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Berg T, Aehling NF, Bruns T, Welker MW, Weismüller T, Trebicka J, Tacke F, Strnad P, Sterneck M, Settmacher U, Seehofer D, Schott E, Schnitzbauer AA, Schmidt HH, Schlitt HJ, Pratschke J, Pascher A, Neumann U, Manekeller S, Lammert F, Klein I, Kirchner G, Guba M, Glanemann M, Engelmann C, Canbay AE, Braun F, Berg CP, Bechstein WO, Becker T, Trautwein C. S2k-Leitlinie Lebertransplantation der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1397-1573. [PMID: 39250961 DOI: 10.1055/a-2255-7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
- Thomas Berg
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Niklas F Aehling
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martin-Walter Welker
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin. Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Tobias Weismüller
- Klinik für Innere Medizin - Gastroenterologie und Hepatologie, Vivantes Humboldt-Klinikum, Berlin, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Pavel Strnad
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martina Sterneck
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Daniel Seehofer
- Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Eckart Schott
- Klinik für Innere Medizin II - Gastroenterologie, Hepatologie und Diabetolgie, Helios Klinikum Emil von Behring, Berlin, Deutschland
| | | | - Hartmut H Schmidt
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Hans J Schlitt
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andreas Pascher
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Ulf Neumann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Steffen Manekeller
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Frank Lammert
- Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - Ingo Klein
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Gabriele Kirchner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg und Innere Medizin I, Caritaskrankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - Markus Guba
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, München, Deutschland
| | - Matthias Glanemann
- Klinik für Allgemeine, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Cornelius Engelmann
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Ali E Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Felix Braun
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
| | - Christoph P Berg
- Innere Medizin I Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Becker
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
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Chen T, Chen G, Wang G, Treeprasertsuk S, Lesmana CRA, Lin HC, Al-Mahtab M, Chawla YK, Tan SS, Kao JH, Yuen MF, Lee GH, Alcantara-Payawal D, Nakayama N, Abbas Z, Jafri W, Kim DJ, Choudhury A, Mahiwall R, Hou J, Hamid S, Jia J, Bajaj JS, Wang F, Sarin SK, Ning Q. Expert consensus on the diagnosis and treatment of end-stage liver disease complicated by infections. Hepatol Int 2024; 18:817-832. [PMID: 38460060 DOI: 10.1007/s12072-023-10637-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/22/2023] [Indexed: 03/11/2024]
Abstract
End-stage liver disease (ESLD) is a life-threatening clinical syndrome and when complicated with infection the mortality is markedly increased. In patients with ESLD, bacterial or fungal infection can induce or aggravate the occurrence or progression of liver decompensation. Consequently, infections are among the most common complications of disease deterioration. There is an overwhelming need for standardized protocols for early diagnosis and appropriate management for patients with ESLD complicated by infections. Asia Pacific region has the largest number of ESLD patients, due to hepatitis B and the growing population of alcohol and NAFLD. Concomitant infections not only add to organ failure and high mortality but also to financial and healthcare burdens. This consensus document assembled up-to-date knowledge and experience from colleagues across the Asia-Pacific region, providing data on the principles as well as evidence-based current working protocols and practices for the diagnosis and treatment of patients with ESLD complicated by infections.
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Affiliation(s)
- Tao Chen
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, 430030, P.R. China
| | - Guang Chen
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, 430030, P.R. China
| | - Guiqiang Wang
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Beijing, China
| | - Sombat Treeprasertsuk
- Department of Medicine, Division of Gastroenterology, Faculty of Medicine, Chulalongkorn University, and Thai Red Cross, Bangkok, Thailand
| | - Cosmas Rinaldi Adithya Lesmana
- Internal Medicine, Hepatobiliary Division, Dr. Captor Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, DKI, Indonesia
| | - Han-Chieh Lin
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Mamun Al-Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Yogesh K Chawla
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Soek-Siam Tan
- Department of Hepatology, Hospital Selayang, Selangor Darul Ehsan, Malaysia
| | - Jia-Horng Kao
- Graduate Institute of Clinical Medicine and Hepatitis Research Center, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Guan-Huei Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | | | - Nobuaki Nakayama
- Department of Gastroenterology & Hepatology, Saitama Medical University, Saitama, Japan
| | - Zaigham Abbas
- Department of Medicine, Ziauddin University Hospital, Karachi, Pakistan
| | - Wasim Jafri
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Dong-Joon Kim
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital of Hallym University Medical Center, Chuncheon, Korea
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Mahiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Jinlin Hou
- Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Guangdong Provincial Clinical Research Center for Viral Hepatitis, Key Laboratory of Infectious Diseases Research in South China, Ministry of Education, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Saeed Hamid
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - J S Bajaj
- Department of Medicine, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA, USA
| | - Fusheng Wang
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Qin Ning
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, 430030, P.R. China.
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Xiang Z, Song Y, Liu J, Xu C, Zhou Z, Li J, Su R, Shu W, Lu Z, Wei X, Yang J, Yang Y, Zheng S, Xu X. Impact of preoperative infection on the outcomes of liver transplant recipients: a national propensity score-matched retrospective cohort study in China. Int J Surg 2024; 110:01279778-990000000-01016. [PMID: 38285095 PMCID: PMC11019992 DOI: 10.1097/js9.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/09/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Impact of preoperative infection on liver transplantation (LT) needs further investigation. MATERIALS AND METHODS From January 1, 2015 to December 31, 2022, 24,122 eligible patients receiving LT were enrolled from the China Liver Transplant Registry database. The outcomes of LT were compared after using the propensity score-matched analysis. RESULTS Compared to the non-infection group, patients in the infection group were more likely to have postoperative effusion, infection, abdominal bleeding and biliary complications (all P<0.01), and they had shorter 30-day, 90-day survival and overall survival (OS) (all P<0.01). Cox proportional hazards regression analysis revealed that MELD score and cold ischemia time were risk factors for the OS in the infection group (both P<0.05). Besides, compared to the non-pulmonary group, patients in the pulmonary group were more likely to have postoperative effusion and infection (both P<0.0001), and less likely to have postoperative abscess and early allograft dysfunction (both P<0.05). Patients in the non-abdominal group also had a higher proportion of postoperative infection than those in the abdominal group (P<0.05). Furthermore, compared to the number=1 group, patients in the number≥2 group were more prone to postoperative effusion and infection (both P<0.01), and they also had shorter 30-day and 90-day survival (both P<0.05). CONCLUSION Preoperative infection can result in a higher incidence of early postoperative complications and shorter survival in liver transplant recipients. The types and number of infection sites will also influence the prognosis of liver transplant recipients.
