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Preemptive VAE-An Important Tool for Managing Blood Loss in MVT Candidates With PMT. Transplant Direct 2021; 7:e670. [PMID: 34104709 PMCID: PMC8183802 DOI: 10.1097/txd.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/27/2020] [Accepted: 12/15/2020] [Indexed: 11/25/2022] Open
Abstract
Explantation of native viscera in multivisceral transplant candidates, particularly in those with extensive portomesenteric thrombosis (PMT), carries considerable morbidity due to extensive vascularized adhesions. Preemptive visceral angioembolization has been previously described as a technique to minimize excessive blood loss during mobilization of the native viscera but is not well described specifically in patients with extensive PMT.
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2
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Cheung D, Garcia J, Beduschi T, Langshaw A, Arheart K, Wunsch C, Vianna R, Gonzalez IA. Re-evaluating Blood Markers as Predictors of Outcome in Multivisceral and Intestinal Transplantation. Transplant Proc 2021; 53:696-704. [PMID: 33558087 DOI: 10.1016/j.transproceed.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/08/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Multivisceral transplant (MVTx) and isolated intestinal transplant (ITx) are complex surgical procedures. The subsequent proinflammatory state in the immediate postoperative period makes interpretation of blood markers difficult. METHOD We aimed to establish the course of various blood markers after MVTx/ITx, and to evaluate their use as diagnostic markers of complications. This was a single center prospective cohort. We analyzed blood markers collected preoperatively, on alternate days for the first postoperative week, and then weekly for 4 weeks. This study was in compliance with The Declaration of Helsinki. RESULTS Over a 16-month period (July 2017-October 2018), 20 subjects aged 2 to 67 years with a median age of 24.5 years received MVTx/ITx. Twelve recipients (60%) had an infection. Neutrophil lymphocyte count ratio (NLCR) was higher than established upper limits of normal, regardless of infection status. NLCR and white blood cell count were useful to identify infected MVTx/ITx recipients, with P values <.05 for 2 and 1 of 7 time points post transplant, respectively. Higher preoperative eosinophil% predicted future acute cellular rejection (P value .023). CONCLUSIONS This is the first study to extensively track the course of blood markers post MVTx/ITx and identified NLCR and white blood cell count as potential diagnostic blood markers of infection.
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Affiliation(s)
- Donna Cheung
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Miami, Miami, Florida.
| | - Jennifer Garcia
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Miami, Miami, Florida
| | - Thiago Beduschi
- Department of Surgery, Division of Liver/GI Transplant, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, Florida
| | - Amber Langshaw
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Miami, Miami, Florida
| | - Kristopher Arheart
- Department of Public Health Sciences, Division of Biostatistics, University of Miami, Miami, Florida
| | - Chris Wunsch
- Department of Pathology, University of Miami, Miami, Florida
| | - Rodrigo Vianna
- Department of Surgery, Division of Liver/GI Transplant, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, Florida
| | - Ivan A Gonzalez
- Department of Pediatrics, Division of Pediatric Infectious Disease and Immunology, University of Miami, Miami, Florida
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3
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Clostridioides difficile Infections in Adult and Pediatric Intestinal and Multivisceral Transplant Patients. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2020. [DOI: 10.1097/ipc.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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4
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Abstract
BACKGROUND Small bowel transplant (SBT) is a surgical procedure that may be used in patients with pathology resulting in severe intestinal failure resistant to conventional forms of surgical and nonsurgical treatment. Intestinal failure is defined as the failure of enterocytes to absorb sufficient macronutrients, water, and/or electrolytes to sustain homeostasis and/or promote growth. With the advancement of surgical techniques and advancements in perioperative transplant management, SBT has become an increasingly common treatment for intestinal failure, with survival rates for SBT comparable to those for other solid organ transplants. MATERIALS AND METHODS This review provides background on SBT, its variations, and the associated preoperative and postoperative imaging studies with regard to surgical planning and anticipated complications. RESULTS AND CONCLUSIONS With the increasing use of SBT, radiologists will be expected to be familiar with the diagnostic studies and available endovascular interventions associated with this procedure.
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5
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Carugati M, Morlacchi LC, Peri AM, Alagna L, Rossetti V, Bandera A, Gori A, Blasi F. Challenges in the Diagnosis and Management of Bacterial Lung Infections in Solid Organ Recipients: A Narrative Review. Int J Mol Sci 2020; 21:E1221. [PMID: 32059371 PMCID: PMC7072844 DOI: 10.3390/ijms21041221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/31/2020] [Accepted: 02/07/2020] [Indexed: 12/11/2022] Open
Abstract
Respiratory infections pose a significant threat to the success of solid organ transplantation, and the diagnosis and management of these infections are challenging. The current narrative review addressed some of these challenges, based on evidence from the literature published in the last 20 years. Specifically, we focused our attention on (i) the obstacles to an etiologic diagnosis of respiratory infections among solid organ transplant recipients, (ii) the management of bacterial respiratory infections in an era characterized by increased antimicrobial resistance, and (iii) the development of antimicrobial stewardship programs dedicated to solid organ transplant recipients.
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Affiliation(s)
- Manuela Carugati
- Internal Medicine Department, Division of Infectious Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, 20122 Milano, Italy; (A.M.P.); (L.A.); (A.B.); (A.G.)
