High plateletcrit is associated with early loss of patency after open and endovascular interventions for chronic limb ischemia

ObjectivePlateletcrit (PCT) reflects the total platelet mass in blood and can be calculated from a complete blood count. We examined the effect of PCT on outcomes of endovascular and open interventions for chronic limb ischemia.MethodsPatients who underwent revascularization for chronic limb ischemia (Rutherford categories 3-6) between June 2001 and December 2014 were retrospectively identified. PCT on admission was recorded. Patients and limbs were divided into tertiles of low (0.046-0.211), medium (0.212-0.271), and high (0.272-0.842) PCT. Patency, limb salvage, major adverse limb events, major adverse cardiac events, and survival rates were calculated using Kaplan-Meier analysis and compared with log-rank test. Cox regression analysis was used for multivariate analysis.ResultsA total of 1431 limbs (1210 patients) were identified and divided into low PCT (477 limbs in 407 patients), medium PCT (477 limbs in 407 patients), and high PCT (477 limbs in 396 patients) groups. The patients in the high tertile were 2 years older that the patients in the other two tertiles (P = .009). Five-year primary patency was 65% ± 3% in the low-PCT group compared with 55% ± 3% and 51% ± 3% in the medium and high PCT groups, respectively (P = .004). Five-year secondary patency was 81% ± 2% in the low PCT group compared with 82% ± 2% and 72% ± 3% in the medium and high PCT groups, respectively (P = .02). Five-year limb salvage rate was 86% ± 2% in the low PCT group compared with 79% ± 3% and 74% ± 3% in the medium PCT and high PCT groups, respectively (P = .004). Multivariate regression analysis showed that low PCT was independently associated with primary patency after endovascular interventions (hazard ratio, 0.67 [0.47-0.95]; P = .02) but not after open interventions (hazard ratio, 0.72 [0.43-1.21]; P = .21).ConclusionsHigh PCT is associated with poor patency and limb salvage rates after interventions for lower extremity chronic limb ischemia. Multivariate regression analysis confirmed association of low PCT with improved primary patency after endovascular interventions but not after open interventions. High PCT may be a marker of increased platelet reactivity and could be used to identify patients at high risk for early thrombosis and failure after interventions.     

The effects of continuous renal replacement therapy with different anticoagulation methods on the expression of cytokines in severe acute pancreatitis

ObjectiveSevere acute pancreatitis (SAP) is a highly morbid condition in general population as well as in solid organ transplant (SOT) recipients. The present study aimed to investigate the effect of continuous renal replacement therapy (CRRT) with different anticoagulation methods on the expression levels of cytokines in SAP.MethodsA total of 120 patients with SAP, admitted into our hospital between September 2017 and July 2020, were enrolled as the research subjects and randomly divided into a control group (60 cases) and a study group (60 cases). CRRT with low molecular weight (LMW) heparin‑calcium anticoagulation was conducted on patients in the control group, and CRRT with topical citrate + low-dose LMW heparin‑calcium anticoagulation was conducted on patients in the study group. The expressions of cytokines in the two groups were compared after treatment.ResultsThere was no significant difference in white blood cells (WBC), C-reactive proteins (CRP), and procalcitonin (PCT) before treatment between the two groups (P > 0.05). After treatment, the levels of WBC (P = 0.006), CRP (P < 0.001), and PCT (P < 0.001) were significantly lower in the study group when compared with those in the control group. There was no significant difference in the concentrations of interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-α (TNF-α) between the two groups before treatment (P > 0.05). After treatment, the concentrations of IL-6, IL-8, and TNF-α were significantly lower in the study group when compared with those in the control group. The APACHEII, SOFA and Ranson scores of the two groups were analyzed, and there was no difference between the two groups before treatment (P > 0.05). After treatment, the score of the study group was lower than that of the control group (P < 0.05).ConclusionCRRT with topical citrate + low-dose LMW heparin‑calcium anticoagulation in the treatment of patients with SAP reduces the levels of WBC, CRP, and PCT and the concentrations of cytokines, including IL-6, IL-8, and TNF-α. This inhibits the release of inflammatory mediators in patients with SAP and reduces damage to the body caused by the inflammatory response, thus effectively improving the patients' condition.     

