Pre-Transplant Seroprevalence, Associated Factors, and Post-Transplant Incidence of Toxoplasma gondii Infection Among Heart Transplant Recipients in Japan

BACKGROUND

Among solid organ transplant (SOT) recipients, heart transplant (HT) recipients are at a higher risk of Toxoplasma gondii infection. As Toxoplasma seroprevalence varies by geographic location, updated local epidemiology is essential to guide preventive and therapeutic strategies. However, the Toxoplasma seroprevalence and incidence of post-transplant toxoplasmosis among SOT recipients in Japan are unknown.

METHODS

We performed a single-center retrospective observational study at an HT center in Tokyo, Japan. All HT recipients aged ≥18 years between 2006 and April 2019 were included. We reviewed patient charts and conducted a questionnaire survey to investigate the risk factors for infection.

RESULTS

Among 105 recipients included in the study, 11 (10.5%) were seropositive before transplant. Ninety-five recipients (90.5%), including all pre-transplant seropositive recipients, answered the questionnaire. The recipients who had lived in Okinawa (odds ratio [OR] 7.5 [95% CI 1.42-39.61]; P = .032) and who reported raw-meat eating habits (OR 4.64 [95% CI 1.04-23.3]; P = .021) were more likely to be seropositive. None of the patients developed symptoms of toxoplasmosis. The post-transplant incidence of other major adverse outcomes was not significantly different according to the pre-transplant serostatus.

CONCLUSIONS

About 10% of HT recipients at an HT center in Tokyo were seropositive for Toxoplasma pre-transplant, and none developed symptomatic toxoplasmosis post-transplant on trimethoprim-sulfamethoxazole. The history of raw meat consumption was associated with seropositivity; therefore, avoiding it might be recommended for HT recipient candidates.

Male-killing virus in a noctuid moth Spodoptera litura

A female-biased sex ratio is considered advantageous for the cytoplasmic elements that inhabit sexually reproducing organisms. There are numerous examples of bacterial symbionts in the arthropod cytoplasm that bias the host sex ratio toward females through various means, including feminization and male killing. Recently, maternally inherited RNA viruses belonging to the family Partitiviridae were found to cause male killing in moths and flies, but it was unknown whether male-killing viruses were restricted to Partitiviridae or could be found in other taxa. Here, we provide compelling evidence that a maternally inherited RNA virus, Spodoptera litura male-killing virus (SlMKV), selectively kills male embryos of the tobacco caterpillar Spodoptera litura, resulting in all-female broods. SlMKV injected into uninfected S. litura can also be inherited maternally and causes male killing. SlMKV has five genomic segments encoding seven open reading frames, has no homolog of known male-killing genes, and belongs to an unclassified group of arthropod-specific viruses closely related to Tolivirales. When transinfected into larvae, both male and female recipients allow SlMKV to proliferate, but only males die at the pupal stage. The viral RNA levels in embryonic and pupal male killing suggest that the mechanism of male killing involves the constitutive expression of viral products that are specifically lethal to males, rather than the male-specific expression of viral products. Our results, together with recent findings on male-killing partiti-like viruses, suggest that diverse viruses in arthropods tend to acquire male killing independently and that such viruses may be important components of intragenomic conflict in arthropods.

Multicenter, single-blind, randomized controlled study of the efficacy and safety of favipiravir and nafamostat mesilate in patients with COVID-19 pneumonia

OBJECTIVES

To evaluate the efficacy and safety of nafamostat combined with favipiravir for the treatment of COVID-19.

METHODS

We conducted a multicenter, randomized, single-blind, placebo-controlled, parallel assignment study in hospitalized patients with mild-to-moderate COVID-19 pneumonia. Patients were randomly assigned to receive favipiravir alone (n = 24) or nafamostat with favipiravir (n = 21). The outcomes included changes in the World Health Organization clinical progression scale score, time to improvement in body temperature, and improvement in oxygen saturation (SpO₂).

RESULTS

There was no significant difference in the changes in the clinical progression scale between nafamostat with favipiravir and favipiravir alone groups (median, -0.444 vs -0.150, respectively; least-squares mean difference, -0.294; P = 0.364). The time to improvement in body temperature was significantly shorter in the combination group (5.0 days; 95% confidence interval, 4.0-7.0) than in the favipiravir group (9.0 days; 95% confidence interval, 7.0-18.0; P =0.009). The changes in SpO₂ were greater in the combination group than in the favipiravir group (0.526% vs -1.304%, respectively; least-squares mean difference, 1.831; P = 0.022). No serious adverse events or deaths were reported, but phlebitis occurred in 57.1% of the patients in the combination group.

CONCLUSION

Although our study showed no differences in clinical progression, earlier defervescence, and recovery of SpO₂ were observed in the combination group.

Neisseria meningitidis serogroup W135 in a traveler visiting Japan from Argentina, 2019

Invasive meningococcal disease (IMD) can occur in travelers returning from mass-gathering events or endemic regions. We present a 60-year-old Argentine traveler to Tokyo who developed IMD by Neisseria meningitidis Serogroup W135 during her stay in Japan. N. meningitidis serogroup W135 infection has become common in Argentina, whereas IMD less commonly occurs in Japan. Considering the prevalence, the patient most likely acquired the infection in Argentina, and it developed in Japan. Air travel enables passengers to reach the four corners of the world within a few days. IMD should be considered in travelers due to its potential to induce rapid clinical deterioration and transmission.

Aureobasidium melanigenum catheter-related bloodstream infection: a case report

BACKGROUND

Aureobasidium melanigenum is a ubiquitous dematiaceous fungus that rarely causes invasive human infections. Here, we present a case of Aureobasidium melanigenum bloodstream infection in a 20-year-old man with long-term catheter use.

CASE PRESENTATION

A 20-year-old man receiving home care with severe disabilities due to cerebral palsy and short bowel syndrome, resulting in long-term central venous catheter use, was referred to our hospital with a fever. After the detection of yeast-like cells in blood cultures on day 3, antifungal therapy was initiated. Two identification tests performed at a clinical microbiological laboratory showed different identification results: Aureobasidium pullulans from matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, and Cryptococcus albidus from a VITEK2 system. Therefore, we changed the antifungal drug to liposomal amphotericin B. The fungus was identified as A. melanigenum by DNA sequence-based analysis. The patient recovered with antifungal therapy and long-term catheter removal.

CONCLUSION

It is difficult to correctly identify A. melanigenum by routine microbiological testing. Clinicians must pay attention to the process of identification of yeast-like cells and retain A. melanigenum in cases of refractory fungal infection.