- Division of Infectious Diseases and International Health, Duke University, Durham, NC 27710, USA
| | - Letizia Corinna Morlacchi
- Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, 20122 Milano, Italy; (L.C.M.); (V.R.); (F.B.)
| | - Anna Maria Peri
- Internal Medicine Department, Division of Infectious Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, 20122 Milano, Italy; (A.M.P.); (L.A.); (A.B.); (A.G.)
| | - Laura Alagna
- Internal Medicine Department, Division of Infectious Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, 20122 Milano, Italy; (A.M.P.); (L.A.); (A.B.); (A.G.)
| | - Valeria Rossetti
- Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, 20122 Milano, Italy; (L.C.M.); (V.R.); (F.B.)
| | - Alessandra Bandera
- Internal Medicine Department, Division of Infectious Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, 20122 Milano, Italy; (A.M.P.); (L.A.); (A.B.); (A.G.)
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milano, Italy
| | - Andrea Gori
- Internal Medicine Department, Division of Infectious Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, 20122 Milano, Italy; (A.M.P.); (L.A.); (A.B.); (A.G.)
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milano, Italy
- Centre for Multidisciplinary Research in Health Science, 20122 Milano, Italy
| | - Francesco Blasi
- Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, 20122 Milano, Italy; (L.C.M.); (V.R.); (F.B.)
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milano, Italy
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6
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Cheung DA, Beduschi T, Tekin A, Selvaggi G, Ruiz P, Vianna RM, Garcia J. Clostridium difficile infection mimics intestinal acute cellular rejection in pediatric multivisceral transplant-A case series. Pediatr Transplant 2020; 24:e13621. [PMID: 31815352 DOI: 10.1111/petr.13621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/22/2019] [Accepted: 10/28/2019] [Indexed: 12/19/2022]
Abstract
Clostridium difficile infection (CDI) is the most common health care-associated infection in the United States. Thirty-nine percent of intestinal transplant recipients may develop CDI. Induction of rejection has been reported as a rare event. To our knowledge, this will be the second report of an association between CDI and rejection in the literature. We describe our experience with four pediatric MVT recipients, three of whom on treatment of their CDI alone had resolution of biopsy findings of intestinal ACR. Our patients were males aged 2-5 years old who had their first CDI post-MVT occurring from 2 months to 15 months post-transplant. All first episodes of CDI were treated with a 10-14 day course of metronidazole with one additionally receiving vancomycin. All four recipients had recurrent CDI, and two recipients had septic shock as a manifestation of their CDI. Three recipients had biopsies showing mild rejection during episodes of CDI, and treatment of the CDI resulted in resolution of biopsy findings of rejection. Our case series suggests CDI may mimic ACR on intestinal biopsy. Treatment of rejection during active CDI carries the risk of over-suppression and worsening of CDI. Our experience has taught us that surveillance endoscopy for rejection may be deceiving during an active CDI, and if mild acute rejection is noted during active CDI, treatment of rejection can be safely delayed and potentially avoided.
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Affiliation(s)
- Donna Ann Cheung
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Miami, Miami, FL, USA
| | - Thiago Beduschi
- Division of Liver/GI Transplant, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Akin Tekin
- Division of Liver/GI Transplant, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Gennaro Selvaggi
- Division of Liver/GI Transplant, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Phillip Ruiz
- Division of Transplantation Laboratories and Immunopathology, Department of Surgery and Pathology, University of Miami, Miami, FL, USA
| | - Rodrigo M Vianna
- Division of Liver/GI Transplant, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Jennifer Garcia
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Miami, Miami, FL, USA
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Haidar G, Green M. Intra-abdominal infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13595. [PMID: 31102546 DOI: 10.1111/ctr.13595] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/11/2019] [Indexed: 02/06/2023]
Abstract
This new guideline from the AST IDCOP reviews intra-abdominal infections (IAIs), which cause substantial morbidity and mortality among abdominal SOT recipients. Each transplant type carries unique risks for IAI, though peritonitis occurs in all abdominal transplant recipients. Biliary infections, bilomas, and intra-abdominal and intrahepatic abscesses are common after liver transplantation and are associated with the type of biliary anastomosis, the presence of vascular thrombosis or ischemia, and biliary leaks or strictures. IAIs after kidney transplantation include renal and perinephric abscesses and graft-site candidiasis, which is uncommon but may require allograft nephrectomy. Among pancreas transplant recipients, duodenal anastomotic leaks can have catastrophic consequences, and polymicrobial abscesses can lead to graft loss and death. Intestinal transplant recipients are at the highest risk for sepsis, infection due to multidrug-resistant organisms, and death from IAI, as the transplanted intestine is a contaminated, highly immunological, pathogen-rich organ. Source control and antibiotics are the cornerstone of the management of IAIs. Empiric antimicrobial regimens should be tailored to local susceptibility patterns and pathogens with which the patient is known to be colonized, with subsequent optimization once the results of cultures are reported.