Increase in different peripheral effector T subsets in acute and chronic gout

ObjectivesGout (GT) belongs to a group of diseases caused by a purine metabolic disorder. GT is an inflammatory disease caused by the local deposition of uric acid in joints or adjacent tissues. The mechanism of GT is not fully explained, especially the involvement of an immune system. The objective of this study was to investigate the change in peripheral CD4⁺T subsets in acute and chronic GT patients.MethodsA total of 205 patients with acute and chronic GT and 87 healthy controls (HCs) were enrolled. The medical history improvement, clinical indicators, immune function, and peripheral CD4⁺T-lymphocyte detected by modified flow cytometry were collected in all subjects.ResultsCompared with healthy controls, acute and chronic GT patients remarkably increased the absolute counts of T helper type 1 (Th1) cells (P < 0.05) and decreased the absolute number of Treg cells without significant difference (P > 0.05). In addition, the absolute number and percentage of Th1 cells and Th1/T helper type 2 (Th2) ratio increased significantly, and the ratio of Th2 cells decreased in patients with chronic GT compared to patients with acute GT (P < 0.05). The results of Spearman correlation analysis showed a notably negative correlation between the level of CRP and the absolute counts of peripheral Th1 and Th17 cells in patients with GT, while the levels of CD4⁺T sunsets had no significant correlation with ESR and uric acid. The course of the disease, the absolute number of Th1 cells, the percentage of Th1 cells and the ratio of Th1/Th2 cells were significantly associated with the progression of the disease, and the course of the disease was an independent risk factor for patients with chronic GT.ConclusionThe balance of Th1 and Th2 were involved throughout the whole stages of GT, Th17 cells then become involved in the disease process as the disease progresses.     

Serial measurement of presepsin,procalcitonin, and C‐reactive protein in the early postoperative period and the response to antithymocyte globulin administration after heart transplantation

Differentiation between systemic inflammatory response syndrome and sepsis in surgical patients is of crucial significance. Procalcitonin (PCT) and C‐reactive protein (CRP) are widely used biomarkers, but PCT becomes compromised after antithymocyte globulin (ATG) administration, and CRP exhibits limited specificity. Presepsin has been suggested as an alternative biomarker of sepsis. This study aimed to demonstrate the role of presepsin in patients after heart transplantation (HTx). Plasma presepsin, PCT, and CRP were measured in 107 patients serially for up to 10 days following HTx. Time responses of biomarkers were evaluated for both noninfected (n=91) and infected (n=16) patients. Areas under the concentration curve differed in the two groups of patients for presepsin (P<.001), PCT (P<.005), and CRP (P<.001). The effect of time and infection was significant for all three biomarkers (P<.05 all). In contrast to PCT, presepsin was not influenced by ATG administration. More than 25% of noninfected patients had PCT above 42 μg/L on the first day, and the peak concentration of CRP in infected patients was reached on the third post‐transplant day (median 135 mg/L). Presepsin seems to be as valuable a biomarker as PCT or CRP in the evaluation of infectious complications in patients after HTx.     

Provider-Documented Dyspnea in Intensive Care Unit After Lung Transplantation

BackgroundDyspnea is an important problem that might affect the clinical course after lung transplantation; however, the prevalence, risk factors, and relevant outcomes of dyspnea in the intensive care unit (ICU) after lung transplantation remain unknown.MethodsThis retrospective, observational study enrolled consecutive patients aged ≥ 20 years who were admitted to the ICU after lung transplantation between January 2010 and December 2020. The main outcome measure was provider-documented dyspnea identified based on a comprehensive retrospective chart review to extract dyspnea episodes (e.g., documented words related to “dyspnea,” “shortness of breath,” or “breathlessness”).ResultsThis study included 184 lung transplant recipients, including 115 bilateral (63%) and 69 single (37%) lung transplants. Fifty-four transplants were from living donors (29%), and 130 were from deceased donors (71%). Dyspnea was documented in 116 patients (63%). Multivariate analysis identified bilateral lung transplantation (odds ratio = 5.127; 95% confidence interval, 2.020-13.014; P < .001) as a risk factor for dyspnea. In addition, postoperative anxiety (odds ratio = 18.605; 95% confidence interval, 7.748-44.674; P < .001) was independently associated with dyspnea. Patients with documented dyspnea showed delayed rehabilitation (P < .001) and weaning from mechanical ventilation (P < .001) and a longer ICU stay (P < .001).ConclusionThis study demonstrated that the prevalence of dyspnea in the ICU after lung transplantation was frequent and identified bilateral lung transplantation as a risk factor. Dyspnea caused a delay in rehabilitation and weaning from mechanical ventilation. Extensive evaluation and care for dyspnea and anxiety may enhance patient recovery.     