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Affiliation(s)
- Ze Xiang
- Zhejiang University School of Medicine
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province
| | - Yisu Song
- Zhejiang University School of Medicine
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province
| | - Jianrong Liu
- Surgical Intensive Care Unit, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou
| | - Chenhao Xu
- Zhejiang University School of Medicine
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province
| | - Zhisheng Zhou
- National Center for Healthcare Quality Management in Liver Transplant
| | - Jiarui Li
- Zhejiang University School of Medicine
| | - Renyi Su
- Zhejiang University School of Medicine
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province
| | - Wenzhi Shu
- Zhejiang University School of Medicine
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province
| | - Zhengyang Lu
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province
| | | | - Jiayin Yang
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, People’s Republic of China
| | - Yang Yang
- Department of Hepatic Surgery and Liver Transplantation Center
| | - Shusen Zheng
- NHC Key Laboratory of Combined Multi-organ Transplantation
- National Center for Healthcare Quality Management in Liver Transplant
- Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou
| | - Xiao Xu
- Zhejiang University School of Medicine
- NHC Key Laboratory of Combined Multi-organ Transplantation
- National Center for Healthcare Quality Management in Liver Transplant
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Incicco S, Tonon M, Zeni N, Gambino C, Gagliardi R, Calvino V, Barone A, Zilio G, Feltracco P, Burra P, Cillo U, Angeli P, Piano S. Impact of bacterial infections prior to liver transplantation on post-transplant outcomes in patients with cirrhosis. JHEP Rep 2023; 5:100808. [PMID: 37534231 PMCID: PMC10393541 DOI: 10.1016/j.jhepr.2023.100808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/08/2023] [Accepted: 05/22/2023] [Indexed: 08/04/2023] Open
Abstract
Background & Aims Bacterial infections are frequent in patients with cirrhosis and increase the risk of death and drop-out from liver transplant (LT) waiting list. In patients with bacterial infections, LT is frequently delayed because of the fear of poor outcomes. We evaluated the impact of pre-LT infections on post-LT complications and survival. Methods From 2012 to 2018, consecutive patients transplanted at the Hospital of Padua were identified and classified in two groups: patients surviving an episode of bacterial infection within 3 months before LT (study group) and patients without infections before LT (control group). Post-LT outcomes (complications, new infections, survival) were collected. Results A total of 466 LT recipients were identified (study group n = 108; control group n = 358). After LT, the study group had a higher incidence of new bacterial (57% vs. 20%, p <0.001) and fungal infections (14% vs. 5%, p = 0.001) and of septic shock (8% vs. 2%, p = 0.004) than the control group. Along with the model for end-stage liver disease (MELD) score and alcohol-related cirrhosis, bacterial infection pre-LT was an independent predictor of post-LT infections (odds ratio = 3.92; p <0.001). Nevertheless, no significant difference was found in 1-year (88% vs. 89%, p = 0.579) and 5-year survival rates (76% vs. 75%, p = 0.829) between the study group and control group. Within the study group, no association was found between the time elapsed from infection improvement/resolution to LT and post-LT outcomes. Conclusions Patients with pre-LT infections have a higher risk of new bacterial and fungal infections and of septic shock after LT. However, post-LT survival is excellent. Therefore, as soon as the bacterial infection is improving/resolving, transplant should not be delayed, but patients with pre-transplant bacterial infections require active surveillance for infections after LT. Impact and Implications Bacterial infections increase mortality and delay transplant in patients with cirrhosis awaiting liver transplantation (LT). Little is known about the impact of adequately treated infections before LT on post-transplant complications and outcomes. The study highlights that pre-LT infections increase the risk of post-LT infections, but post-LT survival rates are excellent despite the risk. These findings suggest that physicians should not delay LT because of concerns about pre-LT infections, but instead should actively monitor these patients for infections after surgery.
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Affiliation(s)
- Simone Incicco
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Nicola Zeni
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Carmine Gambino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Roberta Gagliardi
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Valeria Calvino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Anna Barone
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Gianluca Zilio
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Paolo Feltracco
- Anesthesiology and Intensive Care Unit, Department of Medicine (DIMED), University and Hospital of Padova, Padua, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University and Hospital of Padova, Padua, Italy
| | - Umberto Cillo
- General Surgery 2-Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
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Chen YQ, Liu JL. Advances in research of microbiome regulation as a therapy for liver failure. Shijie Huaren Xiaohua Zazhi 2022; 30:971-977. [DOI: 10.11569/wcjd.v30.i22.971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The intestinal flora of the human body is complex and diverse, and the structure and composition of the intestinal micro-ecosystem formed by the intestinal flora are complicated. Studies have shown that the imbalance of the intestinal micro-ecosystem is closely related to the occurrence and development of liver failure, and the degree of intestinal microecological imbalance is significantly correlated with the severity of liver failure. Therefore, the role of intestinal microbiome regulation in the treatment of liver failure and the improvement of prognosis has increasingly attracting the attention of scholars. However, due to the complexity of the composition and structure of the intestinal flora and its mechanism of action involved in the development of liver failure, the application of intestinal microbiome regulation in the clinic is limited to a certain extent. In this paper, we review the research progress of microbiome regulation as a therapy for liver failure.