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Affiliation(s)
- Ghady Haidar
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael Green
- Departments of Pediatrics, Surgery & Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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8
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Clostridium difficile: A Frequent Infection in Children After Intestinal Transplantation. Transplantation 2019; 104:197-200. [PMID: 31205257 DOI: 10.1097/tp.0000000000002795] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Organ transplantation (Tx) is a risk factor for Clostridium difficile infection (CDI). After intestinal transplantation (ITx), few data are available on the impact of this graft infection and the possible induction of rejection. METHODS We included retrospectively all children after ITx in our unit, with at least 1 year of graft survival. All samples positive for Clostridium difficile (CD) and its toxin were considered. RESULTS Among the 57 ITx recipients (60 Txs), 22 children (39%) developed culture-proven CDI, 12 after isolated small bowel Tx, 9 after liver-small bowel Tx, and 1 after multivisceral Tx. Twenty patients had diarrhea, 8 bloody stools, 4 fever, and 1 hypothermia. Nine were hospitalized for an average of 6.5 days (2-20) and 4 with severe dehydration. Nine (40%) had received antibiotics for an average of 19 days (7-60) before CDI. Two patients were asymptomatic. CDI was treated with metronidazole in 12 children, vancomycin in 6, and both in 3. Three children presented mild-to-severe rejections. Two patients presented concomitantly CDI and rejection. The third patient presented a rejection with severe complications 4 years after CDI. Recurrence of toxinogenic CD was observed in 9 children, in 7 associated with clinical symptoms. During the last follow-up, the stool number was the same as before CDI except for 1 patient with ongoing infection. CONCLUSIONS CDI is more prevalent in children after ITx compared with other organ Tx; it is most often symptomatic but mildly or moderately severe. Standard antibiotics efficiently control the symptoms. Induction of rejection is a rare event.
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9
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Abstract
BACKGROUND This study reports the infection rate, location of infection and pathogen causing bacterial, fungal or viral infections in intestine transplant recipients at a pediatric transplant center. METHODS Records from a pediatric center were reviewed for patients receiving an intestine transplant. Positive cultures and pathology reports were used to diagnose bacterial, fungal and viral infections and also to determine location and infectious agent. Risk for infection was assessed based on liver or colon inclusion, and immunosuppression induction, as part of the intestine transplant. RESULTS During the study period, 52 intestine transplants were performed on 46 patients. Bacterial, fungal and viral infection rates were 90%, 25% and 75%, respectively. Enterococcus spp. (non-vancomycin-resistant enterococci) were the most common pathogens and were isolated from 52% of patients. Non-vancomycin-resistant enterococci was present in 12% of transplant recipients. Candida spp. were the most common fungal pathogens (23% of patients). Respiratory viral infections were common (44%), and Cytomegalovirus infection rate was 17%. Common sites of infection were bloodstream, urinary and upper respiratory tract. Colon and liver inclusion in the transplant graft was not associated with increased risk of infection, nor was addition of rituximab to the immunosuppression induction protocol. CONCLUSIONS Postintestine transplant infections are ubiquitous in the pediatric population, including high rates of infection from bacterial, viral and fungal sources. Inclusion of the liver and/or colon as a component of the transplant graft did not appear to greatly impact the infectious risk. Adding rituximab to the immunosuppression induction protocol did not impact on infectious risk.
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10
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Chatani B, Garcia J, Biaggi C, Beduschi T, Tekin A, Vianna R, Arheart K, Gonzalez IA. Comparison in outcome with tailored antibiotic prophylaxis postoperatively in pediatric intestinal transplant population. Pediatr Transplant 2018; 22:e13277. [PMID: 30091217 DOI: 10.1111/petr.13277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 07/16/2018] [Indexed: 12/23/2022]
Abstract
BIs are ubiquitous among the pediatric intestinal transplant patient population. Personalizing postoperative prophylaxis antibiotic regimens may improve outcomes in this population. A retrospective analysis of all pediatric patients who underwent intestinal transplantation was evaluated to compare standardized and tailored regimens of antibiotics provided as prophylaxis postoperatively. Patients in the standard group have both shorter time to and higher rate of BIs, which was statistically significant (P < 0.001). Of the children who developed a BI, there was no statistical difference in average times to the development of a second BI (293 vs 119 days, P = 0.211). The tailored group had prolonged times until the development of a MDRO (52.6 vs 63.9 days, P = 0.677). Although not statistically significant, the tailored group had a propensity to present with gram-negative pathogens after transplant as compared to the standard regimen group, which presented with gram-positive pathogens (P = 0.103). Children with a history of an MDRO held a 7.3 (P < 0.01) times more likelihood of death within a year of transplant. A tailored prophylactic antibiotic regimen in the post-transplant period appears to prolong the time to the first BI. Although the data do not show differences in mortality, further study may prove the impact of a tailored antibiotic regimen on morbidity and mortality rates.
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Affiliation(s)
| | - Jennifer Garcia
- Pediatric Gastroenterology, University of Miami Miller School of Medicine, Miami, Florida
| | - Chiara Biaggi
- Pediatric Gastroenterology, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Akin Tekin
- Miami Transplant Institute, Miami, Florida
| | | | - Kristopher Arheart
- Biostatistics, University of Miami Miller School of Medicine, Miami, Florida
| | - Ivan A Gonzalez
- Pediatric Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
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11
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Posttransplant complications in adult recipients of intestine grafts without bowel decontamination. J Surg Res 2018; 225:125-130. [DOI: 10.1016/j.jss.2018.01.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/06/2017] [Accepted: 01/05/2018] [Indexed: 11/23/2022]
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12
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Clouse JW, Kubal CA, Fridell JA, Mangus RS. Complications in pediatric intestine transplantation in the absence of peri-operative donor or recipient bowel decontamination. Pediatr Transplant 2018; 22:e13164. [PMID: 29498160 DOI: 10.1111/petr.13164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2018] [Indexed: 12/20/2022]
Abstract
This study reports the clinical complication and infection rates of an active pediatric IT program that has never utilized bowel decontamination in either the donor or the recipient. All patients undergoing IT from 2003 to 2015 at a single pediatric IT center were reviewed. Post-transplant surgical, infectious, and immunosuppressive complications are reported. There were 52 patients who underwent IT during the study period. Among these patients, 4% developed a postoperative abscess, one developed an enteric fistula (2%), and one had an enteric or anastomotic leak (2%). The rate of any bacterial infection was 90% in the first year, with a wound infection rate of 23%. Any fungal infection occurred in 25% of patients. Any viral infection occurred in 75% of patients. Gastrointestinal viruses were diagnosed in 52% of patients, and cytomegalovirus infections occurred in 17%. Rejection rates were 39% at any time post-transplant (isolated 44% and 35% for multivisceral patients). At this center in which no bowel decontamination was used, rates of surgical complications, infections, and rejection were similar to those reported by other centers. These findings suggest bowel decontamination may provide no significant benefit in this population of high-risk transplant patients.