Antifungal Prophylaxis and Treatment Among Lung Transplant Recipients in Early Postoperative Stage: A Single-Center Study

BackgroundLung transplantation remains the only feasible option for certain patients with end-stage lung disease. Lifelong immunosuppression increases the risk of infection, including fungal infections. The aim of this study was to assess the effect of antifungal prophylaxis and treatment among lung transplant recipients in the early postoperative stage.MethodsThis retrospective analysis included 127 patients who underwent lung transplantation between 2014 and 2021 in the lung transplant ward, 65.35% of whom were males. The most common indication for lung transplantation was cystic fibrosis (n = 59; 46.46%). All of the patients were receiving inhaled amphotericin B. Within this group there were patients who also were treated with intravenous caspofungin, intravenous/oral voriconazole, or both.ResultsThe difference in the efficacy against Candida spp. between caspofungin and voriconazole in the early post-transplant period was not statistically significant (χ₂ = 0.5, P = .477). Moreover, the difference in the efficacy against Candida spp. between itraconazole and voriconazole during the first post-transplant year was not statistically significant (χ₂ = 0.46, P = .496).ConclusionCaspofungin and voriconazole are proper and relatively efficient antifungal prophylaxis and treatment options after lung transplantation. There was no significant difference between voriconazole and caspofungin as antifungal agents used in the early post-transplant stage. There was no significant difference between voriconazole and itraconazole as antifungal agents used during the first post-transplant year. Further research on this issue is required.     

Mathematical modeling of peripheral blood neutrophil kinetics to predict CLAD after lung transplantation

BackgroundThe presence of neutrophils in the lung was identified as a factor associated with CLAD but requires invasive samples. The aim of this study was to assess the kinetics of peripheral blood neutrophils after lung transplantation as early predictor of CLAD.MethodsWe retrospectively included all recipients transplanted in our center between 2009 and 2014. Kinetics of blood neutrophils were evaluated to predict early CLAD by mathematical modeling using unadjusted and adjusted analyses.Results103 patients were included, 80 in the stable group and 23 in the CLAD group. Bacterial infections at 1 year were associated with CLAD occurrence. Neutrophils demonstrated a high increase postoperatively and then a progressive decrease until normal range. Recipients with CLAD had higher neutrophil counts (mixed effect coefficient beta over 3 years = +1.36 G/L, 95% Confidence Interval [0.99–1.92], p < .001). A coefficient of celerity (S for speed) was calculated to model the kinetics of return to the norm before CLAD occurrence. After adjustment, lower values of S (slower decrease of neutrophils) were associated with CLAD (Odds Ratio = 0.26, 95% Confidence Interval [0.08–0.66], p = .01).ConclusionA slower return to the normal range of blood neutrophils was early associated with CLAD occurrence.     

Positive Microbiological Cultures in the Respiratory Tract of High Model for End-Stage Liver Disease (MELD) Liver Transplant Recipients With and Without Pneumonia