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Affiliation(s)
- Yue-Qiao Chen
- Department of Hepatology, The First Affiliated Hospital of Guangxi University of Traditional Chinese Medicine, Nanning 530200, Guangxi Zhuang Autonomous Region, China
| | - Jia-Ling Liu
- Department of Hepatology, The First Affiliated Hospital of Guangxi University of Traditional Chinese Medicine, Nanning 530200, Guangxi Zhuang Autonomous Region, China
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Xia L, Qiao ZY, Zhang ZJ, Lv ZC, Tong H, Tong Y, Wu HX, Chen XS, Sun HY, Zhang JJ, Thasler WE, Feng H, Xia Q. Transplantation for EASL-CLIF and APASL acute-on-chronic liver failure (ACLF) patients: The TEA cohort to evaluate long-term post-Transplant outcomes. EClinicalMedicine 2022; 49:101476. [PMID: 35747194 PMCID: PMC9167862 DOI: 10.1016/j.eclinm.2022.101476] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The forecast accuracy of the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) and Asian Pacific Association for the Study of the Liver (APASL) acute-on-chronic liver failure (ACLF) criteria in assessing long-term outcomes after liver transplantation (LT) is still unclear, especially when the staging of the two standards is inconsistent. METHODS A retrospective cohort (NCT05036031) including 565 patients from January 2015 to June 2021 was conducted. The 28 and 90 days, 1- and 3-years overall survival (OS) after LT were compared between different grades. FINDINGS Total of 162 (28.7%) and 230 (40.7%) patients met the ACLF standards. In the EASL-CLIF criteria, the 3-year OS rates were 83·0%, 80·3%, and 69·8% for ACLF1-3, respectively. In the APASL criteria, the 3-year OS rates were 85·7% for APASL ACLF Research Consortium (AARC)-1, similar to ACLF-1. The 3-year OS rates were 84·5% for AARC-2, which were slightly better than ACLF-2. Regarding AARC-3, the 3-year OS rate was 5·8% higher than ACLF-3. For patients who met neither set of criteria for ACLF, the 3-year OS rates were 89·8%. The multivariate analysis showed that alanine aminotransferase >100 U/L, respiration failure, and cerebral failure were independent risk factors for post-LT death. INTERPRETATION This study provides the first large-scale long-term follow-up data in Asia. Both criteria showed favorable distinguishing ability for post-LT survival. Patients with ACLF had a higher post-LT mortality risk, and ACLF-3 and AARC-3 correlated with significantly greater mortality. FUNDING National Natural Science Foundation of China and Science and Technology Commission of Shanghai Municipality.
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Key Words
- AARC, APASL ACLF Research Consortium
- ACLF, acute-on-chronic liver failure
- AD, acute decompensation
- AIH, autoimmune hepatitis
- ALT, alanine aminotransferase
- APASL, Asian Pacific Association for the Study of the Liver
- AST, aspartate aminotransferase
- Acute-on-chronic liver failure
- CLIF-C OFs, CLIF-C organ failure score
- CsA, cyclosporine
- Decompensation
- EASL-CLIF, European Association for the Study of the Liver-Chronic Liver Failure
- ECLIS, ELITA/EF-CLIF collaborative study
- HBV, Hepatitis B virus
- HE, hepatic encephalopathy
- ICU, Intensive care unit
- INR, international normalized ratio
- IQR, interquartile range
- LDLT, living donor liver transplantation
- LT, liver transplantation
- Liver
- Liver transplantation
- MDRO, multidrug-resistant organism
- MELD, Model for End-Stage Liver Disease score
- MMF, mycophenolate mofetil
- OLT, orthotopic liver transplantation
- OS, overall survival
- Overall survival
- SBP, spontaneous bacterial peritonitis
- SLT, split liver transplantation
- TB, total bilirubin
- TEA, Transplantation for EASL-CLIF and APASL acute-on-chronic liver failure (ACLF) patients
- WBC, white blood count
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Affiliation(s)
- Lei Xia
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Zi-yun Qiao
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Zi-jie Zhang
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Zi-cheng Lv
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Huan Tong
- Shanghai First Maternity and Infant Hospital, Shanghai 200127, China
| | - Ying Tong
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Hao-xiang Wu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Xiao-song Chen
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
- Shanghai Engineering Research Centre of Transplantation and Immunology, Shanghai 200127, China
| | - Han-yong Sun
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
- Shanghai Engineering Research Centre of Transplantation and Immunology, Shanghai 200127, China
| | - Jian-jun Zhang
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
- Corresponding author.
| | - Wolfgang Ervin Thasler
- Department of General, Visceral, Thoracic and Minimally Invasive Surgery, Rotkreuzklinikum Munich, Nymphenburger Str. 163 80634, Munich, Germany
| | - Hao Feng
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
- Shanghai Engineering Research Centre of Transplantation and Immunology, Shanghai 200127, China
- Shanghai Institute of Transplantation, Shanghai 200127, China
- Corresponding author at: Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China.
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
- Shanghai Engineering Research Centre of Transplantation and Immunology, Shanghai 200127, China
- Shanghai Institute of Transplantation, Shanghai 200127, China
- Corresponding author.