Protothecosis in the mucosa of the pharynx mimicking pharyngeal cancer in an immunocompetent individual: a case report

Background

Protothecosis is a rare infection in humans and animals caused by the achlorophyllic algae Prototheca species. More than half of the protothecosis cases are cutaneous infections, and most cases are observed in immunocompromised individuals.

Case presentation

We report a case of Prototheca wickerhamii infection in the mucosa of the pharynx in a 53-year-old immunocompetent woman with an incidentally found mass lesion at the left tongue base. Histopathological findings of the mass lesion suggested cryptococcosis, but P. wickerhamii was identified from the oropharynx scrape culture based on DNA sequencing. After surgical resection, fosfluconazole treatment was initiated, and subsequently, treatment was switched to topical amphotericin B. The residual mass lesion did not deteriorate during the 4-month antifungal treatment and 1-year observational period.

Conclusions

Prototheca species can be easily misdiagnosed as yeasts because of their morphological and pathological similarities. Prototheca, in addition to Cryptococcus should be considered if slow-growing, large Gram-positive organisms are encountered. Lactophenol cotton blue staining of the colony helps distinguish these organisms. Further study is needed to determine the appropriate treatment according to the infection focus.

Incidence and Risk Factors for Inappropriate Use of Non-Culture-Based Fungal Assays: Implication for Diagnostic Stewardship

Background

Non-culture-based fungal assays (NCBFAs) have been used increasingly to help diagnose invasive fungal diseases. However, little is known about inappropriate use of NCBFAs. We aimed to investigate inappropriate use of NCBFAs in a tertiary academic hospital.

Methods

This retrospective cohort study included patients who underwent testing with beta-D glucan (BDG) between January and March 2018 or with galactomannan antigen (GMA) or cryptococcal antigen (CRAG) between January and June 2018. Testing was deemed appropriate if the clinical presentation was compatible with a fungal infection and there was a predisposing host factor at the time of ordering. We compared patients with appropriate and inappropriate use of NCBFAs using multivariate logistic regression analysis.

Results

Four hundred seventy patients (BDG, 394; GMA, 138; CRAG, 164) met inclusion criteria and were evaluated. About 80% of NCBFAs were deemed inappropriate. Ordering by transplant medicine physicians, repetitions of the test, the absence of predisposing factors for fungal infections, and the absence of recommendations from infectious diseases consultants were associated with an increased risk of inappropriate NCBFA use.

Conclusions

We found that a large proportion of NCBFAs were deemed inappropriate. There is an opportunity for diagnostic stewardship to reduce avoidable fungal testing among patients at low risk for fungal infection.

Late-phase dominance of a single epitope-specific CD8+ T-cell response in passive neutralizing antibody-infused simian immunodeficiency virus controllers

OBJECTIVE

Analysis of the quantity and quality of epitope-specific CD8+ T-cell responses is crucial for understanding the mechanism of HIV/simian immunodeficiency virus (SIV) replication control. We have previously shown that acute-phase passive infusion of neutralizing antibodies (NAbs) results in augmented broad T-cell responses and robust SIVmac239 control in rhesus macaques. Analyzing long-term dynamics of CD8+ T-cell responses in these SIV controllers provides important insights into designing lasting anti-HIV immunity.

DESIGN

We analyzed dynamics and metabolic/functional profiles of SIV-specific CD8+ T-cell responses in rhesus macaques that controlled SIVmac239 replication following acute-phase passive NAb infusion.

METHODS

SIV epitope-specific CD8+ T-cell responses in peripheral blood at multiple chronic-phase time points were investigated in four passive NAb-infused SIV controllers. In particular, expression patterns of Eomesodermin (Eomes), phosphorylated AMP kinase (pAMPK), CD28 and programmed death-1 (PD-1) were examined.

RESULTS

In the NAb-infused SIV controllers, a single epitope-specific CD8+ T-cell response detected from acute infection and maintaining low levels up to year 1 showed a surge thereafter, up to year 2 postchallenge. Retention of an effector-skewed and unexhausted Eomes-high/pAMPK-low/CD28-negative/PD-1-low subpopulation in these epitope-specific CD8+ T cells implicated their front-line commitment in residual viral replication control.

CONCLUSION

In long-term SIV control following acute-phase passive NAb infusion, a single-epitope, high-quality CTL response was dominantly induced in the chronic phase. These results likely describe one favorable pattern of immunodominant epitope-specific CD8+ T-cell preservation and suggest the importance of incorporating metabolic marker signatures for understanding NAb/T-cell synergism-based HIV/SIV control.

Nef-specific CD107a+ CD4+ T-cell responses in a rhesus macaque (Macaca mulatta) showing partial simian immunodeficiency virus control following passive neutralizing antibody infusion

Acute-phase neutralizing antibody (NAb) passive immunization in simian immunodeficiency virus (SIV)-infected rhesus macaques (Macaca mulatta) can confer stringent viremia control with T-cell augmentation. In one NAb-infused SIV partial controller, we identify chronic-phase Nef-specific CD107a⁺ CD4⁺ T-cell response maintenance, implicating that NAb infusion modulates long-term T-cell responses even within viremic control.

Design of microfluidic channels to prevent negative filtration in implantable hemofiltration devices

In order to improve the quality of life of dialysis patients, our group have been developing an implantable hemofiltration device (IHFD) composed of multiple layers of dialysis membranes and microfluidic channels. To improve the hemodialysis performance of IHFD, preventing the negative filtration, which is caused by the oncotic pressure of blood, is mandatory. In this study, we fabricated IHFDs with five different microchannel designs and experimentally investigated the performance of each device in in vitro experiment. In addition, the successful IHFD was further evaluated by ex vivo experiments with a beagle dog. The experiments verified the effectiveness of the microchannel design, which will be used for the IHFD for in vivo experiments with pigs in the future.

90. Incidence and Risk Factors for Inappropriate Use of Non-culture Based Fungal Assays: Implication for Diagnostic Stewardship

Background

Culture-based diagnostic tests are the gold standard for diagnosing invasive fungal diseases (IFDs). Because these tests have low sensitivity, non-culture-based fungal assays (NCBFAs) have been used increasingly to help diagnose IFDs. However, little is known about inappropriate use of NCBFAs. We aimed to investigate inappropriate use of NCBFAs in a tertiary academic hospital in Tokyo, Japan.

Methods

This retrospective cohort study included all patients who underwent testing with beta-D glucan (BDG) between January and March 2018, or galactomannan antigen (GMA) or cryptococcal antigen (CRAG) between January and June 2018. Patients who had received hematopoietic stem cell or solid organ transplantations were excluded. Appropriateness was assessed according to the previously published study. We compared patients with appropriate and inappropriate use of NCBFAs. Risk factors for inappropriate use were evaluated using multivariate logistic regression analysis.