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Affiliation(s)
- Jared W Clouse
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chandrashekhar A Kubal
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jonathan A Fridell
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Richard S Mangus
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, IN, USA
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13
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Rees MA, Amesur NB, Cruz RJ, Borhani AA, Abu-Elmagd KM, Costa G, Dasyam AK. Imaging of Intestinal and Multivisceral Transplantation. Radiographics 2018. [DOI: 10.1148/rg.2018170086] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Mitchell A. Rees
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Nikhil B. Amesur
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Ruy J. Cruz
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Amir A. Borhani
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Kareem M. Abu-Elmagd
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Guilherme Costa
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Anil K. Dasyam
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
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Abstract
PURPOSE OF REVIEW The purpose of this article is to review the existing literature on the current indications, surgical techniques, immunosuppressive therapy and outcomes following intestinal transplantation (ITx). RECENT FINDINGS Over recent years, ITx has become a more common operation with approximately 2500 procedures carried out worldwide by 2014. It is reserved for patients with intestinal failure and who have developed complications of home parenteral nutrition or who have a high risk of dying from their underlying disease. Recent advances such as the improvement in survival rates, not only for isolated small bowel transplants but also following inclusion of a liver graft in combined liver-small bowel transplant, and the utility of citrulline as a noninvasive biomarker to appreciate acute rejection herald an exciting shift in the field of ITx. SUMMARY With advancements in immunosuppressive drugs, induction regimens, standardization of surgical techniques and improved postoperative care, survival is increasing. In due course, it will most likely become as good as remaining on home parenteral nutrition and as such could become a viable first-line option.
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15
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Galloway D, Danziger-Isakov L, Goldschmidt M, Hemmelgarn T, Courter J, Nathan JD, Alonso M, Tiao G, Fei L, Kocoshis S. Incidence of bloodstream infections in small bowel transplant recipients receiving selective decontamination of the digestive tract: A single-center experience. Pediatr Transplant 2015; 19:722-9. [PMID: 26332092 PMCID: PMC4837460 DOI: 10.1111/petr.12583] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 12/13/2022]
Abstract
Pediatric patients undergoing small bowel transplantation are susceptible to postoperative CLABSI. SDD directed against enteric microbes is a strategy for reducing CLABSI. We hypothesized that SDD reduces the frequency of CLABSI, infections outside the bloodstream, and allograft rejection during the first 30 days following transplant. A retrospective chart review of 38 pediatric small bowel transplant recipients at CCHMC from 2003 to 2011 was conducted. SDD antimicrobials were oral colistin, tobramycin, and amphotericin B. The incidence of CLABSI, infections outside the bloodstream, and rejection episodes were compared between study periods. The incidence of CLABSI did not differ between study periods (6.9 CLABSI vs. 4.6 CLABSI per 1000 catheter days; p = 0.727), but gram positives and Candida predominated in the first 30 days. Incidence of bacterial infections outside the bloodstream did not differ (p = 0.227). Rejection occurred more frequently during the first month following transplant (p = 0.302). SDD does not alter the incidence of CLABSI, bacterial infections outside the bloodstream, or allograft rejection in the immediate 30 days post-transplantation. However, SDD does influence CLABSI organism types (favoring gram positives and Candida) and Candidal infections outside the bloodstream.
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Affiliation(s)
- David Galloway
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Lara Danziger-Isakov
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Monique Goldschmidt
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Trina Hemmelgarn
- Division of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Joshua Courter
- Division of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Jaimie D. Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Maria Alonso
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Greg Tiao
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Lin Fei
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Samuel Kocoshis
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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16
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Paudel S, Zacharioudakis IM, Zervou FN, Ziakas PD, Mylonakis E. Prevalence of Clostridium difficile infection among solid organ transplant recipients: a meta-analysis of published studies. PLoS One 2015; 10:e0124483. [PMID: 25886133 PMCID: PMC4401454 DOI: 10.1371/journal.pone.0124483] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 03/02/2015] [Indexed: 01/10/2023] Open
Abstract
Several factors including antibiotic use, immunosuppression and frequent hospitalizations make solid organ transplant (SOT) recipients vulnerable to Clostridium difficile infection (CDI). We conducted a meta-analysis of published studies from 1991-2014 to estimate the prevalence of CDI in this patient population. We searched PubMed, EMBASE and Google Scholar databases. Among the 75,940 retrieved citations, we found 30 studies coded from 35 articles that were relevant to our study. Based on these studies, we estimated the prevalence of CDI among 21,683 patients who underwent transplantation of kidney, liver, lungs, heart, pancreas, intestine or more than one organ and stratified each study based on the type of transplanted organ, place of the study conduction, and size of patient population. The overall estimated prevalence in SOT recipients was 7.4% [95%CI, (5.6-9.5%)] and it varied based on the type of organ transplant. The prevalence was 12.7% [95%CI, (6.4%-20.9%)] among patients who underwent transplantation for more than one organ. The prevalence among other SOT recipients was: lung 10.8% [95% CI, (5.5%-17.7%)], liver 9.1 % [95%CI, (5.8%-13.2%)], intestine 8% [95% CI, (2.6%-15.9%)], heart 5.2% [95%CI, (1.8%-10.2%)], kidney 4.7% [95% CI, (2.6%-7.3%)], and pancreas 3.2% [95% CI, (0.5%-7.9%)]. Among the studies that reported relevant data, the estimated prevalence of severe CDI was 5.3% [95% CI (2.3%-9.3%)] and the overall recurrence rate was 19.7% [95% CI, (13.7%-26.6%)]. In summary, CDI is a significant complication after SOT and preventive strategies are important in order to reduce the CDI related morbidity and mortality.
