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Tartaglia D, Cremonini C, Annunziata E, Catena F, Sartelli M, Kirkpatrick AW, Musetti S, Strambi S, Chiarugi M, Coccolini F. Acute diverticulitis in immunocompromised patients: evidence from an international multicenter observational registry (Web-based International Register of Emergency Surgery and Trauma, Wires-T). Tech Coloproctol 2023; 27:747-757. [PMID: 36749438 PMCID: PMC10404182 DOI: 10.1007/s10151-023-02758-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/24/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Immunocompromised patients with acute diverticulitis are at increased risk of morbidity and mortality. The aim of this study was to compare clinical presentations, types of treatment, and outcomes between immunocompromised and immunocompetent patients with acute diverticulitis. METHODS We compared the data of patients with acute diverticulitis extracted from the Web-based International Registry of Emergency Surgery and Trauma (WIRES-T) from January 2018 to December 2021. First, two groups were identified: medical therapy (A) and surgical therapy (B). Each group was divided into three subgroups: nonimmunocompromised (grade 0), mildly to moderately (grade 1), and severely immunocompromised (grade 2). RESULTS Data from 482 patients were analyzed-229 patients (47.5%) [M:F = 1:1; median age: 60 (24-95) years] in group A and 253 patients (52.5%) [M:F = 1:1; median age: 71 (26-94) years] in group B. There was a significant difference between the two groups in grade distribution: 69.9% versus 38.3% for grade 0, 26.6% versus 51% for grade 1, and 3.5% versus 10.7% for grade 2 (p < 0.00001). In group A, severe sepsis (p = 0.027) was more common in higher grades of immunodeficiency. Patients with grade 2 needed longer hospitalization (p = 0.005). In group B, a similar condition was found in terms of severe sepsis (p = 0.002), quick Sequential Organ Failure Assessment score > 2 (p = 0.0002), and Mannheim Peritonitis Index (p = 0.010). A Hartmann's procedure is mainly performed in grades 1-2 (p < 0.0001). Major complications increased significantly after a Hartmann's procedure (p = 0.047). Mortality was higher in the immunocompromised patients (p = 0.002). CONCLUSIONS Immunocompromised patients with acute diverticulitis present with a more severe clinical picture. When surgery is required, immunocompromised patients mainly undergo a Hartmann's procedure. Postoperative morbidity and mortality are, however, higher in immunocompromised patients, who also require a longer hospital stay.
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Affiliation(s)
- Dario Tartaglia
- General and Emergency Surgery Unit, Trauma Center, New Santa Chiara Hospital, University of Pisa, Via Paradisa, Pisa, Italy.
| | - Camilla Cremonini
- General and Emergency Surgery Unit, Trauma Center, New Santa Chiara Hospital, University of Pisa, Via Paradisa, Pisa, Italy
| | - Elena Annunziata
- General and Emergency Surgery Unit, Trauma Center, New Santa Chiara Hospital, University of Pisa, Via Paradisa, Pisa, Italy
| | - Fausto Catena
- Department of Surgery, Bufalini" Hospital, Cesena, Italy
| | | | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Canada
| | - Serena Musetti
- General and Emergency Surgery Unit, Trauma Center, New Santa Chiara Hospital, University of Pisa, Via Paradisa, Pisa, Italy
| | - Silvia Strambi
- General and Emergency Surgery Unit, Trauma Center, New Santa Chiara Hospital, University of Pisa, Via Paradisa, Pisa, Italy
| | - Massimo Chiarugi
- General and Emergency Surgery Unit, Trauma Center, New Santa Chiara Hospital, University of Pisa, Via Paradisa, Pisa, Italy
| | - Federico Coccolini
- General and Emergency Surgery Unit, Trauma Center, New Santa Chiara Hospital, University of Pisa, Via Paradisa, Pisa, Italy
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Sommerer C, Schröter I, Gruneberg K, Schindler D, Behnisch R, Morath C, Renders L, Heemann U, Schnitzler P, Melk A, Della Penna A, Nadalin S, Heeg K, Meuer S, Zeier M, Giese T. Incidences of infectious events in a renal transplant cohort of the German Center of Infectious Diseases (DZIF). Open Forum Infect Dis 2022; 9:ofac243. [PMID: 35855001 PMCID: PMC9280327 DOI: 10.1093/ofid/ofac243] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/11/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Infectious complications are a major cause of morbidity and mortality after kidney transplantation.
Methods
In this transplant cohort study at the German Center of Infectious Diseases (DZIF), we evaluated all infections occurring during the first year after renal transplantation. We assessed microbial etiology, incidence rates, and temporal occurrence of these infections.
Results
Of 804 renal transplant recipients (65.2% male, 51 ± 14 years), 439 (54.6%) had 972 infections within the first year after transplantation. Almost half of these infections (47.8%) occurred within the first three months. Bacteria were responsible for 66.4% (645/972) of all infections, followed by viral (28.9%[281/972]) and fungal (4.7%[46/972]) pathogens. The urinary tract was the most common site of infection (42.4%). Enterococcus was most frequently isolated bacteria (20.9%), followed by E.coli (17.6%) and Klebsiella (12.5%). E.coli was the leading pathogen in recipients <50 years of age, whereas Enterococcus predominated in older recipients. Resistant bacteria were responsible for at least one infection in 9.5% (76/804) of all recipients. Viral infections occurred in 201 recipients (25.0%). Of these, herpes viruses predominated (140/281[49.8%]) and cytomegalovirus had the highest incidence rate (12.3%). In the 46 fungal infections, Candida albicans (40.8%) was most commonly isolated. Other fungal opportunistic pathogens, including Aspergillus fumigatus and Pneumocystis, were rare.