BackgroundPneumonia in liver transplant recipients is one of the most common infections in the early phase after transplantation. The diagnosis is based on clinical signs combined with positive microbiological samples taken from the lower respiratory tract. However, the role of bacterial colonization is not clear, nor is its association with pneumonia or its long-term consequences. The aim of this study was to investigate the association between positive microbiological findings and clinically relevant pneumonia and analyze different clinical and laboratory parameters for their association with pneumonia in liver transplant recipients.MethodsThis was a retrospective analysis of 266 adult orthotopic liver transplantations between January 2008 and December 2013. A multidisciplinary in-house specialist panel established and confirmed the diagnosis of clinically relevant pneumonia in microbiologically positive patients.ResultsOf the 266 transplantations analyzed, 54 patients (20%) showed microbiologically positive trachea-bronchial cultures during the first 21 days after liver transplantation. Of those 54 patients, 24 (44.4%) had pneumonia as rated by the multidisciplinary specialist panel. Presence of gram-negative Enterobacteriaceae (P = .013) and positive chest radiologic findings (P = .035) were associated with pneumonia in microbiological-positive patients. Although patients with pneumonia had the lowest long-term survival, those without pneumonia but with positive microbiological cultures had still worse survival compared with the Model for End-Stage Liver Disease–matched control group without positive cultures (P = .012).ConclusionsGram-negative Enterobacteriaceae and positive radiologic findings were associated with pneumonia in liver transplant recipients with positive microbiological trachea-bronchial cultures. Recipients with bacterial colonization without pneumonia also showed decreased long-term survival.     

A case-control study of risk factors for survival after laparotomy in patients with pancreatic trauma

BackgroundPancreatic trauma results in significant morbidity and mortality. However, few studies have investigated the postoperative prognostic factors in patients with pancreatic trauma.Material and methodsA retrospective study was conducted on consecutive patients with pancreatic trauma who underwent surgery in a national referral trauma center. Clinical data were retrieved from the electronic medical system. Univariate and binary logistic regression analyses were performed to identify the perioperative clinical parameters that may predict the factors of mortality of the patients.ResultsA total of 150 patients underwent laparotomy due to pancreatic trauma during the study period. 128(85.4%) patients survived and 22 (14.6%) patients died due to pancreatic injury (10 patients died of recurrent intra-abdominal active hemorrhage and 12 died of multiple organ failure). Univariate analysis showed that age, hemodynamic status, and injury severe score (ISS) as well as postoperative serum levels of C-reactive protein (CRP), procalcitonin, albumin, creatinine and the volume of intraoperative blood transfusion remained strongly predictive of mortality (P < 0.05). Binary logistic regression analysis showed that the independent risk factors for prognosis after pancreatic trauma were age (P = 0.010), preoperative hemodynamic instability (P = 0.015), postoperative CRP ≥154 mg/L (P = 0.014), and postoperative serum creatinine ≥177 μmol/L (P = 0.027).ConclusionsIn this single-center retrospective study, we demonstrated that preoperative hemodynamic instability, severe postoperative inflammation (CRP ≥154 mg/L) and acute renal failure (creatinine ≥177 μmol/L) were associated with a significant risk of mortality after pancreatic trauma.     

Outcome After Lung Transplantation From a Donor With Bacterial Pneumonia Under the Japanese Donor Evaluation System

BackgroundIn Japan, a unique medical consultant system for donor evaluation and management has been developed in an effort to maximize the use of extended criteria donor lungs. The aim of this study was to investigate the impact of donor pneumonia (DP) on the outcome after lung transplantation under this system.Materials and MethodsClinical data of 85 patients who underwent deceased donor lung transplantation (41 single and 44 bilateral lung transplants) between August 2012 and March 2018 were reviewed. DP was defined as the recognition of pneumonia on imaging with positive bacterial culture in the airway at the time of transplantation.ResultsTwenty-three transplanted lung grafts were recognized as having DP (27.1%). Serial chest x-rays at the donor hospital did not show deteriorating infiltration or consolidation. The PaO₂/FiO₂ ratio at brain death evaluations were similar between the donor pneumonia (DP) negative (-) and donor pneumonia (DP) positive (+) groups. Perioperative antibiotics were effective against 94% of isolated bacteria. The duration of postoperative antibiotics therapy was longer in the DP (+) group (P = .02). The incidence of primary graft dysfunction and acute rejection, intensive care unit stay, chronic lung allograft dysfunction–free survival, and overall survival were similar between the DP (+) and DP (?) groups.ConclusionsTransplantation of donor lung grafts harboring pneumonia but having a similar oxygenation level to those without pneumonia was safely performed and did not affect long-term outcome. Appropriate evaluation of serial imaging at donor hospital and suitable perioperative antibiotic management may be reasons for this outcome.     