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Noh BG, Lee N, Lee BC, Yoon M. Selected deceased donor liver transplantation in controlled Fournier's gangrene: a case report. KOREAN JOURNAL OF TRANSPLANTATION 2021; 35:195-199. [PMID: 35769247 PMCID: PMC9235450 DOI: 10.4285/kjt.21.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 11/21/2022] Open
Abstract
Bacterial infection represents a turning point in the natural history of cirrhosis, causing the development of acute-on-chronic liver failure. It significantly affects the outcome of patients listed for liver transplantation. We report the case of a 57-year-old man who had been regularly treated for hepatitis B virus, alcoholic liver cirrhosis, and hepatic failure. The patient was hospitalized again due to variceal bleeding and hepatic coma. He visited the emergency room with painful anal swelling, dysuria, icteric sclera, and serious abdominal distension. The painful anal swelling and necrosis progressed; thus, he was diagnosed with Fournier's gangrene. Enterococcus faecium and Candida albicans were detected in the blood. Gangrene wound debris was studied extensively. Despite appropriate antibiotic treatment, vancomycin-resistant enterococcus and C. albicans were continuously present in the blood. Wide debridement of the wound and T-colostomy were performed. After this, norepinephrine and vasopressin were used to maintain stable vital signs. It was difficult to establish a liver transplant operation. Despite repeated bleeding, bacterial infections improved with additional antibiotics. Finally, selected deceased donor liver transplantation in controlled Fournier's gangrene was successfully performed. Controlled infections may be allowed in transplantation surgery.
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Affiliation(s)
- Byeong Gwan Noh
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Hospital, Busan, Korea
| | - Nuri Lee
- Department of Surgery, Veterans Health Service Medical Center, Seoul, Korea
| | - Byoung Chul Lee
- Division of Colorectal Surgery, Department of Surgery, Pusan National University Hospital, Busan, Korea
| | - Myunghee Yoon
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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8
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Yu J, Shi X, Ma J, Chen R, Dong S, Lu S, Wu J, Yan C, Wu J, Zheng S, Li L, Xu X, Cao H. C-Reactive Protein Is an Independent Predictor of 30-Day Bacterial Infection Post-Liver Transplantation. Biomolecules 2021; 11:biom11081195. [PMID: 34439862 PMCID: PMC8391373 DOI: 10.3390/biom11081195] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/04/2021] [Accepted: 08/07/2021] [Indexed: 12/12/2022] Open
Abstract
The relationship between aseptic systemic inflammation and postoperative bacterial infection is unclear. We investigated the correlation of systemic inflammation biomarkers with 30-day clinically significant bacterial infections (CSI) after liver transplantation (LT). This retrospective study enrolled 940 patients who received LT and were followed for 30 days. The primary end point was 30-day CSI events. The cohort was divided into exploratory (n = 508) and validation (n = 432) sets according to different centers. Area under the receiver operated characteristic (AUROC) and Cox regression models were fitted to study the association between baseline systemic inflammation levels and CSI after LT. A total of 255 bacterial infectious events in 209 recipients occurred. Among systemic inflammation parameters, baseline C-reactive protein (CRP) was independently associated with 30-day CSI in the exploratory group. The combination of CRP and organ failure number showed a good discrimination for 30-day CSI (AUROC = 0.80, 95% CI, 0.76–0.84) and the results were confirmed in an external verification group. Additionally, CRP levels were correlated with bacterial product lipopolysaccharide. In conclusion, our study suggests that pre-transplantation CRP is independent of other prognostic factors for 30-day CSI post-LT, and can be integrated into tools for assessing the risk of bacterial infection post-LT or as a component of prognostic models.
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Affiliation(s)
- Jiong Yu
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China; (J.Y.); (X.S.); (J.M.); (J.W.); (C.Y.); (S.Z.); (L.L.)
- National Clinical Research Center for Infectious Diseases, 79 Qingchun Rd., Hangzhou 310003, China
- Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, 79 Qingchun Rd., Hangzhou 310003, China
| | - Xiaowei Shi
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China; (J.Y.); (X.S.); (J.M.); (J.W.); (C.Y.); (S.Z.); (L.L.)
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou 310003, China; (R.C.); (S.D.); (J.W.)
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jing Ma
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China; (J.Y.); (X.S.); (J.M.); (J.W.); (C.Y.); (S.Z.); (L.L.)
- National Clinical Research Center for Infectious Diseases, 79 Qingchun Rd., Hangzhou 310003, China
- Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, 79 Qingchun Rd., Hangzhou 310003, China
| | - Ronggao Chen
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou 310003, China; (R.C.); (S.D.); (J.W.)
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Siyi Dong
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou 310003, China; (R.C.); (S.D.); (J.W.)
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Sen Lu
- Department of Colorectal Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China;
| | - Jian Wu
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China; (J.Y.); (X.S.); (J.M.); (J.W.); (C.Y.); (S.Z.); (L.L.)
- National Clinical Research Center for Infectious Diseases, 79 Qingchun Rd., Hangzhou 310003, China
- Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, 79 Qingchun Rd., Hangzhou 310003, China
| | - Cuilin Yan
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China; (J.Y.); (X.S.); (J.M.); (J.W.); (C.Y.); (S.Z.); (L.L.)
| | - Jian Wu
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou 310003, China; (R.C.); (S.D.); (J.W.)
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Shusen Zheng
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China; (J.Y.); (X.S.); (J.M.); (J.W.); (C.Y.); (S.Z.); (L.L.)
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou 310003, China; (R.C.); (S.D.); (J.W.)
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Lanjuan Li
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China; (J.Y.); (X.S.); (J.M.); (J.W.); (C.Y.); (S.Z.); (L.L.)
- National Clinical Research Center for Infectious Diseases, 79 Qingchun Rd., Hangzhou 310003, China
- Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, 79 Qingchun Rd., Hangzhou 310003, China
| | - Xiao Xu
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China; (J.Y.); (X.S.); (J.M.); (J.W.); (C.Y.); (S.Z.); (L.L.)
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou 310003, China; (R.C.); (S.D.); (J.W.)
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
- Correspondence: (X.X.); (H.C.)
| | - Hongcui Cao
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China; (J.Y.); (X.S.); (J.M.); (J.W.); (C.Y.); (S.Z.); (L.L.)
- National Clinical Research Center for Infectious Diseases, 79 Qingchun Rd., Hangzhou 310003, China
- Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, 79 Qingchun Rd., Hangzhou 310003, China
- Correspondence: (X.X.); (H.C.)