Results

Of 1,140 patients (BDG, 1,009; GMA 273; CRAG, 310) who underwent tests, 470 patients (BDG, 394; GMA, 138; CRAG, 164) were included in this study. Four hundred thirty-eight patients (93.2%) were aged 18 or older. About 80% of NCBFAs (BDG, 334 patients [74.8%]; GMA, 117 patients [74.8%]; CRAG, 146 patients [89.0%]) were deemed inappropriate. The factors associated with inappropriate NCBFAs use included specialties of ordering physicians, risk factors for fungal infections, and recommendation from infectious disease physicians (Table). Sixty-four patients (13.6%) underwent three inappropriate NCBFAs simultaneously. Furthermore, during the study period, 408 patients (35.8%) with inappropriate NCBFAs underwent the same assays repeatedly during the study period; 643 times for BDG, 163 times for GMA, and 192 times for CRAG.

The Factors Associated with Inappropriate Use of Non-Culture Based Fungal Assays

Conclusion

We found a large proportion of NCBFAs were deemed inappropriate and it was mostly driven by ordering physicians who generally care for transplant patients. Because inappropriate use of NCBFAs could lead to additional inappropriate tests and treatment with substantial costs to patients and health systems, diagnostic stewardship targeting NCBFAs is urgently needed.

Disclosures

All Authors: No reported disclosures

Prevalence and clinical characteristics of patients with biologically false-positive reactions with serological syphilis testing in contemporary practice: 10-year experience at a tertiary academic hospital

OBJECTIVES

Biologically false positive (BFP) reactions are well described in early literature. However, only a few recent reports described the incidence and clinical characteristics of patients with BFP reactions. We reviewed the serological test results of patients tested for syphilis in our hospital in the past decade and described the clinical characteristics of patients with BFP reactions.

METHODS

This is a retrospective study of patients tested for syphilis in a tertiary academic hospital. All serological results were retrieved from the clinical laboratory database. We calculated the incidence of BFP reactions. Clinical characteristics and laboratory data of patients with BFP reactions were reviewed manually.

RESULTS

Among 94 462 subjects, 588 patients had BFP reactions (0.62%). Most BFP reactions were observed in patients aged over 60 years, with a history of malignancy and autoimmune diseases. Eighty-five per cent of patients had low rapid plasma reagin (RPR) titre (≤1:4), but two patients had extremely high RPR titre (≥1:256). BFP reactions were more likely to persist beyond 6 months among patients with RPR titre of ≥1:8. There was no statistically significant correlation between RPR titre and total protein albumin gap, surrogate of immunoglobulin levels among patients with BFP reactions.

CONCLUSION

There was a low incidence of BFP reactions in the last decade. A minority of BFP reactions had high non-treponemal antibody titre and persisted longer than 6 months. In the era of re-emergence of syphilis, this information could help clinicians interpret the results of well-established diagnostic tests for syphilis.

Microbiological analysis of infectious lymphocele: Case series and literature review

BACKGROUND

Infectious lymphocele is a rare post-operative complication of abdominal surgery, and few studies have focused on its causative organisms. The aim in this research is to clarify microbiology and appropriate empiric treatment of infective lymphocele.

METHODS

We performed a single center, retrospective observational study between April 2000 and March 2018 with a case review and literature search. Data were collected in a chart review.

RESULTS

Twenty-four cases were founded in our institution. 153 cases, including 16 cases from our institution, that detected causative organisms was also analyzed. Infectious lymphocele was found to occur post gynecological/urological surgery in cancer patients. We also reported that bacteremia incidence and the mortality rate of infectious lymphocele cases were very low. The major sites of infectious lymphocele were pelvis or inguinal area. Our case series and literature review showed Gram positive cocci were the major causative organisms, with Staphylococcus aureus constituting one third of them (53/153 cases). Streptococcus species (26/153cases) and coagulase negative Staphylococci (17/153 cases) were the second and third most detected organisms.

CONCLUSION

In gynecologic and urologic cancer patients, Gram positive cocci were the most common organisms causing lymphocele infection. Gram-positive coverage might be reasonable for empiric therapy in infectious lymphocele.

Heparin affects the induction of regulatory T cells independent of anti-coagulant activity and suppresses allogeneic immune responses

Heparin is a widely used anti-coagulant that enhances anti-thrombin (AT) activity. However, heparin also suppresses immune and inflammatory responses in various rodent models and clinical trials, respectively. The mechanism by which heparin suppresses immune responses is unclear. The effect of heparin on regulatory T cells (T_regs ) in allogeneic immune responses was analysed using an acute graft-versus-host disease (aGVHD) mouse model and mixed lymphocyte reactions (MLRs). In-vitro culture systems were utilized to study the effects of heparin on T_regs . Heparin administration reduced mortality rates and increased the proportion of T_regs in the early post-transplantation period of aGVHD mice. In both murine and human MLRs, heparin increased T_regs and inhibited responder T cell proliferation. Heparin promoted functional CD4⁺ CD25⁺ forkhead box protein 3 (FoxP3)⁺ T_reg generation from naive CD4⁺ T cells, increased interleukin (IL)-2 production and enhanced the activation of pre-existing T_regs with IL-2. Heparin-induced T_reg increases were not associated with anti-coagulant activity through AT, but required negatively charged sulphation of heparin. Importantly, N-acetyl heparin, a chemically modified heparin without anti-coagulant activity, induced T_regs and decreased mortality in aGVHD mice. Our results indicate that heparin contributes to T_reg -mediated immunosuppression through IL-2 production and suggest that heparin derivatives may be useful for immunopathological control by efficient T_reg induction.

P3578Determinants of visual-functional mismatches as assessed by coronary angiography and 3-D angiography-based quantitative flow ratio

Background

Quantitative flow ratio (QFR) is a novel three-dimensional quantitative coronary angiography (QCA)-based computational index that can estimate fractional flow reserve (FFR) without pharmacologically induced hyperemia or the use of a pressure wire.

Purpose

We aimed to evaluate the determinants of visual-functional mismatches between conventional two-dimensional QCA and QFR.

Methods

A total of 504 de novo intermediate-to-severe lesions from 504 patients with stable angina who underwent angiographical and physiological assessments were analyzed. All lesions were divided into four groups based on the significance of visual (QCA-diameter stenosis [DS] >50% and ≤50%) and functional (QFR <0.80 and ≥0.80) stenosis severity. Patient characteristics, angiographic findings, QFR computations, and physiological indices were compared among the four groups.