A Retrospective Study of Posttransplant Amiodarone Exposition on Clad Development and Survival After Lung Transplantation

BackgroundLung transplantation is a lifesaving procedure, still marred by worse results than other solid organ transplants. The 1-year mortality is 10%, and within 5 years after the procedure, half of patients develop chronic lung allograft dysfunction (CLAD), which also is the main limiting factor for long-term survival. Heart arrhythmias are also common directly after a lung transplant, and 1 treatment for this is the drug amiodarone. Recent research suggests that amiodarone exposure leads to activation of fibroblasts, a cell type that synthesizes stroma in the lung, associated with acute respiratory distress syndrome and CLAD. This study aims to retrospectively investigate the effect of posttransplant amiodarone treatment on survival and CLAD.Material and MethodsAll patients transplanted at Sahlgrenska University Hospital between 2007 and 2018 were reviewed, and adult patients with a follow-up within Sweden were included. Of the 394 patients who met this inclusion criteria, retrospective data concerning postoperative complications and long-term outcomes were retrieved. A multivariable Cox proportional hazards model was applied to identify a set of independently significant predictors.ResultsPosttransplant use of amiodarone was associated with shorter survival (hazard ratio = 1.65; 95% confidence interval, 1.08-2.54; P = .02). Amiodarone exposure was not associated with CLAD (hazard ratio = 0.64; 95% confidence interval, 0.33-1.22; P = .17).ConclusionsAn increased risk of death but not CLAD was observed in patients treated with amiodarone postoperatively after lung transplantation in the current cohort.     

Kinetics of Interleukin-6, Procalcitonin,and C-Reactive Protein After Pediatric Liver Transplantation

In the early phase after pediatric liver transplantation (pLT) several concomitant factors may reduce the performance of established sepsis markers. To date, their clinical interpretation is hindered by a lack of information on their postoperative kinetics. To gather more information on the postoperative course and their changes in bacterial sepsis, we prospectively studied C-reactive protein (CRP), interleukin-6 (IL-6), and procalcitonin (PCT) on 9 perioperative days in 25 consecutive pLTs. After an initial postoperative peak, IL-6 and CRP levels significantly re-increased in patients with bacterial sepsis (P < .001). In contrast, PCT had very high postoperative levels; therefore severe infection was a comparatively inferior trigger for PCT elevation compared with the initial operation. The area under the receiver operating characteristic curve to diagnose postoperative sepsis for PCT was only 0.52, compared with 0.95 for IL-6 and 0.89 for CRP. None of the studied biomarkers were depressed by poor graft function. In conclusion, PCT performs poorly as a biomarker for sepsis in the early phase after pLT. With a rapid decline of initially elevated levels, IL-6 provides the best kinetics for detection of postoperative bacterial sepsis.     

Intraoperative Support for Primary Bilateral Lung Transplantation: A Propensity-Matched Analysis

BackgroundSingle-center studies support benefits of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a method of intraoperative support. Propensity-matched data from a large cohort, however, are currently lacking. Therefore, our goal was to compare outcomes of intraoperative VA-ECMO and cardiopulmonary bypass (CPB) during bilateral lung transplantation (LTx) with a propensity analysis.MethodsWe performed a retrospective analysis of 795 consecutive primary adult LTx patients (June 1, 2011-December 26, 2020) using no intraoperative support (n = 210), VA-ECMO (n = 150), or CPB (n = 197). Exclusion criteria included LTx on venovenous-ECMO, single/redo LTx, ex vivo lung perfusion, and concomitant solid-organ transplantation or cardiac procedure. Propensity analysis was performed comparing patients who underwent intraoperative CPB or VA-ECMO.ResultsThe propensity CPB group required more blood products at 72 hours (P = .02) and longer intensive care unit length of stay (P < .001) and ventilator dependence days (P < .001). There were no differences in cerebrovascular accident (P = 1), reintubation (P = .4), dialysis (P = .068), in-hospital mortality (P = .33), and 1-year (P = .67) and 3-year (P = .32) survival. The CPB group had a higher incidence of grade 3 primary graft dysfunction at 72 hours (P < .001). Neither support strategy was a predictor of 1- and 3-year mortality in our multivariable model (VA-ECMO, P = .72 and P = .57; CPB, P = .45 and P = .91, respectively).ConclusionsIntraoperative VA-ECMO during lung transplantation was associated with fewer postoperative blood transfusions, shorter length of mechanical ventilation, and lower incidence of a grade 3 primary graft dysfunction at 72 hours. Although there were some differences in the postoperative course between the VA-ECMO and CPB groups, support type was not associated with differences in survival.     

