Cardiovascular outcomes after simultaneous pancreas kidney transplantation compared to kidney transplantation alone: a propensity score matching analysis

Background

Coronary heart disease due to arteriosclerosis is the leading cause of death in type 1 diabetic patients with end-stage renal disease (ESRD). The aim of this study was to evaluate the effect of simultaneous pancreas kidney transplantation (SPKT) compared to kidney transplantation alone (KTA) on survival, cardiovascular function and metabolic outcomes.

Methods

A cohort of 127 insulin-dependent diabetes mellitus (IDDM) patients with ESRD who underwent either SPKT (n = 100) or KTA (n = 27) between 1998 and 2019 at the University Hospital of Leipzig were retrospectively evaluated with regard to cardiovascular and metabolic function/outcomes as well as survival rates. An additional focus was placed on the echocardiographic assessment of systolic and diastolic cardiac function pretransplant and during follow-up. To avoid selection bias, a 2:1 propensity score matching analysis (PSM) was performed.

Results

After PSM, a total of 63 patients were identified; 42 patients underwent SPKT, and 21 patients received KTA. Compared with the KTA group, SPKT recipients received organs from younger donors (p < 0.05) and donor BMI was higher (p = 0.09). The risk factor-adjusted hazard ratio for mortality in SPKT recipients compared to KTA recipients was 0.63 (CI: 0.49–0.89; P < 0.05). The incidence of pretransplant cardiovascular events was higher in the KTA group (KTA: n = 10, 47% versus SPKT: n = 10, 23%; p = 0.06), but this difference was not significant. However, the occurrence of cardiovascular events in the SPKT group (n = 3, 7%) was significantly diminished after transplantation compared to that in the KTA recipients (n = 6, 28%; p = 0.02). The cardiovascular death rate was higher in KTA recipients (19%) than in SPK recipients with functioning grafts (3.3%) and comparable to that in patients with failed SPKT (16.7%) (p = 0.16).

In line with pretransplant values, SPKT recipients showed significant improvements in Hb1ac values (p = 0.001), blood pressure control (p =  < 0.005) and low-density lipoprotein/high-density lipoprotein (LDL/HDL) ratio (p =  < 0.005) 5 years after transplantation. With regard to echocardiographic assessment, SPKT recipients showed significant improvements in left ventricular systolic parameters during follow-up.

Conclusions

Normoglycaemia and improvement of lipid metabolism and blood pressure control achieved by successful SPKT are associated with beneficial effects on survival, cardiovascular outcomes and systolic left ventricular cardiac function. Future studies with larger samples are needed to make predictions regarding cardiovascular events and graft survival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02522-8.

De-novo Upper Gastrointestinal Tract Cancer after Liver Transplantation: A Demographic Report

BACKGROUND

Immunosuppression is essential after liver transplantation (LT). It, however, increases the risk for cancer.

OBJECTIVE

To evaluate the prevalence and outcome of upper gastrointestinal (GI) tract cancer in LT patients and assess the perioperative risk of surgery for the upper GI malignancies post-LT.

METHODS

2855 patients underwent LT at our clinic from 1988 to 2018. 20 patients developed upper GI cancer. Data were retrospectively extracted from our database. Analysis included patients' specific data, tumor histopathology and stage, the treatment given and survival.

RESULTS

23 patients developed upper GI malignancies (2 gastric and 18 esophageal cancers; 3 excluded), translating to a incidence of 26.4 per 100,000 population per year. All patients were male. 80% showed alcohol-induced cirrhosis before LT. Most of the tumors were diagnosed at a stage ≥III. 70% underwent surgery and 78.6% developed postoperative complications. One-year-survival was 50%. Total survival rate was 28.6% with a median follow-up of 10 months (range: 0-184).

CONCLUSION

Upper GI malignancies are more common after LT compared to the general population. Men after LT, due to alcohol-induced liver cirrhosis, are at a higher risk. Upper GI surgery after LT can be safe, but the severe risk for complications and a poor survival require strict indications.

[Surgical approach to benign bile duct alterations]

BACKGROUND

Benign biliary diseases comprise entities, which present with very similar pathognomonic symptoms despite fundamental etiological differences. Obstructions of intrahepatic and extrahepatic bile ducts due to stones, tumors or parasites as well as stenoses and cystic alterations belong to the group of benign biliary diseases.