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9
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Kim JE, Sinn DH, Choi GS, Kim JM, Joh JW, Kang W, Gwak GY, Paik YH, Choi MS, Lee JH, Koh KC, Paik SW. Predictors and outcome of emergent Liver transplantation for patients with acute-on-chronic liver failure. Dig Liver Dis 2021; 53:1004-1010. [PMID: 33931340 DOI: 10.1016/j.dld.2021.03.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Controversy exists over whether emergent liver transplantation (LT) should be performed for patients with acute-on-chronic liver failure (ACLF), especially for patients with multiple organ failure. METHODS A total of 110 ACLF patients, defined by the European Association for the Study of the Liver (EASL) Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) criteria were analyzed. The primary outcome was overall survival after ACLF diagnosis. RESULTS During follow-up, 76 patients received LT (59 received deceased-donor LT and 17 patients received living-donor LT). The overall survival was better for patients who received LT than patients who did not (82.9% vs. 17.6%, P < 0.001). Among the 76 patients who received LT, the overall survival was not different according to ACLF grade at diagnosis (70.0%, 85.3%, and 84.4% at one-year for ACLF grades 1, 2, and 3, respectively, P = 0.45). The baseline model for end-stage liver disease (MELD) score and progression of the ACLF grade during the pre-transplant period were independent factors for survival after LT. The one-year survival rate was 92.3% for patients with baseline MELD scores of ≤ 32 without ACLF grade progression, whereas it was 33.3% for those with baseline MELD scores of > 32 and ACLF grade progression. CONCLUSIONS Emergent LT provided a significant survival benefit to ACLF patients, regardless of the baseline ACLF grade. Post-LT outcomes were associated with baseline MELD scores and ACLF progression during the pre-transplant period, which might be used in the emergent LT plan for patients presenting with ACLF.
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Affiliation(s)
- Ji Eun Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wonseok Kang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Geum-Youn Gwak
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong-Han Paik
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Seok Choi
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Hyeok Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Cheol Koh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Woon Paik
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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10
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Pre-transplant Psoas Muscle Density as a Ready-to-Use and Low-cost Predictor of Patient Survival After Liver Transplant. HEPATITIS MONTHLY 2021. [DOI: 10.5812/hepatmon.99690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Background: Sarcopenia, defined as low muscle mass with reduced function, is frequently encountered in cirrhotic patients and is a major predictor of adverse events, including post-liver transplant (LT) outcome. Objectives: This study assessed the impact of sarcopenia using computed tomography (CT)-based measurements on post-LT mortality and complications. Methods: From January 2008 to June 2016, 646 adult patients underwent 613 LTs at our institution. We analyzed the postoperative outcome of 287 patients who had pathologically proven cirrhosis on the explanted liver and who had performed a CT examination three months before LT. Psoas muscle density (PMD) was detected for every patient using standard instruments present in the radiological workstation and was related to postoperative survival rates and complications. Statistical analysis was carried out using the appropriate tests. Results: Postoperative mortality was 6.3%. At least one grade III-IV postoperative complication was experienced by 121 patients. Respiratory and infective complications occurred in 30 and 32 patients, respectively. Also, PMD was an independent predictor of postoperative mortality (P = 0.021), respiratory complications (P = 0.015), and infections (P = 0.010). The ROC analysis identified a PMD ≤ 43.72 HU as the best cutoff value for predicting 90-day mortality after LT. Conclusions: Psoas muscle density accurately predicted post-LT mortality and complications. Its ease and low-cost determination can allow widespread use of this parameter to improve clinical care and help with the decision to give these patients some priority on the transplant waiting list.
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11
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Gabrielyan NI, Sharapchenko SО, Kisil ОV, Kormilitsina VG, Drabkina IV, Safonova ТB, Petrukhina МI, Saitgareev RS, Zakharevich VМ. [The problem of global development of antibiotic resistant nosocomial pathogens]. TERAPEVT ARKH 2020; 92:110-116. [PMID: 33720615 DOI: 10.26442/00403660.2020.11.000783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 12/26/2020] [Indexed: 11/22/2022]
Abstract
The problem of global expansion of multidrug-resistant nosocomial infections pathogens is under special attention at the moment. Antibiotic resistance increasing give us the limited treatment options. This problem is particularly acute for transplant clinics, because of patients need lifelong immunosuppressive therapy. From the one hand this ensures stable allograft functioning, but from the other increases the risk of severe infectious complications in the postoperative period. The purpose of this article is analysis carbapenem resistance dynamics of Klebsiella spp., Acinetobacter spp., Pseudomonas spp. and Staphylococcus spp. isolated from the blood of recipients of donor organs from 2009 to 2019 in the Shumakov National Medical Research Center of Transplantology and Artificial Organs. A significant annual decrease of carbapenem-sensitive strains of Klebsiella spp. and Acinetobacter spp. are shown. The study of a distinctive pathogen resistance profile specific to each institution can help one in selecting an adequate antimicrobial strategy and is an effective predictive tool for controlling the growth of multidrug-resistant microorganisms.