Results

Among 504 lesions, 153 lesions (30.4%) showed concordantly negative (DS ≤50% and QFR >0.80) and 170 lesions (33.7%) showed concordantly positive (DS >50% and QFR ≤0.80) visual and functional assessments. Among 181 lesions (35.9%) with discordant results, 75 lesions (14.9%) showed a mismatch (DS >50% and QFR >0.80) and 106 lesions (21.0%) showed a reverse mismatch (DS ≤50% and QFR ≤0.80), respectively. Reverse mismatch was associated with smaller reference diameter (odds ratio [OR] 0.561; P=0.036), greater DS (OR 1.039, P=0.013), lower coronary flow reserve (CFR) (OR 0.571, P<0.001, non-diabetes mellitus (OR 2.141, P=0.013) and lower ejection fraction (OR 0.961, P=0.011). Mismatch was associated with smaller DS (OR 0.914, P<0.001), shorter lesion length (OR 0.894, P=0.001), higher CFR (OR 1,633, P<0.001), and lower estimated glomerular filtration rate (OR, 0.968, P=0.001). Lesion location and the index of microcirculatory resistance was not associated with the prevalence of reverse mismatch or mismatch.

Conclusions

There was a high prevalence of visual-functional mismatches between QCA-DS and QFR, and CFR was an important functional factor of mismatches. Our results suggested the difference between predictors of reported visual-functional mismatches of QCA/FFR and those of QCA/QFR.

P2705Hybrid QFR-FFR decision making strategy for revascularization

Background

Measurement of the fractional flow reserve (FFR) has become a standard practice for revascularization decision-making in evaluating the functional significance of angiographically intermediate epicardial coronary stenosis. The quantitative flow ratio (QFR) is a novel method for rapid computational estimation of FFR without pressure wire and vasodilator drugs.

Purpose

Nevertheless, the evidence was shown the clinical better outcome of coronary revascularization stratified by FFR, the adoption of FFR remains low. We hypothesized that combined QFR and FFR hybrid strategy could improve the physiological assessment without pressure wire and drugs.

Methods and results

We performed a post-hocanalysis of 549 vessels with angiographically intermediate stenosis in 549 patients who underwent measurement of FFR. The median FFR and QFR values were 0.81 (0.73–0.87) and 0.79 (0.74–0.87), respectively.The ischemic threshold was defined as 0.80 for both QFR and FFR measures. The diagnostic sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the QFR for predicting an FFR of ≤0.80 were 86.2%, 71.9%, 78.9%, 74.5%, and 84.5%, respectively. The area under the receiver operating characteristic curve using the cut-off threshold of ≤0.80 for the FFR was 0.85 (95% confidence interval [CI], 0.81–0.88) for the QFR.In total, 433 (78.9%) and 116 (21.1%) lesions showed concordant and discordant FFR and QFR functional classifications, respectively. A hybrid QFR-FFR strategy was developed, by allowing deferral when QFR values providing negative predictive value greater than 90% and treat others when QFR values greater than that showing 90% positive predictive value, with adenosine being given only to patients with QFR in between those values. For the FFR cut-off (0.8), an QFR of <0.73 could be used to confirm treatment (PPV of 90.7%), while an QFR value of >0.83 could be used to defer revascularization (NPV of 90.0%). When QFR values fall between 0.73 and 0.84, adenosine is given for hyperemic induction and the FFR cut-off of 0.8 is used to guide revascularization. This hybrid QFR-FFR approach has a 95% agreement with an FFR-only decision making, and 285 lesions (51.9%) would have obviated the need of a pressure wire and adenosine.

Hybrid QFR-FFR strategy

Conclusions

A hybrid QFR-FFR strategy for coronary revascularization could reduce the need of a pressure wire and vasodilator drugs, which may increase the penetration of functional assessment of coronary lesions.

P5619Comparison of different resting physiological indices: are diastolic pressure ratio and resting full-cycle ratio equal?

Background

Previous reports showed all diastolic resting indexes tested were virtually identical to the instantaneous wave-free ratio (iFR). Although RFR has been also reported to be diagnostically equivalent to iFR, no comparisons have been reported about the prevalence and characteristics of discordance in diagnosis between diastolic pressure ratio (dPR) and resting full-cycle ratio (RFR).

Purpose

This study sought to determine the coronary pressure characteristics of lesions classified as discordant between dPR and RFR in angiographically intermediate stenoses.

Methods

We recruited 532 patients with 668 intermediate (angiographically stenosis between 30% to 70% severity) coronary lesions undergoing FFR assessment and analyzed DICOM pressure tracings of resting state (dPR and RFR) using a fully automated off-line software algorithm in a blind fashion. Diagnostic performance of dPR and RFR was evaluated using FFR as a reference. Furthermore, we investigated similarity and difference between dPR and RFR.

Results

Median FFR was 0.81 with an interquartile range of 0.74 to 0.87. RFR was highly correlated to dPR (R2=0.94, p<0.001), with a mean bias of 0.012 (95% limits of agreement −0.008 to 0.031). The diagnostic performance of RFR versus dPR was diagnostic accuracy 95.4%, sensitivity 100.0%, specificity 91.6%, positive predictive value 90.6%, negative predictive value 100.0%). Using the binary cut-off of dPR ≤0.89 as a cut-off value, RFR showed near identical agreement according to ROC curve analysis (AUC: 0.996, 95% CI: 0.994–0.999, p<0.001). Although dPR and RFR demonstrated equivalent performance against FFR ≤0.8 (79.5% vs. 79.3% accuracy; p=0.960; area under the receiver-operating characteristic curve: 0.869 vs. 0.870; p=0.528), RFR disagreed with dPR in 4.6% (31 of 668). When all lesions (668 vessels) were divided into groups according to the concordance and discordance between dPR and RFR: RFR+/dPR+ (298 vessels, n=240), RFR+/dPR– (31 vessels, n=31 patients), RFR-/dPR- (339 vessels, n=259). There was no lesion showing RFR-/dPR+. The prevalence of ischemia was tended to be higher in lesions evaluated by RFR (49.3% vs 44.6%, P=0.100) when using FFR ≤0.80 as a reference standard. An overall significant difference in the prevalence of FFR ≤0.80 and the FFR values were detected among these 3 groups. Furthermore, pairwise comparison also revealed the prevalence of FFR >0.80 and the FFR values were significantly lower in RFR+/dPR– than in RFR-/dPR-, and significantly higher in RFR+/dPR– than in RFR+/dPR+. (P<0.001 and P<0.001, respectively)

Conclusion

Significant difference in FFR values was observed according to dPR/RFR agreement and disagreement. Revascularization decision making might defer according to the resting index used. Compared with RFR, lesions might be more frequently deferred when dPR was used to assess physiological significance.