Outcomes Associated With COVID-19 Hospitalization in Heart Transplantation Patients

BackgroundHeart transplantation (HT) recipients infected with COVID-19 may be at an increased risk of severe illness due to chronic immunosuppression.Materials and MethodsAdult HT patients hospitalized with COVID-19 at the Cleveland Clinic between March 2020 and March 2021 were included in this retrospective cohort analysis. Twenty-four HT cases were matched to 96 non-HT controls, similarly hospitalized with COVID-19, out of 11,481 patients based on different baseline characteristics. Primary outcome was all-cause mortality; secondary outcomes included mechanical ventilation, intensive care unit admission, vasopressor need, dialysis, pneumonia, and 90-day readmission. Subgroup analysis was performed based on the time from transplantation (within 1 year of transplantation and greater than 1 year since transplantation).ResultsBoth primary and secondary outcomes were not significant. Subgroup analysis did not show a significant difference in mortality (P = .355) or 30-day readmission (P = .841) between patients who were within 1 year of transplantation and remote transplantation beyond 1 year. Univariable analysis of immunosuppressant continuation, dose-reduction, or discontinuation did not significantly affect HT mortality.ConclusionsDespite limited sample size, our results suggest that HT patients do not show worse outcomes after acquiring COVID-19, whether in the first year of transplantation or after a remote transplantation procedure. Future studies with multicenter data that incorporate the subsequent COVID-19 variants (eg, Delta and Omicron), the impact of long COVID-19, and assessing full vs reduced immunosuppression regimens would add insights to this patient population.     

Differences Between Patients With Idiopathic Pleuroparenchymal Fibroelastosis and Those With Other Types of Idiopathic Interstitial Pneumonia in Candidates for Lung Transplants

IntroductionThe prognostic implications of having patients with idiopathic pleuroparenchymal fibroelastosis (IPPFE) on lung transplantation waiting lists have been unclear. In Japan, where a severe shortage of brain-dead donors remains a major limitation for organ transplantation, it is particularly important to predict the prognoses of patients when they are listed for transplantation. The purpose of this study was to investigate the characteristics of lung transplantation candidates with IPPFE and the influence of those characteristics on prognosis.MethodsThis was a retrospective review of 29 consecutive adult lung transplant candidates with idiopathic interstitial pneumonia between January 2014 and April 2018.ResultsEight patients with IPPFE and 21 with other types of idiopathic interstitial pneumonia were included. Body mass index (median 17.1 kg/m² vs 23.5 kg/m², P < .01) and ratio of anteroposterior to transverse diameter of the thoracic cage were significantly lower (0.530 vs 0.583, P = .02) in the IPPFE group. Patients with a body mass index <20.0 kg/m² (P = .02), 6-minute walk distance <250.0 m (P < .01), ratio of PaO₂ to fraction of inspiratory oxygen <300.0 mm Hg (P < .01), and an inability to perform the diffusing capacity of carbon monoxide test (P < .01) had significantly shorter survival times in the other idiopathic interstitial pneumonia, but not in the IPPFE, group. Some patients with IPPFE survived for long enough to undergo transplantation.ConclusionsPatients with IPPFE waiting for transplantation have some distinctive characteristics and should be retained on waiting lists to receive transplants.     