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Affiliation(s)
- Suresh Paudel
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Ioannis M. Zacharioudakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Fainareti N. Zervou
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Panayiotis D. Ziakas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
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Shao M, Wan Q, Xie W, Ye Q. Bloodstream infections among solid organ transplant recipients: Epidemiology, microbiology, associated risk factors for morbility and mortality. Transplant Rev (Orlando) 2014; 28:176-81. [PMID: 24630890 DOI: 10.1016/j.trre.2014.02.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 09/26/2013] [Accepted: 02/09/2014] [Indexed: 12/15/2022]
Abstract
Bloodstream infections (BSIs) remain important causes of morbidity and mortality among solid organ transplant (SOT) recipients and still threaten the success of SOT. In general, among SOT recipients, risk factors for BSIs are associated with prior ICU admission, catheterization, older recipient or donor age…etc. Pulmonary focus, nosocomial source of BSIs, lack of appropriate antibiotic therapy and other variables have significant impacts on BSIs-related mortality in SOT. Most of BSIs in SOT are caused by gram-negative bacteria. However, all aspects including microbiological spectrum, morbidity and mortality rates, risk factors of BSIs and BSIs-related death depend on the type of transplantation. The purpose of this review is to summarize the epidemiology, microbiologic features including antimicrobial resistance of organisms, and associated risk factors for morbidity and mortality of BSIs according to different type of transplantation to better understand the characteristics of BSIs and improve the outcomes after SOT.
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Turner DL, Gordon CL, Farber DL. Tissue-resident T cells,in situimmunity and transplantation. Immunol Rev 2014; 258:150-66. [DOI: 10.1111/imr.12149] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Damian L. Turner
- Columbia Center for Translational Immunology; Columbia University Medical Center; New York NY USA
- Department of Medicine; Columbia University Medical Center; New York NY USA
| | - Claire L. Gordon
- Columbia Center for Translational Immunology; Columbia University Medical Center; New York NY USA
- Department of Medicine; Columbia University Medical Center; New York NY USA
- Department of Medicine; University of Melbourne; Melbourne Vic. Australia
| | - Donna L. Farber
- Columbia Center for Translational Immunology; Columbia University Medical Center; New York NY USA
- Department of Surgery; Columbia University Medical Center; New York NY USA
- Department of Microbiology and Immunology; Columbia University Medical Center; New York NY USA
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Primeggia J, Matsumoto CS, Fishbein TM, Karacki PS, Fredette TM, Timpone JG. Infection among adult small bowel and multivisceral transplant recipients in the 30-day postoperative period. Transpl Infect Dis 2013; 15:441-8. [PMID: 23809406 DOI: 10.1111/tid.12107] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 08/13/2012] [Accepted: 01/08/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Intestinal transplantation is a potential option for patients with short gut syndrome (SGS), and infection is common in the postoperative period. The aim of our study was to identify the incidence and characteristics of bacterial and fungal infections of adult small bowel or multivisceral (SB/MV) transplantation recipients in the 30-day postoperative period. METHODS This retrospective chart review assessed the incidence and characteristics of bacterial and fungal infections in patients who underwent SB/MV transplant at our center between April 2004 and November 2008. Patient data were retrieved from computerized databases, flow-charts, and medical records. RESULTS A total of 40 adult patients with a mean age of 38.7 ± 13.4 years received transplants during this period: 27 patients received isolated SB, 12 received MV, and 1 received SB and kidney. Our immunosuppressive regimen included basiliximab for induction, and tacrolimus, sirolimus, and methylprednisolone for maintenance therapy. The most common indications for transplant were SGS, intestinal ischemia, Crohn's disease, trauma, motility disorders, and Gardner's syndrome. We report a 30-day postoperative infection rate of 57.5% and mean time to first infection of 10.78 ± 8.99 days. A total of 36 infections were documented in 23 patients. Of patients who developed infections, 56.5% developed 1 infection, 30.4% developed 2 infections, and 13% developed 3 infections. The most common site of infection was the abdomen, followed by blood, urine, lung, and wound infection. The isolates were gram-negative bacteria in 49.3%, gram-positive bacteria in 39.4%, and 11.3% were fungi. The most common organisms were Pseudomonas (19%), Enterococcus (15%), and Escherichia coli (13%). Overall, 47% of infections were due to drug-resistant pathogens; 31% of E. coli and Klebsiella species were extended-spectrum beta-lactamase-producing organisms, 36% of Pseudomonas was multidrug resistant (MDR), 75% of Enterococcus was vancomycin resistant, and 100% of Staphylococcus aureus was methicillin resistant. CONCLUSION These findings demonstrate that bacterial and fungal infections remain an important complication in SB/MV transplant recipients within the early postoperative period. Infections due to MDR organisms have emerged as an important clinical problem in this patient population.