Acknowledgement/Funding

None

P2704The association between global coronary flow reserve and coronary inflammation assessed by attenuation index on computed tomography in patients with stable angina pectoris

Background

Impaired global coronary flow reserve (G-CFR) is known to predict worse outcomes in patients with coronary artery disease. Phase contrast cine-magnetic resonance imaging (PC-CMR) of the coronary sinus (CS) is a promising approach for quantifying coronary sinus flow (CSF) and G-CFR without the need for ionizing radiation, radioactive tracers, or intravascular catheterization. Although G-CFR impairment is previously reported to be linked with endothelium dysfunction and progression of atherosclerosis, the association of perivascular adipose tissue inflammation with myocardial coronary flow remains to be determined.

Purpose

We evaluated the association between G-CFR by quantifying CSF using PC-CMR and the extent of coronary inflammation evaluated by perivascular adipose tissue inflammatory status using CT to assess if coronary inflammation is linked with G-CFR in patients with stable angina pectoris (SAP) treated with elective percutaneous coronary intervention (PCI).

Methods

The study enrolled 74 SAP patients with single denovo lesion who underwent coronary CT angiography and PC-CMR within 90 days before coronary intervention. Proximal 40-mm segments of all three major epicardial coronary vessels were traced and examined. Coronary inflammation was assessed by the CT fat attenuation index of perivascular adipose tissue (FAI-PVAT) defined as the mean attenuation of the perivascular adipose tissue (−190 to −30 Hounsfield units (HU)) in a layer of tissue within a radial distance from the outer coronary artery wall equal to the diameter of the vessel. CMR images were also acquired to assess absolute CSF at rest and during maximum hyperemia before elective PCI. The patients were divided into 4 groups according to the number of inflamed vessels as defined by showing FAI ≥−70.1 HU.

Results

In the final analysis of 69 patients (mean age 67, Male 45 (65.2%)), 18, 19, 20, 12 patients exhibited none, 1, 2, 3 inflamed vessels with FAI ≥−70.1 HU, respectively. Rest and maximal hyperemic CSF and corrected G-CFR were 1.28 [0.76,1.55] vs 1.47 [1.11, 1.81] vs 1.30 [0.94, 1.64] vs 1.27 [1.11, 2.00] ml/min/g; P=0.49, 3.50 [2.84, 5.25] vs 3.28 [2.62, 4.31] vs 3.11 [2.16, 3.63] vs 2.37 [1.40, 2.98] ml/min/g; P=0.049, 3.57 [2.17, 4.54] vs 2.25 [1.73, 3.49] vs 2.26 [1.64, 3.38] vs 1.89 [0.89, 2.32]; P=0.023, respectively. G-CFR and hyperemic CSF were both significantly lower in the group with larger number of inflamed vessels.

Conclusions

In SAP patients with significant coronary artery stenosis, G-CFR obtained by PC-CMR significantly associated with the prevalence of inflamed vessels detected by coronary CT. The extent of coronary inflammation may influence global coronary endothelium dysfunction, resulting in decreased G-CFR.

P5617Repeatability of instantaneous wave-free ratio in comparison with fractional flow reserve

Background

Instantaneous wave-free ratio (iFR) has been recently introduced as an adenosine free alternative for fractional flow reserve (FFR) to assess the functional significance of epicardial coronary stenosis. Little is known, however, regarding the repeatability and stability of iFR in comparison with FFR.

Purpose

The aim of this study was to evaluate the repeatability of iFR and compare it to that of FFR.

Methods

Patients with stable coronary artery disease who underwent physiological assessment twice within 90 days were enrolled. Repeated measurements were performed at diagnostic and therapeutic catheterization in about 70% of studied population. The remaining patients were measured twice for non-culprit lesion assessment at primary PCI and subsequent non-culprit and ischemia-documented lesion PCI. The calculation of iFRmatlab from DICOM pressure tracing data of resting state was performed using a fully automated off-line software algorithm in a blind fashion. FFR values were also measured by a fully automated algorithm in the same core laboratory by using hyperemic pressure tracing data. The repeatability of the two indices were evaluated and compared. The inter-rater agreement between iFRmatlab and FFR values of two measurements was assessed by κ coefficient. The pressure rate product during each assessment was also documented and evaluated.

Results

Ninety-three lesions from 92 patients were included in the study. The time interval between the two assessments was 38.4±19.0 days. iFRmatlab and FFR both showed significant correlation within the two assessments (iFRmatlab: r=0.75, 95% confidence interval, 0.64 to 0.83; mean difference, −0.006 [−0.18 to −0.01], FFR: r=0.86, 95% confidence interval, 0.79 to 0.90; mean difference, 0.004 [−0.07 to 0.03]). The inter-rater agreement of functional ischemia for iFRmatlab and FFR were κ=0.449 and κ=0.732, respectively. Although the prevalence of functional ischemia during the first and second assessment were consistent for both indices (iFRmatlab: 70.0%/67.7%, FFR: 86.0%/ 86.0%), significant difference was observed in the prevalence of clinical disagreement on the diagnosis of functional ischemia (FFR=0.80, iFR=0.89 used as cut-off values, respectively) between the first and second assessment among the two indices (iFRmatlab: 6.5%, FFR: 23.7%, p=0.002). iFRmatlab was significantly associated with pressure rate product during the examination compared to FFR (iFRmatlab: r= −0.25, 95% confidence interval, −0.43 to −0.04, P=0.018, FFR: r=−0.08, 95% confidence interval, −0.28 to −0.13, p=0.467).

Conclusion

Our results suggested that iFRmatlab showed lower repeatability and reliability for decision making compared to FFR. The instability of iFRmatlab potentially derives at least in part from its association with heart rate and blood pressure product.

P2703Impact of subtended myocardial mass on the assessment of functional ischemia as evaluated by FFR and QFR

Background

The fractional flow reserve (FFR) becomes a standard practice for revascularization decision-making in evaluating the functional significance of angiographically intermediate epicardial coronary stenosis. The quantitative flow ratio (QFR) is a novel method for rapid computational estimation of FFR without pressure wire and hyperemic induction. FFR has been reported to be associated with not only epicardial stenosis but also subtended myocardial mass (Vsub). In contrast, the relationship between QFR and Vsub has not been clarified.

Purpose

We sought to examine if subtended myocardial mass (Vsub) assessed by coronary computed tomography showed a significant relationship with QFR in comparison with FFR.