Proteína C reactiva y escala SOFA: una simple escala como factor predictivo temprano de la necesidad de cuidados críticos en los pacientes con neumonía causada por COVID-19 en España

ObjectiveTo identify potential markers at admission predicting the need for critical care in patients with COVID-19 pneumonia.Material and methodsAn approved, observational, retrospective study was conducted between March 15 to April 15, 2020. 150 adult patients aged less than 75 with Charlson comorbidity index ≤ 6 diagnosed with COVID-19 pneumonia were included. Seventy-five patients were randomly selected from those admitted to the critical care units (critical care group [CG]) and seventy-five hospitalized patients who did not require critical care (non-critical care group [nCG]) represent the control group. One additional cohort of hospitalized patients with COVID-19 were used to validate the score.Measurements and main resultsMultivariable regression showed increasing odds of in-hospital critical care associated with increased C-reactive protein (CRP) (odds ratio 1.052 [1.009-1.101]; P = .0043) and higher Sequential Organ Failure Assessment (SOFA) score (1.968 [1.389-2.590]; P < .0001), both at the time of hospital admission. The AUC-ROC for the combined model was 0.83 (0.76-0.90) (vs AUC-ROC SOFA P < .05). The AUC-ROC for the validation cohort was 0.89 (0.82-0.95) (P > 0.05 vs AUC-ROC development).ConclusionPatients COVID-19 presenting at admission SOFA score ≥ 2 combined with CRP ≥ 9,1 mg/mL could be at high risk to require critical care.     

Hemoderivative Transfusion in Liver Transplantation: Comparison Between Recipients of Grafts From Brain Death Donors and Recipients of Uncontrolled Donors After Circulatory Death

IntroductionIntraoperative bleeding during liver transplantation has been correlated with a higher risk of morbidity and mortality and decrease in patient and graft survival.Materials and MethodsBetween January 2006 and December 2016 we performed 783 orthotopic liver transplants. After applying exclusion criteria, we found liver grafts from donors after circulatory death (DCD, group A) were used in 69 patients and liver grafts from donors after brain death (group B) were used in 265 patients.ResultsNo difference was found in terms of sex, body mass index, Model for End-Stage Liver Disease score, indication for transplantation, intensive care unit stay, and Child-Pugh score. The mean transfusion of hemoderivates was as follows: red blood cell 9 (0-28) units in group A vs 6 (0-20) units in group B (P = .004) and fresh frozen plasma 10 (0-29) units in group A vs 9.5 (0-23) in group B (P = .000). The only 2 factors related to massive blood transfusion (>6 units of red blood cell) were uncontrolled DCD condition (odds ratio = 2.38; 95% confidence interval, 1.32-4.31; P = .004), and higher Model for End-Stage Liver Disease score (odds ratio = 2.63; 95% confidence interval, 1.53-4.55; P = .001). Survival at 1, 3, and 5 years was 81.3%, 70.2%, and 68.9% in group A vs 89%, 83.7%, and 78% in group B (P = .070).ConclusionThe use of liver grafts from DCDs is associated with increased necessity of transfusion of hemoderivates in comparison with the use of liver grafts from donors after brain death.     

Genetic Association of Tumor Necrosis Factor-β, Interleukin-10, and Interleukin-1 Gene Cluster Polymorphism With Susceptibility to Pneumonia in Kidney Transplant Recipients

Introduction

Pneumonia remains a significant cause of morbidity and mortality after kidney transplantation. The present study was therefore conducted to investigate whether or not the polymorphisms of tumor necrosis factor (TNF)β, interleukin (IL)-10, IL-1β, and IL-1 receptor antagonist (IL-1ra) gene predicted the susceptibility to pneumonia within the first year after kidney transplantation.

Methods

Subjects comprised 33 kidney transplant recipients with pneumonia and 63 noninfected kidney transplant recipients. Genomic DNA from these 96 kidney transplant recipients was extracted from peripheral blood leukocytes. The regions containing the NcoI polymorphic site at position +252 of TNFβ gene, the RsaI polymorphic site at position −592 of IL-10 gene, and the AvaI polymorphic site at position −511 of IL-1β gene were amplified by polymerase chain reaction (PCR) and subsequently digested with NcoI, RsaI, and AvaI restriction enzyme, respectively. The polymorphic regions with intron 2 of the IL-1 ra gene (IL-1 RN) containing variable numbers of a tandem repeat of 86 base pairs, were amplified by PCR.