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Affiliation(s)
- N I Gabrielyan
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - S О Sharapchenko
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | | | - V G Kormilitsina
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - I V Drabkina
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - Т B Safonova
- Russian Medical Academy of Continuous Professional Education
| | - М I Petrukhina
- Russian Medical Academy of Continuous Professional Education
| | - R S Saitgareev
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - V М Zakharevich
- Shumakov National Medical Research Center of Transplantology and Artificial Organs.,Sechenov First Moscow State Medical University (Sechenov University)
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12
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Nikam V, Srivastava M. The outcome of living donor liver transplant recipients with recent episodes of spontaneous bacterial peritonitis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:251-254. [PMID: 33207887 DOI: 10.17235/reed.2020.6780/2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND spontaneous bacterial peritonitis (SBP) is a common complication in patients with cirrhosis and is associated with a high mortality rate. Only a few reports have analyzed the impact of treated SBP that occurs in the immediate pre-operative period on outcome after a living donor liver transplantation (LDLT). The results of whether post-transplant patients are dependent on pre-transplant infections are still debatable and unclear. Therefore, this study examined the outcomes of LDLT recipients with recent episodes of SBP and LDLT recipients without prior episodes of SBP. PATIENTS the records of 62 LDLT recipients who underwent LDLT were retrospectively reviewed. Twenty-four (36 %) recipients had at least one episode of SBP before LDLT. However, active SBP was not present in any of the recipients at the time of LDLT. Both recipient groups were compared in terms of demographic profile, perioperative and postoperative variables and outcomes. RESULTS higher pre-operative Child-Turcotte-Pugh (CTP) score (mean [SD] 11.77 [1.37] vs 10.5 [1.22], p < 0.001) and prior history of renal dysfunction (mean serum creatinine [SD] 1.715 [1.08] vs 1.02 [0.479] mg/dl, p = 0.002) were more commonly associated with the SBP group as compared to the non-SBP group. However, there was no statistically significant difference between the two groups in terms of the following variables: previous diabetes mellitus (3 [12.5 %] vs 6 [15.8 %]), pre-operative model for end-stage liver disease (MELD) score (median [IQR] 21 [10-37] vs 22 [9-39]), operative time (mean [SD] 789.57 [153.49] vs 800.86 [138.69] min), total number of blood transfusion (median [IQR] 10 [2-19] vs 8 [1-18]), hospital stay (median 21 vs 20 days), re-exploration (4 [16.6 %] vs 2 [5.3 %]), postoperative sepsis (8 [33 %] vs 5 [13 %]) and 30-day mortality (3 [12.5 %] vs 2 [5.3 %]). CONCLUSIONS the presence of previous episodes of pre-operative SBP in LDLT recipients does not result in adverse post-operative short-term outcomes.
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Affiliation(s)
- Vinayak Nikam
- Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, India
| | - Manish Srivastava
- Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, India
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13
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Trebicka J, Sundaram V, Moreau R, Jalan R, Arroyo V. Liver Transplantation for Acute-on-Chronic Liver Failure: Science or Fiction? Liver Transpl 2020; 26:906-915. [PMID: 32365422 DOI: 10.1002/lt.25788] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/02/2020] [Accepted: 04/05/2020] [Indexed: 12/17/2022]
Abstract
Acute clinical deterioration of a patient with chronic liver disease remains a decisive time point both in terms of medical management and prognosis. This condition, also known as acute decompensation (AD), is an important event determining a crossroad in the trajectory of patients. A significant number of patients with AD may develop hepatic or extrahepatic organ failure, or both, which defines the syndrome acute-on-chronic liver failure (ACLF), and ACLF is associated with a high morbidity and short-term mortality. ACLF may occur at any phase during chronic liver disease and is pathogenetically defined by systemic inflammation and immune metabolic dysfunction. When organ failures develop in the presence of cirrhosis, especially extrahepatic organ failures, liver transplantation (LT) may be the only curative treatment. This review outlines the evidence supporting LT in ACLF patients, highlighting the role of timing, bridging to LT, and possible indicators of futility. Importantly, prospective studies on ACLF and transplantation are urgently needed.
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Affiliation(s)
- Jonel Trebicka
- Translational Hepatology, Department of Internal Medicine I, Goethe University Clinic Frankfurt, Frankfurt, Germany.,European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Institute for Bioengineering of Catalonia, Barcelona, Spain
| | - Vinay Sundaram
- Division of Gastroenterology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,U1149, Centre de Recherche sur l'Inflammation, UMRS1149 Université de Paris, INSERM, Paris, France.,Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Rajiv Jalan
- Translational Hepatology, Department of Internal Medicine I, Goethe University Clinic Frankfurt, Frankfurt, Germany.,Royal Free Hospital, London, United Kingdom
| | - Vicente Arroyo
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
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14
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Tomescu D, Popescu M, Biancofiore G. Liver transplantation for acute-on-chronic liver failure. Best Pract Res Clin Anaesthesiol 2019; 34:25-33. [PMID: 32334784 DOI: 10.1016/j.bpa.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 11/24/2022]
Abstract
Acute-on-chronic liver failure (AoCLF) represents a newly defined entity in patients with liver disease leading to multiple organ failures and increased mortality. To date, no universally accepted definition exists, and different academic societies developed guidelines on the early diagnosis and classification of AoCLF. Recently published trials focused on factors associated with a poor outcome and on the development of severity scores aimed to identify patients who may benefit for advanced monitoring and treatment. No specific therapies are demonstrated to improve survival, and liver transplantation (LT) remains the only treatment associated with improved outcome. Our review focuses on current evidence for early diagnosis and prognostication of disease in patients with AoCLF, as well of criteria for intensive care unit admission, indication, and futility markers of LT, as well as bridging therapy and optimal timing of surgery.
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Affiliation(s)
- Dana Tomescu
- "Carol Davila" University of Medicine and Pharmacy, Department of Anesthesiology and Critical Care, Bucharest, Romania; Fundeni Clinical Institute, Department of Anesthesiology and Critical Care III, Bucharest, Romania
| | - Mihai Popescu
- "Carol Davila" University of Medicine and Pharmacy, Department of Anesthesiology and Critical Care, Bucharest, Romania; Fundeni Clinical Institute, Department of Anesthesiology and Critical Care III, Bucharest, Romania.