Conclusions
Renal allograft recipients in Germany experience a high burden of infectious complications in the first year after transplantation. Bacteria were the predominating pathogen, followed by opportunistic infections such as cytomegalovirus. Microbial etiology varied between age groups and resistant bacteria were identified in 10% of recipients.
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Affiliation(s)
- Claudia Sommerer
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Iris Schröter
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Katrin Gruneberg
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Daniela Schindler
- Department of Nephrology, Klinikum rechts der Isar of the Technical University Munich, Munich, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Rouven Behnisch
- Institute of Medical Biometry, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Morath
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Lutz Renders
- Department of Nephrology, Klinikum rechts der Isar of the Technical University Munich, Munich, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar of the Technical University Munich, Munich, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Paul Schnitzler
- Department of Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Andrea Della Penna
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Klaus Heeg
- Department of Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Stefan Meuer
- Department of Immunology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Martin Zeier
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Thomas Giese
- Department of Immunology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
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Sommerer C, Brunet M, Budde K, Millán O, Guirado Perich L, Glander P, Meuer S, Zeier M, Giese T. Monitoring of gene expression in tacrolimus-treated de novo renal allograft recipients facilitates individualized immunosuppression: Results of the IMAGEN study. Br J Clin Pharmacol 2021; 87:3851-3862. [PMID: 33620734 DOI: 10.1111/bcp.14794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/06/2021] [Accepted: 02/13/2021] [Indexed: 12/25/2022] Open
Abstract
AIMS Calcineurin inhibitors (CNI) have a small therapeutic window, and drug monitoring is required. Pharmacokinetic monitoring does not correlate sufficiently with clinical outcome. Therefore, the expression of nuclear factor of activated T cells (NFAT)-regulated genes in the peripheral blood has been suggested as a potentially useful immune monitoring tool to optimize CNI therapy. NFAT-regulated gene expression (RGE) was evaluated in renal allograft recipients as predictive biomarker to detect patients at risk of acute rejection or infections. METHODS NFAT-RGE (interleukin-2, interferon-γ, granular-macrophage colony-stimulating factor) was evaluated by quantitative real-time polymerase chain reaction in whole blood samples at day 7, day 14, month 1, 3, and 6 after transplantation in 64 de novo renal allograft recipients from 3 European centres. Immunosuppression consisted of tacrolimus (Tac), mycophenolic acid, and corticosteroids. RESULTS Tac concentrations (C0 and C1.5) correlated inversely with NFAT-RGE (P < .01). NFAT-RGE showed a high interindividual variability (1-61%). Patients with high residual gene expression (NFAT-RGE ≥30%) were at the increased risk of acute rejection in the following months (35 vs. 5%, P = .02), whereas patients with low residual gene expression (NFAT-RGE <30%) showed a higher incidence of viral complications, especially cytomegalovirus and BK virus replication (52.5 vs. 10%, P = .01). CONCLUSIONS NFAT-RGE was confirmed as a potential noninvasive early predictive biomarker in the immediate post-transplant period to detect patients at risk of acute rejection and infectious complications in Tac-treated renal allograft recipients. Monitoring of NFAT-RGE may provide additional useful information for physicians to achieve individualized Tac treatment.
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Affiliation(s)
- Claudia Sommerer
- Department of Nephrology, University of Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Mercè Brunet
- Pharmacology and Toxicology Laboratory, CDB, CIBERehd, IDIBAPS, Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - Klemens Budde
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Olga Millán
- Pharmacology and Toxicology Laboratory, CDB, CIBERehd, IDIBAPS, Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - Lluis Guirado Perich
- Renal Transplant Unit, Nephrology Department, Fundació Puigvert, Barcelona, Spain
| | - Petra Glander
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Stefan Meuer
- Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, University of Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Giese
- Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany
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Belatacept in Solid Organ Transplant: Review of Current Literature Across Transplant Types. Transplantation 2019; 102:1440-1452. [PMID: 29787522 DOI: 10.1097/tp.0000000000002291] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Calcineurin inhibitors (CNIs) have been the backbone immunosuppressant for solid organ transplant recipients for decades. Long-term use of CNIs unfortunately is associated with multiple toxicities, with the biggest concern being CNI-induced nephrotoxicity. Belatacept is a novel agent approved for maintenance immunosuppression in renal transplant recipients. In the kidney transplant literature, it has shown promise as being an alternative agent by preserving renal function and having a minimal adverse effect profile. There are emerging studies of its use in other organ groups, particularly liver transplantation, as well as using with other alternative immunosuppressive strategies. The purpose of this review is to analyze the current literature of belatacept use in solid organ transplantation and discuss its use in current practice.
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Spicer P, Runkel L. Costimulatory pathway targets for autoimmune and inflammatory conditions: clinical successes, failures, and hope for the future. Expert Opin Investig Drugs 2019; 28:99-106. [DOI: 10.1080/13543784.2019.1557146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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