Methods and results

We performed a post-hoc analysis of 152 territories (LAD 116, RCA 25 and LCX 11 lesions) with angiographically intermediate-to-severe stenosis in 152 patients who underwent FFR assessment. The median FFR and QFR values were 0.76 (0.64–0.84) and 0.76 (0.72–0.83), respectively. The median diameter stenosis (%DS) and minimum lumen diameter (MLD) were 54.5 (43.9–64.2) and 1.2 (0.9–1.6), respectively. In total, 123 (80.9%) and 29 (19.1%) lesions showed concordant and discordant FFR and QFR functional classifications, respectively. The ability of Vsub/MLD2 to discriminate lesions with FFR≤0.80 and QFR≤0.80 was assessed compared with QCA data. FFR values were associated with Vsub (R=0.37, P<0.001). In contrast, a trend albeit no significant linear relationshipwas detected between QFR and Vsub (R=0.15, P=0.060). The area under the curve (AUC) of Vsub/MLD2 predicting FFR≤0.80 (0.88: 95% confidence interval [CI], 0.83–0.94)was significantly better than that of MLD (0.80: 95% [CI], 0.72–0.88) (P<0.001). On the other hand, the AUC of Vsub/MLD2 predicting QFR≤0.80 (0.82: 95% [CI], 0.75–0.90) was similar to that of MLD (0.80: 95% [CI], 0.72–0.87) (P=0.276). Multivariate analysis showed that the value of Vsub/MLD2 was an independent predictor of FFR≤0.80 (odds ratio [OR]: 1.09, 95% [CI]: 1.03–1.15, P=0.002), whereas it was not an independent predictor of QFR≤0.80.

Conclusions

Subtended cardiac mass volume derived from CT segmentation improved the diagnostic performance of angiography-derived parameters to identify ischemia-producing lesions when FFR used as a reference standard, whereas QFR showed non-significant relationship with subtended cardiac mass.

6113Gender differences in long-term outcomes in patients with deferred revascularization following fractional flow reserve assessment: international collaboration registry of physiologic evaluation

Background

Studies of sex differences in fractional flow reserve (FFR) measurements have shown that in comparison with men, angiographic lesions of similar visual severity are less likely to be ischemia producing in women. Gender specific differences may influence revascularization decision making and prognosis after deferred revascularization following FFR measurement.

Purpose

This study sought to investigate the gender difference in long-term prognosis of patients of deferred revascularization following FFR assessment.

Methods

A total of 879 patients (879 vessels) with deferred revascularization with FFR >0.75 who underwent FFR and CFR measurements were enrolled from 3 countries (Korea, Japan, and Spain). Long-term outcomes were assessed in 649 men and 230 women by the patient-oriented composite outcome (POCO, a composite of any death, any myocardial infarction [MI], and any revascularization). We applied inverse-probability weighting (IPW) based on propensity scores to account for differences at baseline between women and men (age, hypertension, hyperlipidemia, diabetes mellitus, lesion location, clinical status, FFR, Reference diameter, Diameter stenosis, lesion length). The median follow-up duration was 1855 days (745–1855 days).

Results

Median FFR values were 0.88 (0.83–0.93) in men and 0.89 (0.85–0.94) in women, respectively. The occurrences of POCO were significantly high in men compared with that in women (10.5% vs 4.2%, P=0.007). Kaplan–Meier analysis revealed that women had a significantly lower risk of POCO (χ2=7.2, P=0.007). Multivariate COX regression analysis revealed that age, male, diabetes mellitus, diameter stenosis, lesion length, and coronary flow reserve were independent predictors of POCO. After applying IPW, the hazard ratio of male for POCO was 2.20 (95% confidence interval: 1.12 to 4.33, P=0.023).

Conclusion

This large multinational study reveals that long-term outcome differs between women and men in favour of women after FFR-guided revascularization deferral.

Acknowledgement/Funding

None

P2239The association between global coronary flow reserve and coronary inflammation assessed by fat attenuation index on computed tomography in patients with acute coronary syndrome

Background

Impaired global coronary flow reserve (G-CFR) is known to predict worse outcomes in patients with coronary artery disease. Phase contrast cine-magnetic resonance imaging (PC-CMR) of the coronary sinus (CS) is a promising approach for quantifying coronary sinus flow (CSF) and global coronary flow reserve (G-CFR) without the need for ionizing radiation, radioactive tracers, or intravascular catheterization. Although G-CFR impairment has been previously reported to be linked with endothelium dysfunction and subsequent atherosclerosis, the relationship between coronary inflammation and absolute coronary blood flow volume or coronary flow reserve remains elusive.

Purpose

We evaluated the association between G-CFR by quantifying CSF using PC-CMR and the extent of coronary inflammation in patients with ACS treated with emergent percutaneous coronary intervention (PCI).

Methods

The study enrolled 107 ACS patients who underwent uncomplicated emergent PCI within 48 hours of symptom onset and coronary CT angiography were performed before PCI. Proximal 40-mm segments of all three major epicardial coronary vessels were examined. Coronary inflammation was assessed by the CT fat attenuation index of perivascular adipose tissue (FAI−PVAT) defined as the mean attenuation of the perivascular adipose tissue (−190 to −30 Hounsfield units (HU)) in a layer of tissue within a radial distance from the outer coronary artery wall equal to the diameter of the vessel, as previously reported. CMR images were acquired to assess absolute CSF at rest and during maximum hyperemia within 30 days after emergent PCI and revascularization of non-culprit significant lesions. The patients were divided into 4 groups according to the number of inflamed vessels (defined as 0, 1, 2, 3 vessels with FAI ≥−70.1 HU).

Results

In the final analysis of 102 patients (mean age 64, Male 65 (63.7%)) including 77 patients with non-ST-segment elevation myocardial infarction (NSTEMI) (75.5%) and 25 patients with unstable angina pectoris (UAP), 25, 30, 26, 21 patients exhibited none, 1, 2, 3 inflamed vessels with FAI ≥−70.1 HU, respectively. Rest and maximal hyperemic CSF and corrected G-CFR were 1.17 [0.63, 1.71] vs 1.36 [1.05, 1.67] vs 1.21 [0.83, 1.94] vs 1.35 [0.96, 1.67] ml/min/g; P=0.61, 3.26 [2.62, 2.99] vs 3.50 [2.60, 4.03] vs 3.34 [1.78, 4.20] vs 2.48 [1.54, 3.43]; P=0.061, 2.95 [2.05, 4.30] vs 2.63 [1.80, 3.56] vs 2.15 [1.37, 2.91] vs 2.18 [1.46, 2.42]; P=0.018, respectively. G-CFR was significantly lower in group with increased number of inflamed vessels.