OBJECTIVE

This article provides a systematic overview of the indications and differential treatment of benign biliary diseases with special emphasis on the surgical treatment.

MATERIAL AND METHODS

The presented recommendations are in accordance with national and international guidelines, current scientific papers and expert opinions.

RESULTS

Essentially the surgical options for benign biliary diseases consist of revision, reconstruction through bilioenteric anastomosis, resection and complete organ replacement in the sense of liver transplantation. The location of the affected segment of the biliary tree, the symptoms, the progress of the disease and suspected malignancy essentially determine the level of escalation in the described treatment level scheme.

CONCLUSION

The treatment of benign biliary diseases is complex and requires achievement of unimpaired, unobstructed bile drainage. It serves the purpose of resolving cholestasis and thereby avoiding recurrent cholangitis and long-term complications, such as biliary cirrhosis and malignant transformation; however, in some cases of premalignant lesions of the bile ducts the strategy resembles cancer surgery, including resection of the affected tissue.

Effect of Sodium Selenite Administration and Procalcitonin-Guided Therapy on Mortality in Patients With Severe Sepsis or Septic Shock: A Randomized Clinical Trial

IMPORTANCE

High-dose intravenous administration of sodium selenite has been proposed to improve outcome in sepsis by attenuating oxidative stress. Procalcitonin-guided antimicrobial therapy may hasten the diagnosis of sepsis, but effect on outcome is unclear.

OBJECTIVE

To determine whether high-dose intravenous sodium selenite treatment and procalcitonin-guided anti-infectious therapy in patients with severe sepsis affect mortality.

DESIGN, SETTING, AND PARTICIPANTS

The Placebo-Controlled Trial of Sodium Selenite and Procalcitonin Guided Antimicrobial Therapy in Severe Sepsis (SISPCT), a multicenter, randomized, clinical, 2 × 2 factorial trial performed in 33 intensive care units in Germany, was conducted from November 6, 2009, to June 6, 2013, including a 90-day follow-up period.

INTERVENTIONS

Patients were randomly assigned to receive an initial intravenous loading dose of sodium selenite, 1000 µg, followed by a continuous intravenous infusion of sodium selenite, 1000 µg, daily until discharge from the intensive care unit, but not longer than 21 days, or placebo. Patients also were randomized to receive anti-infectious therapy guided by a procalcitonin algorithm or without procalcitonin guidance.

MAIN OUTCOMES AND MEASURES

The primary end point was 28-day mortality. Secondary outcomes included 90-day all-cause mortality, intervention-free days, antimicrobial costs, antimicrobial-free days, and secondary infections.

RESULTS

Of 8174 eligible patients, 1089 patients (13.3%) with severe sepsis or septic shock were included in an intention-to-treat analysis comparing sodium selenite (543 patients [49.9%]) with placebo (546 [50.1%]) and procalcitonin guidance (552 [50.7%]) vs no procalcitonin guidance (537 [49.3%]). The 28-day mortality rate was 28.3% (95% CI, 24.5%-32.3%) in the sodium selenite group and 25.5% (95% CI, 21.8%-29.4%) (P = .30) in the placebo group. There was no significant difference in 28-day mortality between patients assigned to procalcitonin guidance (25.6% [95% CI, 22.0%-29.5%]) vs no procalcitonin guidance (28.2% [95% CI, 24.4%-32.2%]) (P = .34). Procalcitonin guidance did not affect frequency of diagnostic or therapeutic procedures but did result in a 4.5% reduction of antimicrobial exposure.

CONCLUSIONS AND RELEVANCE

Neither high-dose intravenous administration of sodium selenite nor anti-infectious therapy guided by a procalcitonin algorithm was associated with an improved outcome in patients with severe sepsis. These findings do not support administration of high-dose sodium selenite in these patients; the application of a procalcitonin-guided algorithm needs further evaluation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00832039.

Simplified lung ultrasound protocol shows excellent prediction of extravascular lung water in ventilated intensive care patients

Introduction

Ultrasound of the lung and quantification of B lines was recently introduced as a novel tool to detect overhydration. In the present study, we aimed to evaluate a four-region protocol of lung ultrasound to determine the pulmonary fluid status in ventilated patients in the intensive care unit.

