The Peritoneovenous Shunt: Expectations and Reality

Since the introduction of the LeVeen modification of the peritoneovenous shunt (PVS) in 1974, these devices have been placed in a relatively large number of patients. The most common indication has been for medically intractable ascites in the setting of chronic liver disease. A review of a series of studies shows that we can expect approximately an 18% perioperative overall mortality rate, a 46% survival rate at 21 months, and loss of ascites in 59% of the survivors at 18 months. The PVS has not been shown by prospective trials to prolong survival significantly in patients with either intractable ascites or the hepatorenal syndrome (HRS), although it may shorten hospitalizations, compared with medical controls. A few well-documented cases of reversal of the HRS have been documented. The best results of PVS therapy have been evident in those patients with milder liver disease. The loss of ascites need not correlate with a functioning shunt. Alcohol abstinance is associated with hepatic functional recovery and may relate to the disappearance of renal sodium retention, resulting in shunt occlusion due to low flow. A number of serious complications with the PVS have been described. Nutritional repletion follows successful shunting, but might, in part, relate to simultaneous alcohol abstention. The more common complications of coagulopathy and fluid overload are preventable by total ascitic drainage at the time of surgery. Shunt patency remains a clinical problem. Only 18.6% of the total shunts placed functioned in the survivors at 2 yr. Perioperative infections with staphylococcal and Gram-negative organisms occur. Postoperative bacterial peritonitis or septicemia requires shunt removal for cure.     

Prognosis Assessment of Cirrhotic Patients with Refractory Ascites Treated with a Peritoneovenous Shunt

Objective: The role of peritoneovenous shunt in the management of refractory ascites has not been clearly established. The aim of this study was to determine readily accessible predictive survival factors in cirrhotic patients with refractory ascites treated with a peritoneovenous shunt.
Methods: We studied a cohort of 100 cirrhotic patients with refractory ascites who underwent peritoneovenous-shunt placement in a university-based reference hospital.
Results: The estimated median survival of patients after shunt placement was 11 months (95% CI, 7-14 months). Multivariate analysis based on the proportional hazards model disclosed four independent variables associated with poor survival: high Pugh score, nonalcoholic etiology, low ascitic fluid protein concentration, and history of spontaneous bacterial peritonitis.
Conclusions: Mortality of cirrhotic patients treated with a peritoneovenous shunt can be determined by a prognostic index using four easily available variables. Such a prognostic index, once prospectively validated, could be used as an adjunct in planning treatment of cirrhotic patients with refractory ascites.     

Fatal Air Embolism Following Perforation of the Cecum in a Patient with Peritoneovenous Shunt for Ascites

The authors report the occurrence of fatal embolism as a complication of a LeVeen peritoneovenous shunt performed four months previously in a 67-year old man with ascites. Air embolism was caused by perforation of the cecum following cauterization of a vascular malformation of the mucosa through a flexible colonoscope. An autopsy demonstrated air within the peritoneal cavity, the LeVeen shunt and both ventricles of the heart. In the patient with a LeVeen shunt, gastrointestinal perforation from any cause is an indication for immediate closure of the shunt.     

Infectious Complications in Patients with Severe Acute Pancreatitis

This study aims to investigate the clinical characteristics of infectious complications in severe acute pancreatitis (SAP). From September 2003 to March 2005, 140 patients with SAP were retrospectively identified. SAP was defined by the diagnostic criteria formulated for SAP at the 2002 Bangkok World Congress of Gastroenterology in Thailand. Clinical data of the infected and non-infected patients was compared and the characteristics of infection were also analyzed. There were 44 patients who developed infectious complications with a rate of 31.4% (44/140). The severity index, the incidence of complications and mortality, was significantly higher in the infected patients than in the non-infected patients (P < 0.05). Of 65 episodes of infection, infected (peri) pancreatic necrosis accounted for 47.7% (31/65), pneumonia for 27.7% (18/65), bacteremia for 10.8% (7/65), urinary tract infection for 6.1% (4/65), and gastrointestinal tract infection for 7.7% (5/65). The earliest infection was observed in pneumonia (10.7 ± 2.5 days), followed by bacteremia (13.7 ± 1.5 days), gastrointestinal tract infection (16.8 ± 3.9 days), infected (peri)pancreatic necrosis (17.6 ± 2.9 days), and urinary tract infection (20.5 ± 4.8 days). Gram-negative bacteria were preponderantly found, comprising 56.6% (64/113) of the isolated strains. Gram-positive bacteria and fungus accounted for 22.1% (25/113) and 21.2% (24/113) of the isolated strains, respectively. Infectious complications in patients with SAP occurred in those who had severe episodes, and consequently complicated the clinical courses. Infected (peri)pancreatic necrosis is the most susceptible and pneumonia is the earliest. Gram-negative bacteria were predominant in multi-microorganisms.     

Diagnosis and Management of Infectious Complications of Childhood Rheumatic Diseases

Progress in the diagnosis and management of pediatric rheumatic disease has improved complications from underlying disease and the survival of children. However, as a consequence, infection has now become one of the leading causes of morbidity and mortality. Differentiating between infections and disease flares in children with rheumatic conditions can often pose diagnostic quandaries. Children with rheumatic diseases are at risk of infection, not only because of the use of immune-modulating medications but also because of underlying immune dysfunction associated with their disease. Although bacterial infections are the most common, any organism can potentially be a causative agent and, at times, more invasive measures of diagnosis, for example bronchoscopy and tissue biopsies may be necessary. Maintaining a high index of suspicion of infection with prompt diagnosis and treatment are important to further improve patient outcomes.     

Peritoneovenous shunt for pancreatic ascites

Summary A chronically ill patient with pancreatic ascites was successfully treated with a temporary Le Veen peritoneovenous shunt. This observation supports the use of a peritoneovenous shunt in the treatment of pancreatic ascites which is refractory to medical therapy and not amenable to major pancreatic surgery.     