Results

Univariate analysis showed that recipient IL-10, IL-1β, and IL-1 RN polymorphisms were not associated with the presence of pneumonia (P = .589, .940, and .286, respectively). However, compared with GG genotype, recipient TNFβ +252AA + AG genotype was significantly associated with susceptibility to pneumonia (P = .006). Age of 45 years or older was not significantly associated with susceptibility to develop pneumonia but had a tendency to develop it (P = .119). After adjusting for age of 45 years or older, recipient TNFβ+252 AA + AG genotype (odds ratio = 5.366, 95% confidence intervals = 1.470 − 19.589, P = .011) independently predicted the risk for pneumonia within the first year after kidney transplantation in the multivariate analysis.

Conclusion

These results suggested that recipient TNFβ gene polymorphism may be useful in predicting pneumonia, hence identifying individuals who could benefit from preventive treatment and a less potent immunosuppression regimen.     

C-reactive protein (CRP) as a biomarker of pulmonary exacerbation presentation and treatment response

BackgroundC-reactive protein (CRP) has been proposed as a biomarker for pulmonary exacerbation (PEx) diagnosis and treatment response. CRP >75mg/L has been associated with increased risk of PEx treatment failure. We have analyzed CRP measures as biomarkers for clinical response during the STOP2 PEx study (NCT02781610).MethodsCRP measures were collected at antimicrobial treatment start (V1), seven to 10 days later (V2), and two weeks after treatment end (V3). V1 log₁₀CRP concentrations and log₁₀CRP change from V1 to V3 correlations with clinical responses (changes in lung function and symptom score) were assessed by least squares regression. Odds of intravenous (IV) antimicrobial retreatment within 30 days and future PEx hazard associated with V1 and V3 CRP concentrations and V1 CRP >75 mg/L were studied by adjusted logistic regression and proportional hazards modeling, respectively.ResultsIn all, 951 of 982 STOP2 subjects (92.7%) had CRP measures at V1. V1 log₁₀CRP varied significantly by V1 lung function subgroup, symptom score quartile, and sex, but not by age subgroup. V1 log₁₀CRP correlated moderately with log₁₀CRP change at V3 (r²=0.255) but less so with lung function (r²=0.016) or symptom (r²=0.031) changes at V3. Higher V1 CRP was associated with greater response. CRP changes from V1 to V3 only weakly correlated with lung function (r²=0.061) and symptom (r²=0.066) changes. However, V3 log₁₀CRP was associated with increased odds of retreatment (P = .0081) and future PEx hazard (P = .0114).DiscussionDespite consistent trends, log₁₀CRP change was highly variable with only limited utility as a biomarker of PEx treatment response.     

Evaluation of procalcitonin (PCT) as a marker of infection in early post living donated liver transplant period

Background and aimProcalcitonin (PCT) has been increasingly used as a biomarker of bacterial infection and as a tool to guide antimicrobial therapy. Despite its increased use, data in patients with solid organ transplants are limited.The study aimed to assess the frequency of rising PCT associated with infectious complications in immunosuppressed living donated liver transplantation.MethodsA single-center, retrospective observational study. Preoperative patients' demographic data, operative, anesthetic data, and postoperative clinical course were analyzed post-liver transplant (LT) till discharge from the intensive care unit.ResultsSixty patients were classified according to the culture results' into a positive culture group & a negative one and then followed up the sepsis variables in each group. Total leukocyte count (TLC) was elevated in the positive culture group in comparison to the negative culture one and was statistically significant (P-value <0.05) till the fourth day postoperative. Procalcitonin was higher in the positive culture group than in the negative one on days 1, 3, and 5 postoperative and was statistically significant (P-value <0.05).The cutoff values in the receiver operating characteristic curve (ROC) with >90% specificity to infection post LT were PCT of ≥9 ng/ml and TLC of ≥17.3/mm3 on day one.ConclusionsFollowing up PCT level on day one with TLC is essential and will help to detect sepsis and guide early antimicrobial initiation post-liver transplantation.Combined measurements of PCT and TLC with cutoff values of <9 ng/ml and < 17.3/mm³ respectively will help to exclude infections in 83.7% of patients, thus avoiding unnecessary usage of higher generations empiric antimicrobials.