| | - Gianni Biancofiore
- University School of Medicine, Department of Anesthesia and Critical Care, Pisa, Italy
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15
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Ferrarese A, Vitale A, Sgarabotto D, Russo FP, Germani G, Gambato M, Cattelan AM, Angeli P, Cillo U, Burra P, Senzolo M. Outcome of a First Episode of Bacterial Infection in Candidates for Liver Transplantation. Liver Transpl 2019; 25:1187-1197. [PMID: 31021050 DOI: 10.1002/lt.25479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 04/22/2019] [Indexed: 12/13/2022]
Abstract
Bacterial infection (BI) is a major cause of worsening of liver function and death in patients with cirrhosis who are awaiting liver transplantation (LT). This study aimed to evaluate the outcome of LT candidates after a first episode of BI between January 2006 and December 2014 at Padua University Hospital. Among 876 LT candidates with cirrhosis, 114 (13%) experienced an episode of BI. Of the 114 patients, 79 were male and 35 were female, and the median (interquartile range) age and Model for End-Stage Liver Disease scores were 58 (12) years and 19 (8), respectively. When compared with matched LT candidates who experienced no BI, they had a higher probability of death (P = 0.004) and a lower probability of undergoing LT (P = 0.01). Considering only patients who recovered from BI within 30 days, their probabilities of death and of undergoing LT were similar to those of matched controls (P = 0.34 and P = 0.43, respectively). The 90-day post-LT mortality was equal between groups (P = 0.90). BI was a strong predictor of early death on the waiting list for LT. Conversely, patients who fully recovered from a BI episode within 30 days did not have a higher mortality risk than matched controls without infection.
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Affiliation(s)
- Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Alessandro Vitale
- Hepatobiliary Surgery and Liver Transplant Center, Padua University Hospital, Padua, Italy
| | - Dino Sgarabotto
- Tropical and Infectious Diseases Unit, Padua University Hospital, Padua, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Anna Maria Cattelan
- Tropical and Infectious Diseases Unit, Padua University Hospital, Padua, Italy
| | - Paolo Angeli
- Internal Medicine, Padua University Hospital, Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Center, Padua University Hospital, Padua, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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16
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Saleh AM, Hassan EA, Gomaa AA, El Baz TM, El-Abgeegy M, Seleem MI, Abo-Amer YEE, Elsergany HF, Mahmoud EIED, Abd-Elsalam S. Impact of pre-transplant infection management on the outcome of living-donor liver transplantation in Egypt. Infect Drug Resist 2019; 12:2277-2282. [PMID: 31413604 PMCID: PMC6661986 DOI: 10.2147/idr.s208954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 06/17/2019] [Indexed: 12/20/2022] Open
Abstract
Background and aim Liver transplantation (LT) has emerged as an established therapeutic option for patients with chronic liver disease. Patients with end-stage liver disease are at high risk of infection with multidrug-resistant organisms, which may affect the outcome of LT. The aim of this study was to evaluate the impact of pre-transplant infection on the outcome of living-donor LT. Methods Prospective follow-up was done for 50 patients with chronic liver disease who had had LT performed from September 2013 to December 2017. We divided patients into group 1 (patients who had had infection within 3 months before transplantation with adequate treatment [n=20]), and group 2 (patients without infection [n=30]). Both groups were followed for 4 months post-operatively. Results Patients with high Model
for End-Stage Liver Disease scores were more susceptible to infection pre- and post-operatively, and chest infection was the most common infection pre-transplant. There were no significant statistical differences regarding hospital and ICU stay and post-operative course between the groups, but the mortality rate was higher in group 1 (40%) than in group 2 (23.3%), and the causes of mortality in the group 1 were mainly due to medical causes (infections and sepsis, 75%) versus 28.6% in group 2. Conclusion Liver-cell failure and concomitant infection 3 months before LT with adequate treatment had no significant statistical differences regarding hospital, ICU stay, or medical complications, but post-operative infection and mortality rate were more frequent in group 1 and the causes of mortality were mainly medical.
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Affiliation(s)
| | - Essam Ali Hassan
- Tropical Medicine Department, Fayoum University, Al Fayyum, Egypt
| | - Ahmed Ali Gomaa
- Tropical Medicine Department, Fayoum University, Al Fayyum, Egypt
| | | | - Mohamed El-Abgeegy
- Liver Transplantation Team, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Mohamed Ismail Seleem
- Liver Transplantation Team, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Yousry Esam-Eldin Abo-Amer
- Hepatology, Gastroenterology, and Infectious Diseases Department, Mahala Hepatology Teaching Hospital, Gharbia, Egypt
| | - Heba Fadl Elsergany
- Liver Transplantation Team, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
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Nakamura K, Kageyama S, Ito T, Hirao H, Kadono K, Aziz A, Dery KJ, Everly MJ, Taura K, Uemoto S, Farmer DG, Kaldas FM, Busuttil RW, Kupiec-Weglinski JW. Antibiotic pretreatment alleviates liver transplant damage in mice and humans. J Clin Invest 2019; 129:3420-3434. [PMID: 31329160 PMCID: PMC6668671 DOI: 10.1172/jci127550] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 05/21/2019] [Indexed: 12/13/2022] Open
Abstract
Although modifications of gut microbiota with antibiotics (Abx) influence mouse skin and cardiac allografts, its role in orthotopic liver transplantation (OLT) remains unknown. We aimed to determine whether and how recipient Abx pretreatment may affect hepatic ischemia-reperfusion injury (IRI) and OLT outcomes. Mice (C57BL/6) with or without Abx treatment (10 days) were transplanted with allogeneic (BALB/c) cold-stored (18 hours) livers, followed by liver and blood sampling (6 hours). We divided 264 human OLT recipients on the basis of duration of pre-OLT Abx treatment into control (Abx-free/Abx <10 days; n = 108) and Abx treatment (Abx ≥10days; n = 156) groups; OLT biopsy (Bx) samples were collected 2 hours after OLT (n = 52). Abx in mice mitigated IRI-stressed OLT (IRI-OLT), decreased CCAAT/enhancer-binding protein homologous protein (CHOP) (endoplasmic reticulum [ER] stress), enhanced LC3B (autophagy), and inhibited inflammation, whereas it increased serum prostaglandin E2 (PGE2) and hepatic PGE2 receptor 4 (EP4) expression. PGE2 increased EP4, suppressed CHOP, and induced autophagosome formation in hepatocyte cultures in an EP4-dependent manner. An EP4 antagonist restored CHOP, suppressed LC3B, and recreated IRI-OLT. Remarkably, human recipients of Abx treatment plus OLT (Abx-OLT), despite severe pretransplantation clinical acuity, had higher EP4 and LC3B levels but lower CHOP levels, which coincided with improved hepatocellular function (serum aspartate aminotransferase/serum aspartate aminotransferase [sALT/sAST]) and a decreased incidence of early allograft dysfunction (EAD). Multivariate analysis identified "Abx-free/Abx <10 days" as a predictive factor of EAD. This study documents the benefits of Abx pretreatment in liver transplant recipients, identifies ER stress and autophagy regulation by the PGE2/EP4 axis as a homeostatic underpinning, and points to the microbiome as a therapeutic target in OLT.