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Affiliation(s)
- J Primeggia
- Division of Infectious Diseases, Department of Internal Medicine, Georgetown University Hospital, Washington, DC, USA
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Abstract
BACKGROUND Little information regarding bloodstream infections (BSIs) in small bowel transplantation has been published. METHODS We reviewed the medical records of 98 pediatric patients who underwent small bowel transplantation. Patients' characteristics were analyzed with Wilcoxon rank-sum, χ or Fisher's exact tests. We estimated the overall survival by the Kaplan-Meier method and compared survival distributions between groups with the log-rank test. RESULTS Sixty-eight patients developed ≥1episode of BSIs (total of 146 episodes), and 69.1% of the first infections were diagnosed in the 3 months post-transplantation. The most common sources of infection were as follows: central venous catheters (49.3%) and intra-abdominal infections (32.9%). Central venous catheters were present in 86.3%, and total parenteral nutrition within 7 days before infection was administered in 72.6% of episodes. Gram-positive bacteria (96 isolates) were more frequently isolated than Gram-negative bacteria (52 isolates), with Enterococcus spp. being the most commonly identified (48 isolates), followed by coagulase-negative Staphylococcus (40 isolates). Patients with infections were younger than those without (median 1.4 versus 2.1 years, P=0.02). Four grafts were lost after transplantation in patients with BSIs and 2 in patients without BSIs (P = 0.99). One-year survival rate for patients without BSIs was 86.7% (95% confidence interval: 68.3%-94.8%) versus 72.1% in patients with BSIs (95% confidence interval: 59.8%-81.2%). Overall time to death was shorter in patients with BSIs than in patients without BSIs (P=0.056). CONCLUSIONS Almost 70% of small bowel transplantation recipients developed BSIs, mainly in the early months after transplantation. BSIs were mainly from a central venous catheter or intra-abdominal source. Enterococcus spp were the most frequently isolated organisms. Patients with BSIs had worse survival than patients with BSIs.
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Akhter K, Timpone J, Matsumoto C, Fishbein T, Kaufman S, Kumar P. Six-month incidence of bloodstream infections in intestinal transplant patients. Transpl Infect Dis 2011; 14:242-7. [PMID: 22093913 DOI: 10.1111/j.1399-3062.2011.00683.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 07/19/2011] [Accepted: 08/13/2011] [Indexed: 01/29/2023]
Abstract
BACKGROUND Intestinal transplantation has emerged as an established treatment for life-threatening intestinal failure. The most common complication and cause of death is infection. Risk of infection is highest during the first 6 months, as a consequence of maximal immunosuppression, greater than that required for any other organ allograft. METHODS We performed a retrospective chart review of all (56) adult and pediatric (<18 years) small bowel transplant patients at our institution between November 2003 and July 2007, and analyzed the 6-month post-transplant incidence of bloodstream infections (BSIs). We evaluated multiple risk factors, including inclusion of a colon or liver, total bilirubin >5, surgical complications, and acute rejection. RESULTS A BSI developed in 34 of the 56 patients, with a total of 85 BSI episodes. Of these BSI episodes, 65.9% were due to gram-positive organisms, 34.1% gram-negative organisms, and 2.4% due to fungi. The most common isolates were Enterococcus species, Enterobacter species, Klebsiella species, and coagulase-negative staphylococci. Inclusion of the liver and/or a preoperative bilirubin >5 mg/dL appeared to increase the incidence of BSI (P = 0.0483 and 0.0005, respectively). Acute rejection and colonic inclusion did not appear to affect the incidence of BSI (P = 0.9419 and 0.8248, respectively). The BSI incidence was higher in children (P = 0.0058). CONCLUSIONS BSIs are a common complication of intestinal transplantation. Risk factors include age <18, inclusion of the liver, and pre-transplant bilirubin >5. Acute rejection and colon inclusion do not appear to be associated with increased BSI risk.
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Affiliation(s)
- K Akhter
- Infectious Diseases Faculty Practice, Orlando Health, Orlando, Florida 32806, USA.
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Kimura T, Lauro A, Cescon M, Zanfi C, Dazzi A, Ercolani G, Grazi GL, Vivarelli M, Ravaioli M, Del Gaudio M, Cucchetti A, Zanello M, LaBarba G, Pironi L, Lazzarotto T, Pinna AD. Impact of induction therapy on bacterial infections and long-term outcome in adult intestinal and multivisceral transplantation: a comparison of two different induction protocols: daclizumab vs. alemtuzumab. Clin Transplant 2009; 23:420-5. [DOI: 10.1111/j.1399-0012.2008.00922.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Chen ZS, Meng FY, Chen XP, Liu DG, Wei L, Jiang JP, Du DF, Zhang WJ, Ming CS, Gong NQ. Combined en bloc liver/pancreas transplantation in two different patients. World J Gastroenterol 2009; 15:2552-5. [PMID: 19469010 PMCID: PMC2686918 DOI: 10.3748/wjg.15.2552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Combined en bloc liver/pancreas transplantation (CLPT) was used primarily in the treatment of otherwise non-resectable upper abdominal malignancy. In fact, a more appropriate indication is in patients with liver disease and insulin-dependent diabetes mellitus (IDDM). Here, we report on two successful cases of CLPT at our hospital. One was a patient with non-resectable advanced liver cancer. The recipient survived for 23 mo and finally died of recurrent tumor. The other was a patient with severe biliary complication after orthotopic liver transplantation and preoperative IDDM. We performed CLPT with a modified surgical technique of preserving the native pancreas. He is currently liver-disease- and insulin-free more than 27 mo post-transplant. Based on our experience in two cases of abdominal cluster transplantation, we describe the technical details of CLPT and a modification of the surgical procedure.