Conclusions

In ACS patients successfully revascularized within 48 hours of onset, G-CFR obtained by noninvasive PC-CMR significantly associated with the prevalence of inflamed vessels detected by coronary CT. Further large population study is warranted to test the hypothesis that the extent of coronary inflammation before coronary revascularization in patients with ACS might provide prognostic information.

P5251Prognostic value of unrecognized myocardial infarction detected by cardiac magnetic resonance imaging in patients presenting with first acute myocardial infarction

Background

Unrecognized myocardial infarction (UMI) has been reported to be strongly associated with worse outcome in patients with cardiovascular disease. Cardiac magnetic resonance (CMR) imaging is a useful instrument for the assessment of pathological and functional conditions.

Purpose

This study sought to evaluate the prognostic value of the presence of unrecognized non-infarct-related late gadolinium enhancement (non-IR LGE) evaluated by cardiac magnetic resonance imaging in patients presenting with a first acute myocardial infarction (AMI).

Methods

We studied 311 AMI patients including 213 STEMI and 98 NSTEMI patients without the history of prior MI who underwent uncomplicated primary or emergent PCI within 48 hours of symptom onset between October, 2012 and June, 2017. CMR images were acquired at 28 [21, 32] days after primary/emergent PCI. UMI was defined as having LGE separately in the different and remote area from the perfused territory by infarct-related artery. In case of multiple LGE areas of infarction, the coronary angiography findings were used to support identification of the area corresponding to the culprit artery of AMI. The association of CMR variables and other clinical characteristics with major adverse cardiac events (cardiac death, nonfatal myocardial infarction, nonfatal stroke) were investigated.

Results

Forty-six patients (14.8%) showed UMI defined by the presence of non-IR LGE (27 STEMI and 19 NSTEMI). During the follow up for 830 [385, 1309] days, cardiovascular death occurred in 7 patients (2.3%), and non-fatal MI and non-fatal stroke occurred in 10 and 1 patients, respectively (3.2%, 0.3%, respectively). There was no significant difference in the prevalence of UMI and incidence of MACE between the patients with STEMI and NSTEMI (p=0.13, p=0.11, respectively). Event-free survival was significantly worse in patients with UMI (log-rank χ2=16.3, P=0.001) in a total cohort. Cox proportional hazards analysis showed that UMI was independent predictors of adverse cardiac events during follow-up in patients with first MI (hazard ratio, 7.60, 95% confidence interval, 2.78–20.8, p=0.0001).

Conclusions

In first AMI patients, UMI defined by non-IR LGE obtained by noninvasive CMR provides significant prognostic information. Early detection of UMI by CMR may help risk stratification of patients with AMI and support adjunctive aggressive patient management such as strong statin therapy and life style intervention.

P6393Differences in coronary inflammation between the culprit and non-culprit vessels assessed by fat attenuation index on computed tomography in patients with acute coronary syndromes

Background

Inflammation is linked with progression of coronary atherosclerosis. Recent studies have reported the association between elevated perivascular fat attenuation index (FAI) on computed tomography (CT) and worse cardiac outcomes in patients with coronary artery disease.

Purpose

We aimed to investigate the differences in FAI-defined peri-coronary inflammation status between the culprit and non-culprit vessels in patients with acute coronary syndromes (ACS).

Methods

A total of 78 ACS patients with left anterior descending coronary arteries (LAD) as a culprit vessel who underwent coronary CT angiography and invasive coronary angiography were studied. Proximal 40-mm segments of the LAD and the right coronary artery (RCA) were traced. Coronary inflammation was assessed by the FAI defined as the mean CT attenuation value of perivascular adipose tissue (−190 to −30 Hounsfield units [HU]) in a layer of tissue within a radial distance from the outer coronary artery wall equal to the diameter of the vessel. All patients were divided into two groups according to the values of FAI in the LAD: high FAI group (FAI-LAD > median; n=39) and low FAI group (FAI-LAD ≤ median; n=39). Patient characteristics, angiographic and CT findings were compared between the two groups.

Results

In a total of 78 patients, median FAI in the LAD was −70.20 (interquartile range, −74.81 to −64.58) HU. High FAI group was associated with male sex and lower left ventricular ejection fraction compared with Low FAI group. Minimal lumen diameter, reference diameter, diameter stenosis, and lesion length on quantitative coronary angiography analysis and coronary artery calcium score on CT was not different between the groups. FAI in the RCA was also higher in High FAI group than that in Low FAI group (−67.64±8.31 vs. −76.47±6.25 HU, P<0.001). Paired t-test comparison demonstrated that culprit vessel showed higher FAI than the non-culprit vessel (−69.85±7.74 vs. −72.11±8.54 HU, P=0.013).

Conclusions

In ACS patients with culprit LAD lesions, FAI-defined peri-coronary inflammation status is higher in the culprit vessel than in the non-culprit vessel.

P3585Prognostic value of the assessment of coronary sinus flow by phase contrast cine-magnetic resonance imaging in patients with acute coronary syndrome

Background

Phase contrast cine-magnetic resonance imaging (PC-CMR) of the coronary sinus (CS) is a promising approach for quantifying global coronary sinus flow (CSF) and global coronary flow reserve (G-CFR) without the need for ionizing radiation, radioactive tracers, or intravascular catheterization.

Purpose

We evaluated the prognostic value of G-CFR by quantifying CSF using PC-CMR in patients with ACS treated with primary or emergent percutaneous coronary intervention (PCI).

Methods

The study prospectively enrolled 387 ACS patients who underwent uncomplicated primary or emergent PCI within 48 hours of symptom onset. Breath-hold PC-CMR images of CS were acquired to assess absolute CSF at rest and during maximum hyperemia within 30 days after primary PCI and revascularization of functionally significant non-culprit lesions of ACS. The association of G-CFR and baseline clinical characteristics with major adverse cardiac events (cardiac death, nonfatal myocardial infarction, late revascularization, or hospitalization for congestive heart failure) was investigated.

Results

In the final analysis of 366 patients (Male 294 (80.3%), mean age 65) including 233 patients (63.7%) with ST-segment elevation myocardial infarction (STEMI) and 133 patients (36.3%) with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), rest and maximal hyperemic CSF and corrected G-CFR were 1.24 [0.83, 1.71] ml/min/g, 2.56 [1.87, 3.66] ml/min/g, and 2.20 [1.53, 3.17], respectively. During a median follow-up of 16 months, MACE occurred in 84 patients (cardiac death: 9, nonfatal myocardial infarction: 11, late revascularization: 59, hospitalization for congestive heart failure: 5). Cardiac event-free survival was significantly worse in patients with a corrected G-CFR <2.00 (log-rank χ2=20.2, P<0.001). Cox proportional hazards analysis showed that corrected G-CFR were independent predictors of adverse cardiac events during follow-up in patients with STEMI (hazard ratio, 0.66, 95% confidence interval, 0.51–0.85, p=0.001) and NSTE-ACS (hazard ratio, 0.64, 95% confidence interval, 0.43–0.95, p=0.026), respectively.