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Affiliation(s)
- Kojiro Nakamura
- Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Shoichi Kageyama
- Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Takahiro Ito
- Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Hirofumi Hirao
- Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Kentaro Kadono
- Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Antony Aziz
- Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Kenneth J. Dery
- Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | - Kojiro Taura
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Douglas G. Farmer
- Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Fady M. Kaldas
- Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ronald W. Busuttil
- Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jerzy W. Kupiec-Weglinski
- Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Gustot T, Moreau R. Acute-on-chronic liver failure vs. traditional acute decompensation of cirrhosis. J Hepatol 2018; 69:1384-1393. [PMID: 30195459 DOI: 10.1016/j.jhep.2018.08.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 08/22/2018] [Accepted: 08/30/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Thierry Gustot
- Dept. Gastroenterology and Hepato-Pancreatology, C.U.B. Erasme Hospital, Brussels, Belgium; Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium; Inserm Unité 1149, Centre de Recherche sur l'inflammation (CRI), Paris, France; UMR S_1149, Université Paris Diderot, Paris, France; The EASL-CLIF Consortium, European Foundation-CLIF, Barcelona, Spain.
| | - Richard Moreau
- Inserm Unité 1149, Centre de Recherche sur l'inflammation (CRI), Paris, France; UMR S_1149, Université Paris Diderot, Paris, France; The EASL-CLIF Consortium, European Foundation-CLIF, Barcelona, Spain; Départment Hospitalo-Universitaire (DHU) UNITY, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Laboratoire d'Excellence (Labex) Inflamex, CUE Sorbonne Paris Cité, Paris, France
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Multidrug-Resistant Bacterial Infections in Solid Organ Transplant Candidates and Recipients. Infect Dis Clin North Am 2018; 32:551-580. [DOI: 10.1016/j.idc.2018.04.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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20
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Vesco NDL, Fragoso LVC, Beserra FDM, Aguiar MIFD, Alves NP, Bonates LAM. INFECÇÕES RELACIONADAS À ASSISTÊNCIA À SAÚDE E FATORES ASSOCIADOS NO PÓS-OPERATÓRIO DE TRANSPLANTE HEPÁTICO. TEXTO & CONTEXTO ENFERMAGEM 2018. [DOI: 10.1590/0104-070720180002150017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023] Open
Abstract
RESUMO Objetivo: identificar a incidência das infecções relacionadas à assistência à saúde e seus fatores associados, durante o primeiro mês do pós-operatório de pacientes adultos submetidos ao transplante hepático em um hospital público de Fortaleza. Método: estudo retrospectivo, descritivo com abordagem quantitativa, realizado com 53 receptores de fígado no primeiro semestre do ano de 2015. Os dados foram coletados através dos prontuários, fichas ambulatoriais e de notificação de infecções. Resultados: dos pacientes avaliados, 15 (28,3%) apresentaram infecção durante o primeiro mês, em que o mais prevalente foi a sepse clínica (n=6; 37,4%), seguida de infecção do trato respiratório (n=3; 18,8%), trato urinário (n=3;18,8%), sítio cirúrgico (n=3; 18,8%) e por último, infecção de corrente sanguínea (n=1; 6,2%). Os que apresentaram associação estatística em relação a não ocorrência de infecções foram o grupo dos pacientes casados e a indicação de cirrose por hepatite C. A média dos dias de internação no pós-operatório, o uso do imunossupressor micofenolato de mofetil e a média do uso de alguns dispositivos invasivos, foram identificados como os fatores associados à ocorrência de infecções, sendo estatisticamente significativos para p=<0,05. Conclusão: a identificação da incidência das infecções relacionadas à assistência à saúde e seus fatores associados em pacientes submetidos ao transplante hepático, poderá subsidiar o direcionamento das ações de saúde, com a finalidade de diminuir a morbimortalidade associada às infecções e otimizando a recuperação desses pacientes.
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Ferrarese A, Zanetto A, Becchetti C, Sciarrone SS, Shalaby S, Germani G, Gambato M, Russo FP, Burra P, Senzolo M. Management of bacterial infection in the liver transplant candidate. World J Hepatol 2018; 10:222-230. [PMID: 29527258 PMCID: PMC5838441 DOI: 10.4254/wjh.v10.i2.222] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 12/29/2017] [Accepted: 01/24/2018] [Indexed: 02/06/2023] Open
Abstract
Bacterial infection (BI) is a common cause of impairment of liver function in patients with cirrhosis, especially in the liver transplant candidates. These patients share an immunocompromised state and increased susceptibility to develop community and hospital-acquired infections. The changing epidemiology of BI, with an increase of multidrug resistant strains, especially in healthcare-associated settings, represents a critical issue both in the waiting list and in the post-operative management. This review focused on the role played by BI in patients awaiting liver transplantation, evaluating the risk of drop-out from the waiting list, the possibility to undergo liver transplantation after recovery from infection or during a controlled infection.
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Affiliation(s)
- Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Chiara Becchetti
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Salvatore Stefano Sciarrone
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Sarah Shalaby
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
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