Strategies to reduce infectious complication using epidemiologic data analysis in liver transplant recipients

Effect of Pretransplant Infections on Clinical Outcomes in Live-Donor Liver Transplant Recipients

Owing to impaired immune function, surgical procedures, and multiple hospitalizations, patients with end-stage liver disease are at risk for numerous infectious complications while waiting for transplantation. Infection in transplant recipients remains the main cause of mortality and morbidity, despite advances in surgical techniques and the development of new repressive agents. The purpose of this study is to examine the infections that develop during the pretransplantion period in live donor liver transplant recipients and their effect on post-transplant clinical outcomes. The retrospective analysis of adult live donor liver transplant recipients in the last 4 years was conducted at Ankara University Hospital, a 1900-bed tertiary-care university hospital, in Ankara, Turkey. Demographic characteristics, preoperative infections, and clinical outcomes were analyzed. Patients were divided into 2 groups according to whether they had developed an infection before transplantation. The diagnoses were based on clinical, laboratory, and microbiological findings. Statistical analyses were performed using Stata version 9.0 (StataCorp, College Station, Tex., United States), and P < .05 were considered statistically significant. In univariate analyses, having diabetes mellitus or a pretransplant infection, the number of pretransplant infection attacks, the need for a reoperation, and developing a post-transplant infection were the statistically significant factors associated with 1-year mortality (P < .001, χ² test). In multivariate analyses, diabetes mellitus (Odds ratio [OR] = 7.44, 95% confidence interval [CI], .03-45.79; P = .013), reoperation (OR = .33, 95% CI, .25-2.20; P < .001), having a pretransplantation infection (OR = 12.47, 95% CI, .011-87.67; P = .013), and the number of pretransplantation infection attacks (OR = .028, 95% CI, .013-.47; P < .001) were found to be statistically significant risk factors for 1-year mortality. Our study showed the effect of pretransplantation infections on post-transplant morbidity but not on rejection or mortality. According to the situation of patients, manageable pretransplantation infection is not an absolute contraindication for liver transplantation. Awareness of the increased risk for post-transplant infections and fast-acting antimicrobial coverage are the most important facts for patient survival.

Risk index for early infections following living donor liver transplantation

INTRODUCTION

Post-operative infections in patients undergoing living donor liver transplantation (LDLT) are a major cause of morbidity and mortality. This study aims to develop a practical and efficient prognostic index for early identification and possible prediction of post-transplant infections using risk factors identified by multivariate analysis.

MATERIAL AND METHODS

One hundred patients with post-hepatitic cirrhosis, HCV positive, genotype 4, Child B/C or MELD score 13-25 undergoing LDLT were included. All potential predictors of infection were analyzed by backward logistic regression. Cut-off values were obtained from ROC curve analysis. Significant predictors were combined into a risk index, which was further tested and compared by ROC curve analysis.

RESULTS

Post-operative infection was associated with a significantly higher mortality (50.7% vs. 33.3%). Total leucocyte count, total bilirubin, early biliary complications, fever and C-reactive protein were found to be independent predictors of early infectious complications after LDLT. The risk index predicted infection with the highest sensitivity and specificity as compared with each predictor on its own (AUC = 0.91, 95% CI: 0.830-0.955, p < 0.0001).

CONCLUSIONS

The use of a combined risk index for early diagnosis of post-operative infections can efficiently identify high risk patients.

Impact of Pretransplant Infections on Clinical Course in Liver Transplant Recipients

BACKGROUND

Uncontrolled infections are known to be an absolute contraindication for liver transplantation; however, the posttransplant prognosis of recipients treated for pretransplant infection is unclear. The aim of this study was to analyze pretransplant infections among liver transplant recipients and to determine their impact on posttransplant clinical outcomes.

METHODS

This study retrospectively analyzed 357 subjects who had undergone living-donor liver transplantation between January 2008 and May 2014.

RESULTS

Among 357 recipients, 71 patients (19.8%) had 74 episodes of infectious complications before liver transplantation. These complications consisted of pneumonia (n = 13), spontaneous bacterial peritonitis (n = 12), catheter-related infection (n = 10), urinary tract infection (n = 12), biliary tract infection (n = 6), and skin and soft-tissue infection (n = 3). Twenty-six patients experienced 29 episodes of bacteremia, and the most common pathogens were coagulase-negative staphylococci (n = 8), followed by Klebsiella pneumoniae (n = 7), Staphylococcus aureus (n = 4), and Streptococcus species (n = 3). Twenty-one bacteremic episodes (70%) occurred within 1 month before transplantation (n = 4). Recipients with pretransplant infections had significantly more frequent posttransplant infections (71.8% [51 of 71] vs 47.2% [35 of 286]; P = .0001), posttransplant bacteremia (33.8% [24 of 71] vs 20.3% [58 of 286]; P = .015), and longer posttransplant intensive care unit stays (11.2 ± 10.7 days vs 7.3 ± 4.2 days; P = .0004) than those without pretransplant infections. However, episodes of rejection (P = .36), length of hospitalization (P = .10), 28-day mortality (P = .31), and 1-year mortality (P = .61) after transplantation were not significantly different between the 2 groups.

CONCLUSIONS

Pretransplant infection had an impact on posttransplant morbidity, although not on rejection and mortality. Alertness for posttransplant infection and proper management (including effective antimicrobial coverage) would improve patient morbidity.