Conclusions

In ACS patients successfully revascularized within 48 hours of onset, G-CFR obtained by noninvasive PC-CMR provided significant prognostic information independent of infarction size and conventional risk scores.

CD8+ T cell-based strong selective pressure on multiple simian immunodeficiency virus targets in macaques possessing a protective MHC class I haplotype

In human immunodeficiency virus (HIV) and simian immunodeficiency virus (SIV) infections, host major histocompatibility complex class I (MHC-I) genotypes have a great impact on viral replication and MHC-I-associated viral genome mutations are selected under CD8⁺ T-cell pressure. Association of MHC-I genotypes with HIV/SIV control has been investigated at MHC-I allele levels but not fully at haplotype levels. We previously established groups of rhesus macaques sharing individual MHC-I haplotypes. In the present study, we compared viral genome diversification after SIV infection in macaques possessing a protective MHC-I haplotype, 90-010-Id, with those possessing a non-protective MHC-I haplotype, 90-010-Ie. These two MHC-I haplotypes are associated with immunodominant CD8⁺ T-cell responses targeting similar regions of viral Nef antigen. Analyses of viral genome sequences and antigen-specific T-cell responses showed four and two candidates of viral CD8⁺ T-cell targets associated with 90-010-Id and 90-010-Ie, respectively, in addition to the Nef targets. In these CD8⁺ T-cell target regions, higher numbers of mutations were detected at the setpoint after SIV infection in macaques possessing 90-010-Id than those possessing 90-010-Ie. These results indicate higher selective pressure on overall CD8⁺ T-cell targets associated with the protective MHC-I haplotype, suggesting a pattern of HIV/SIV control by multiple target-specific CD8⁺ T-cell responses.

Enfold-type connecting system of artificial blood vessels for micro implantable dialysis device

This paper reports the connecting mechanism for the artificial blood vessels along with the recent development of the micro implantable dialysis device. Our group has been studying the micro implantable dialysis device, which will drastically improve the quality of life of dialysis patients. We expect to replace the device every couple of years, which will involve surgery. In order to simplify the surgery to reduce the load to the patients, we develop a connector for the artificial vessels, which allows the exchange of the device by low invasive surgery. The connector needs to be designed not to induce blood coagulation. We designed a connecting mechanism that enfolds the artificial vessels to allow blood to contact only to the surface of the artificial vessels. In order to verify effectiveness of the proposed connecting mechanism, we investigated the connector surfaces with SEM after blood circulation tests. Then, we evaluated blood coagulation capacity of the connecting system as well as the set of the connecting system and the micro dialysis device with respect to the activated partial thromboplastin time (APTT). No remarkable increase of blood coagulation at the connecting point was observed after 72 hours of blood circulation tests. Short-term experiments for 120 minutes to evaluate APTT showed a small decrease of APTT, which needs to be further investigated in a longer-term experiments.

Evaluation of biofouling for implantable micro dialysis system

Implantable artificial kidney can drastically improve the quality of life of the renal disease patients. In previous study, our group has developed a multi-layered micro dialysis device which is composed of micro stainless steel channels and nano-porous polyethersulfone (PES) membranes. The device conducts hemofiltration without dialysis fluids, which is advantageous in miniaturization. We investigated the water-permeability of the PES membrane through in vivo experiments using rat model of renal disease for 5 hours and verified the effectiveness of the device. We investigated the permeability of PES membrane via in vitro experiments for 24 days. Biofouling on the PES membrane was found and caused deterioration of dialysis performance of the membrane. In this research, we investigated the biofouling such as thrombus, coagulation and protein adhesion on the sidewall of the micro fluidic channels. We investigated the micro fluidic channel geometry and surface condition associated with the processing methods. Conducting in vitro experiment for 7 days, biofouling was found to be mainly caused by the surface conditions. The mirror surface formed by electrolytic etching could substantially prevent biofouling.

Catheter-related bloodstream infection caused by Kodamaea ohmeri: A case report and literature review

Kodamaea ohmeri is a rare yeast pathogen that has recently emerged as an important cause of fungemia in immunocompromised patients. However, appropriate therapy for this infection remains unclear. We report a case of catheter-related blood stream infection caused by K. ohmeri in a 58-year-old patient who improved after removal of the central venous catheter and administration of micafungin. Considering the antibiotic susceptibility of this pathogen and reviewing literature, echinocandins may be the first choice for an empiric therapy for this pathogen.

Does the Age of Donor Kidneys Affect Nocturnal Polyuria in Patients With Successful Real Transplantation?

BACKGROUND

We investigated whether the age of donor kidneys influences the incidence of nocturnal polyuria in patients with successful renal transplantation (RTX).

METHODS

Eighty-five patients (45 men and 40 women) undergoing RTX (median age, 47 years) were included in this study. Twenty-four-hour bladder diaries were kept for 3 days, and nocturnal polyuria was defined as a nocturnal polyuria index (nocturnal urine volume/24-hour urine volume) of >0.33. Risk factors for nocturnal polyuria were analyzed in patients with RTX by means of the Mann-Whitney U test, χ² test, and a logistic regression analysis.

RESULTS

End-stage renal disease (ESRD) developed from diabetes mellitus in 16 patients (19%). Sixty-five patients (76%) received pre-transplant dialysis, with a median duration of 5 years. The median serum creatinine level and body mass index at the most recent visit were 1.2 mg/dL and 21.2 kg/m², respectively. On the basis of the 24-hour bladder diaries, nocturnal polyuria was identified in 48 patients (56%). A logistic regression analysis revealed that diabetes mellitus as the original disease for ESRD was the only risk factor for nocturnal polyuria (odds ratio, 8.95; 95% confidence interval, 2.01-65.3; P = .0028). The age of donor kidneys at examination did not affect the incidence of nocturnal polyuria (P = .9402).

CONCLUSIONS

Nocturnal polyuria was not uncommon in patients with successful RTX. Diabetes mellitus as the original disease for ESRD was the only risk factor for nocturnal polyuria, whereas the age of donor kidneys at examination did not affect the incidence of nocturnal polyuria. Thus, nocturnal polyuria is caused by recipient factors but not donor factors.