction and haematological abnormalities. One patient succumbed to the infection. Significant difference was seen in the incidence of CMV infections among patients who had received different antirejection therapy, being the highest (37%) among those who had received either Atgam or OKT3. Among the various secretions, urine gave the best yield of virus cultures.     

Mycobacterial infections in marrow transplant patients

Bone marrow transplant recipients undergo ablation of host immune defenses with total-body irradiation or high dose chemotherapy, or both. Over a 5.6-year period, mycobacterial infections were observed in 7 of 682 patients with leukemia who received marrow grafts. Four patients had pulmonary and three extrapulmonary infection. Granulomas were observed in the lungs of three patients, in the liver of one patient, and in the skin of one patient. Cultures revealed Mycobacterium tuberculosis in two patients, Mycobacterium fortuitum in two patients, and Mycobacterium kansasii in one patient. In the six patients treated with antimycobacterial therapy in either the pretransplant or posttransplant period, complete resolution of the infection was achieved. Pretransplant chest radiograph abnormalities suggesting mycobacterial infections should be aggressively evaluated in these immunocompromised hosts. Prophylaxis should be considered in marrow graft recipients with a well-established history of inadequately treated tuberculosis, previous Bacille Calmette-Guerin immunotherapy, known family contacts, recent skin test conversion, or past skin test positivity.     

Human herpesvirus-6 in liver transplant recipients: role in pathogenesis of fungal infections, neurologic complications, and outcome

BACKGROUND: The clinical impact and relevance of human herpesvirus-6 (HHV-6) infection in liver transplant recipients, has not been fully discerned. METHODS: A prospective study of 80 consecutive liver transplant recipients was performed using surveillance cultures for HHV-6 at weeks 2, 3, 4, and 6 after transplantation. Viral isolation was used for the detection of HHV-6. RESULTS: HHV-6 infection occurred in 39% (31 of 80) of the patients. Patients with HHV-6 infection were more likely to have hepatocellular carcinoma as underlying liver disease (P=.09). Mental status changes of unidentifiable etiology were significantly more likely to occur in patients with HHV-6 compared with those without (26%, 9 of 31 vs. 6%, 3 of 49, P=.008). HHV-6 infection was an independent predictor of invasive fungal infections (odds ratio 8.3, 95% confidence interval, 1.2-58.0, P=.03). A significant association between HHV-6 infection and CMV infection after transplantation, CMV recipient and donor serostatus, rejection, or fever of unknown origin, could not be documented. Mortality at last follow-up in patients with HHV-6 infection (29%, 9 of 31) was significantly greater than those without HHV-6 (6%, 3 of 49, P=.008). CONCLUSIONS: Central nervous system complications of unknown etiology after liver transplantation may be related to HHV-6 infection. HHV-6 viremia was an independently significant predictor of invasive fungal infections and was associated with late mortality in liver transplantation recipients.     

Etiology, diagnosis and therapy of soft tissue infections

Soft tissue infections are caused by a multitude of bacteria. Their pathogenicity depends on the ability to adhere to surfaces, certain characteristics of the cell wall, exoenzymes or exotoxins, and endotoxins. Because etiologic classification of soft tissue infections is not satisfactory, we propose a clinical classification. 1. Abscesses are caused by staphylococci (carbuncle or suppurative hydroadenitis) or by polymicrobial infections (most subcutaneous abscesses). They are treated by incision and drainage and primary closure of the skin after drainage and curettage is often successful. Only in special cases are antibiotics indicated. 2. Cellulitis mostly caused by streptococci responds well to antibiotic therapy without surgery. 3. Ulcerative lesions i.e. pseudomonal gangrene and Meleney's gangrene need specific antibiotic therapy and complete excision with delayed grafting.