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Kostopanagiotou G, Sidiropoulou T, Pyrsopoulos N, Pretto EA, Pandazi A, Matsota P, Arkadopoulos N, Smyrniotis V, Tzakis AG. Anesthetic and perioperative management of intestinal and multivisceral allograft recipient in nontransplant surgery. Transpl Int 2008; 21:415-27. [DOI: 10.1111/j.1432-2277.2007.00627.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Treatment of short bowel syndrome (SBS) is often a difficult endeavor due to the high variability among patients with SBS in regard to remaining anatomical structure and functional capacity. Research efforts to substantiate the use of existing therapies in the treatment of SBS are ongoing, with newer developments yet to be fully explored. Current therapy for SBS begins with the implementation of a modified diet based on the presence or absence of the colon. Patients with difficulty ingesting enough nutrients and fluids for weight maintenance and fluid balance may benefit from nocturnal enteral nutrition and hydration. Those with inadequate absorptive capacity despite maximization of oral and enteral intake will need parenteral nutrition (PN) or hydration. Medications, including antisecretory agents, antidiarrheals, pancreatic enzymes, bile acid sequestrants, and antibiotics, often are useful in abating symptoms commonly associated with SBS. Growth factors, including recombinant human growth hormone and glucagon-like peptide 2, may be trialed to stimulate intestinal adaptation and enhance absorption in PN-dependent SBS patients. The gradual refinement of surgical procedures for SBS, including small bowel transplantation, has led to improved outcomes, and early referral of SBS patients to centers of excellence will optimize care.
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Affiliation(s)
- Neha R Parekh
- Ezra Steiger, MD Intestinal Rehabilitation Program, Cleveland Clinic, 9500 Euclid Avenue, Desk A80, Cleveland, OH 44195, USA.
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Transplantation of the Intestine. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The First Intestinal-Multivisceral Transplant in Poland — A Case Report. POLISH JOURNAL OF SURGERY 2007. [DOI: 10.2478/v10035-007-0019-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Berger N, Guggenbichler S, Steurer W, Margreiter C, Mayer G, Kafka R, Mark W, Rosenkranz AR, Margreiter R, Bonatti H. Bloodstream infection following 217 consecutive systemic-enteric drained pancreas transplants. BMC Infect Dis 2006; 6:127. [PMID: 16895603 PMCID: PMC1570140 DOI: 10.1186/1471-2334-6-127] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2005] [Accepted: 08/08/2006] [Indexed: 11/21/2022] Open
Abstract
Background Combined kidney pancreas transplantation (PTx) evolved as excellent treatment for diabetic nephropathy. Infections remain common and serious complications. Methods 217 consecutive enteric drained PTxs performed from 1997 to 2004 were retrospectively analyzed with regard to bloodstream infection. Immunosuppression consisted of antithymocyteglobuline induction, tacrolimus, mycophenolic acid and steroids for the majority of cases. Standard perioperative antimicrobial prophylaxis consisted of pipercillin/tazobactam in combination with ciprofloxacin and fluconazole. Results One year patient, pancreas and kidney graft survival were 96.4%, 88.5% and 94.8%, surgical complication rate was 35%, rejection rate 30% and rate of infection 59%. In total 46 sepsis episodes were diagnosed in 35 patients (16%) with a median onset on day 12 (range 1–45) post transplant. Sepsis source was intraabdominal infection (IAI) (n = 21), a contaminated central venous line (n = 10), wound infection (n = 5), urinary tract infection (n = 2) and graft transmitted (n = 2). Nine patients (4%) experienced multiple episodes of sepsis. Overall 65 pathogens (IAI sepsis 39, line sepsis 15, others 11) were isolated from blood. Gram positive cocci accounted for 50 isolates (77%): Coagulase negative staphylococci (n = 28, i.e. 43%) (nine multi-resistant), Staphylococcus aureus (n = 11, i.e. 17%) (four multi-resistant), enterococci (n = 9, i.e. 14%) (one E. faecium). Gram negative rods were cultured in twelve cases (18%). Patients with blood borne infection had a two year pancreas graft survival of 76.5% versus 89.4% for those without sepsis (p = 0.036), patient survival was not affected. Conclusion Sepsis remains a serious complication after PTx with significantly reduced pancreas graft, but not patient survival. The most common source is IAI.