Peritoneovenous shunts in malignant ascites

Summary A 51-year-old woman with malignant ascites secondary to hepatocellular carcinoma had a peritoneovenous (Le Veen) shunt inserted with effective control of ascites and amelioration of symptoms. The results of 12 recent series evaluating the efficacy of peritoneovenous shunts in the treatment of 198 patients with malignant ascites were reviewed. Peritoneovenous shunts effectively controlled malignant ascites in 77% of patients. Complications occurred in 25%, although the majority of these were related to shunt occlusion and transient congestive heart failure.     

Infectious Complications in Kidney-Transplant Recipients Desensitized with Rituximab and Intravenous Immunoglobulin

Summary

Background and objectives

Rituximab and intravenous Ig (IVIG) are commonly used for desensitization of HLA and blood group–incompatible (ABOi) transplants. However, serious infections have been noted in association with rituximab administration. In this study, we retrospectively compared infectious outcomes in those who received rituximab plus IVIG for HLA or ABOi transplants (RIT group) with a group of nonsensitized, ABO-compatible transplant recipients (non-RIT group).

Design, setting, participants, & measurements

Patients undergoing kidney transplantation at Cedars-Sinai Medical Center were included in the analysis. A total of 361 patients were identified. All received antimicrobial prophylaxis and viral surveillance. The primary outcome was infection.

Results

Overall patient survival was 97 and 96%, and graft survival was 91 and 89% in the RIT and non-RIT groups, respectively, after an average follow-up of 18 months. There were equal rates of bacterial (34.7% versus 39.1%), viral (21.8% versus 25.1%), fungal (5.9% versus 5.2%), and serious infections (22.9% versus 25.5%) in the RIT and non-RIT groups respectively. Urinary tract infection was the most common infection, accounting for 50% of all bacterial infections. Cytomegalovirus viremia was nonsignificantly more common in the nonrituximab-treated group (15.2% versus 10%), whereas BK viremia was marginally more frequent in the rituximab-treated group (10.6% versus 5.8%). There were no graft losses caused by BK-associated nephropathy. There were two deaths in each group related to infection (1%).

Conclusion

Rituximab does not increase infection risk when used with intravenous Ig for desensitization.     

Immune Reconstitution and Early Infectious Complications Following Nonmyeloablative Hematopoietic Stem Cell Transplantation

Non-myeloablative stem cell transplantation (NMT) has been increasingly used in compromised patients who would otherwise have been unable to undergo allotransplant. There is little understanding of the kinetics of immune reconstitution and its influence on infective complications following NMT.

The aim of present study was to evaluate lymphocyte subset reconstitution over the first 12 months post-transplant in 15 adult patients receiving NMT with comparison to that of 30 patients grafted with a conventional hemopoietic stem cell transplantation (HSCT). NMT recipients were conditioned with fludarabine-based conditioning regimens. Peripheral blood stem cell (PBSC) was the source of stem cells in 13 NMT recipients and in 24 conventional HSCT recipients.

Absolute numbers of helper (CD4+) T cells, naive (CD4+ CD45RA+) and memory (CD4+ CD45RO+) T cells as well as suppressor (CD8+) T cells, CD19+ B cells and NK cells were comparable in the two groups at all time points after transplantation. A median value of 200 CD4+ T cells/μl was achieved at 2 months post-transplant by the NMT and HSCT recipients. The CD4:CD8 ratio remained severely depressed throughout the study period. Almost all CD4+ lymphocytes expressed CD45RO antigen in the both groups of patients B lymphocytes showed low counts throughout the entire study period in both groups.

Bacteremia and CMV antigenemia occurred respectively in 13 and 36% of the patients in the NMT group and in 15 and 39% of the patients in the HSCT group. Our preliminary data indicate that patients receiving a NMT have a lymphocyte reconstitution similar to that observed in patients who received a conventional HSCT. The incidence of bacteremia and CMV infection were not significantly different between the groups. Nevertheless, due to the small sample size, these results should be considered suggestive rather than definitive.     

Incidence and Risk Factors for Infectious Complications of EBUS-TBNA: Prospective Multicenter Study

The aim of our study was to describe the incidence of infectious complications of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) and to analyze the potential risk factors in a prospective cohort of patients.MethodsWe conducted a prospective multicenter study, with all consecutive patients referred for an EBUS-TBNA with patients at risk of developing an infectious complication (considering > 10 nodal samplings, known immunosuppression, bronchial colonization and cavitated or necrotic lesions) and a second group without any risk factor.ResultsThree hundred seventy patients were included: 245 with risk factors and 125 without risk factors (as the control group). Overall, 15 patients (4.05%) presented an acute infectious complication: fourteen in cases (5.7%) and 1 in controls (0.8%). Of these, 4 patients presented pneumonia, 1 mediastinitis, 4 obstructive pneumonitis and 6 mild complications (respiratory tract infection that resolved with antibiotic). Also 7 (1.9%) patients had self-limited fever. One-month follow-up showed 1 mediastinitis at sixteenth day post-EBUS, which required surgical treatment, and 3 pneumonias and 3 respiratory tract infections at nineteenth day (1.9%). All patients had a good evolution and there were no deaths related with infectious complication. We observed an increased risk of complication in patients with risk factors and in patients with necrosis (p = 0.018).ConclusionsThe incidence of infectious complications in a subgroup of patients with risk factors was higher than in patients without risk factors. Nevertheless, it remains low, and no fatal complication occurred, which reinforces the idea that EBUS-TBNA is a safe technique for the assessment of the mediastinum. Necrotic lesions are a risk factor of post-EBUS infection, and their puncture should be avoided.