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Affiliation(s)
- Natalie Berger
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | - Sigmund Guggenbichler
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | - Wolfgang Steurer
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | - Christian Margreiter
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | - Gert Mayer
- Clinical Division of Nephrology, Medical University, Innsbruck, Austria
| | - Reinhold Kafka
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | - Walter Mark
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | | | - Raimund Margreiter
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | - Hugo Bonatti
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
- Department of Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Nolt DL, Green M. Surveillance stool cultures: to collect or not collect, that is the question. Pediatr Transplant 2006; 10:133-5. [PMID: 16573593 DOI: 10.1111/j.1399-3046.2005.00479.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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John M, Gondolesi G, Herold BC, Kaufman S, Fishbein T, Posada R. Impact of surveillance stool culture guided selection of antibiotics in the management of pediatric small bowel transplant recipients. Pediatr Transplant 2006; 10:198-204. [PMID: 16573607 DOI: 10.1111/j.1399-3046.2005.00424.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Surveillance stool cultures (SSC) have been used in immunocompromised populations to predict the organisms associated with invasive infections and aid in the selection of empiric antibiotic regimens. To evaluate the utility of this approach in pediatric small bowel transplant (SBT) recipients, we conducted a retrospective review of 33 patients who underwent SBT, 16 of whom had SSC done. In no case was the same organism isolated from SSC and subsequent blood, peritoneal fluid or wound cultures. In the first month post-transplantation, blood cultures were positive in 44% and 35% of patients that had and did not have SSC done, respectively (p = 0.73); peritoneal fluid cultures in 44% and 65% (p = 0.30); and wound cultures in 44% and 24% (p = 0.28). There were no significant differences among both groups in time to first infection, duration of ICU stay following SBT, graft survival or long-term patient survival. We conclude that SSC-guided antibiotic selection does not have a significant impact on the incidence of invasive infections in the first month following SBT or on specific indicators of patient outcome. This suggests that empiric antibiotic regimens should be selected based on clinical presentation and hospital flora and susceptibility patterns.
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Affiliation(s)
- Minnie John
- Department of Pediatrics, The Mount Sinai School of Medicine, New York, NY 10029, USA
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Guaraldi G, Cocchi S, Codeluppi M, Di Benedetto F, De Ruvo N, Masetti M, Venturelli C, Pecorari M, Pinna AD, Esposito R. Outcome, Incidence, and Timing of Infectious Complications in Small Bowel and Multivisceral Organ Transplantation Patients. Transplantation 2005; 80:1742-8. [PMID: 16378070 DOI: 10.1097/01.tp.0000185622.91708.57] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Infectious complications still represent a major cause of morbidity and mortality in patients with organ transplantation. In particular, small bowel or multivisceral transplantation is complicated to a greater extent than other grafts as a consequence of infectious complications including sepsis. METHODS This prospective study assessed outcome, incidence, and timing of infections in sequential patients undergoing small bowel or multivisceral transplantation (SB/MVTx) performed at a university transplant center between January 2001 and October 2003. Nineteen patients underwent transplantation during this period, 13 of whom (68%) undergoing isolated SB and 6 (32%) MV grafts with or without liver. RESULTS The median follow up was 524 days (interquartile range=252-730) with an overall 24.4 person/year of observation. Postoperative mortality rate was 0.1 death/person/year; all patients, except one who died intraoperatively, were alive 6 months postsurgery. There were 100 documented infections including: 59 bacterial (2.4 events/person/year), 35 viral (1.4 events/person/year) and 6 fungal (0.2 events/person/year). Patients developed at least one episode of bacterial infection in 94% of the cases, viral infection in 67%, and fungal infection in 28%. CONCLUSIONS This cohort describes the very common and complex nature of infectious complications in this challenging group of transplantation patients. Larger cohorts are needed to specifically address infection risk factors and longer term outcomes.
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Affiliation(s)
- Giovanni Guaraldi
- Department of Medicine and Medical Specialities, Infectious Diseases Clinic, University of Modena and Reggio Emilia, Modena, Italy.
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Reyes J, Mazariegos GV, Abu-Elmagd K, Macedo C, Bond GJ, Murase N, Peters J, Sindhi R, Starzl TE. Intestinal transplantation under tacrolimus monotherapy after perioperative lymphoid depletion with rabbit anti-thymocyte globulin (thymoglobulin). Am J Transplant 2005; 5:1430-6. [PMID: 15888051 PMCID: PMC2976476 DOI: 10.1111/j.1600-6143.2005.00874.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Modifications in the timing and dosage of immunosuppression can ameliorate the morbidity and mortality that has prevented widespread use of intestinal transplantation (ITx) in children. Thirty-six patients receiving ITx, aged 5 months to 20 years were given 2-3 mg(kg of rabbit anti-thymocyte globulin (rATG, thymoglobulin) just before ITx, and 2-3 mg(kg postoperatively (total 5 mg(kg). Twice daily doses of tacrolimus (TAC) were begun enterally within 24 h after graft reperfusion with reduction of dose quantity or frequency after 3 months. Prednisone or other agents were given to treat breakthrough rejection. After 8-28 months follow-up (mean 15.8 +/- 5.3), 1- and 2-year patient and graft survival is 100% and 94%, respectively. Despite a 44% incidence of acute rejection in the first month, 16 of the 34 (47%) survivors are on TAC (n = 14) or sirolimus (n = 2) monotherapy; 15 receive TAC plus low dose prednisone; one each receive TAC plus sirolimus, TAC plus azathioprine and TAC plus sirolimus and prednisone. There was a low incidence of immunosuppression-related complications. This strategy of immunosuppression minimized maintenance TAC exposure, facilitated the long-term control of rejection, decreased the incidence of opportunistic infections, and resulted in a high rate of patient and graft survival.
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Abstract
Multivisceral transplantation is defined as the en bloc transplantation of three or more abdominal organs. Although multivisceral transplant recipients do not yet enjoy the same survival rates as renal and liver transplant recipients, this procedure can be life saving and has shown improvements in survival rates over time. Advances in immunosuppression hold promise for the future of multivisceral transplantation.
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Affiliation(s)
- James J Jacque
- Division of Liver and Gastrointestinal Transplantation, Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, FL 33136, USA.
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36
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Indications for intestinal transplantation and graft allocation. Curr Opin Organ Transplant 2004. [DOI: 10.1097/01.mot.0000127452.89937.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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