Methods

Fifty patients underwent both lung ultrasound and transpulmonary thermodilution measurement with the PiCCO system. An ultrasound score based on number of single and confluent B lines per intercostal space was used to quantify pulmonary overhydration. To check for reproducibility, two different intensivists who were blinded as to the ultrasound pictures reassessed and classified them using the same scoring system. The results were compared with those obtained using other methods of evaluating hydration status, including extravascular lung water index (EVLWI) and intrathoracic blood volume index calculated with data from transpulmonary thermodilution measurements. Moreover, chest radiographs were assessed regarding signs of pulmonary overhydration and categorized based on a numeric rating scale.

Results

Lung water assessment by ultrasound using a simplified protocol showed excellent correlation with EVLWI over a broad range of lung hydration grades and ventilator settings. Correlation of chest radiography and EVLWI was less accurate. No correlation whatsoever was found with central venous pressure measurement.

Conclusion

Lung ultrasound is a useful, non-invasive tool in predicting hydration status in mechanically ventilated patients. The four-region protocol that we used is time-saving, correlates well with transpulmonary thermodilution measurements and performs markedly better than chest radiography.

Erdheim-Chester disease and knee pain in a dialysis patient

Erdheim-Chester disease is a rare inflammatory condition characterized by a non-Langerhans histiocytic infiltration, involving the skeleton, nervous system, viscera, retroperitoneum and elsewhere. The aetiology is unknown. Positron emission tomography shows areas of involvement. We managed a dialysis patient with knee pain; a bone marrow specimen showed typical CD68 positive, but CD1a negative cells. We initiated interferon-α therapy although other options remain open. In our patient, the simultaneous presence of secondary hyperparathyroidism with tumorous calcifications provided an interesting additional differential diagnostic possibility regarding skeletal pain.

Twenty-year longitudinal follow-up after orthotopic liver transplantation: a single-center experience of 313 consecutive cases

With excellent short-term survival in liver transplantation (LT), we now focus on long-term outcome and report the first European single-center 20-year survival data. Three hundred thirty-seven LT were performed in 313 patients (09/88-12/92). Impact on long-term outcome was studied and a comparison to life expectancy of matched normal population was performed. A detailed analysis of 20-years follow-up concerning overweight (HBMI), hypertension (HTN), diabetes (HGL), hyperlipidemia (HLIP) and moderately or severely impaired renal function (MIRF, SIRF) is presented. Patient and graft survival at 1, 10, 20 years were 88.4%, 72.7%, 52.5% and 83.7%, 64.7% and 46.6%, respectively. Excluding 1-year mortality, survival in the elderly LT recipients was similar to normal population. Primary indication (p < 0.001), age (p < 0.001), gender (p = 0.017), impaired renal function at 6 months (p < 0.001) and retransplantation (p = 0.034) had significant impact on patient survival. Recurrent disease (21.3%), infection (20.6%) and de novo malignancy (19.9%) were the most common causes of death. Prevalence of HTN (57.3-85.2%, p < 0.001), MIRF (41.8-55.2%, p = 0.01) and HBMI (33.2-45%, p = 0.014) increased throughout follow-up, while prevalence of HLIP (78.0-47.6%, p < 0.001) declined. LT has conquered many barriers to achieve these outstanding long-term results. However, much work is needed to combat recurrent disease and side effects of immunosuppression (IS).

Artificial extracorporeal liver support therapy in patients with severe liver failure

Severe liver failure is common and carries a high mortality risk in patients with both acute and acute-on-chronic liver failure. The failing liver constitutes a medical emergency, and in many cases liver transplantation is the only definite treatment. Extracorporeal liver support can be employed as a strategy for bridging to transplantation or recovery. This article focuses on options for artificial (nonbiological) extracorporeal treatment: single-pass albumin dialysis, fractionated plasma separation and adsorption (Prometheus(®)) and the molecular adsorbent recirculatory system. Their different principles, potential advantages and indications are discussed. Despite proven biochemical efficacy, there are little data regarding clinical end points. Thus far, molecular adsorbent recirculatory system therapy in acute and acute-on-chronic liver failure showed no survival benefit compared with standard medical therapy. Prometheus therapy showed reduced mortality in subgroups of higher severity of disease compared with standard medical therapy. Nevertheless, the value of extracorporeal liver support remains to be corroborated by further clinical studies that include the optimal timing, mode, intensity and duration of this treatment.

Extracorporeal liver support therapy with Prometheus in patients with liver failure in the intensive care unit

Acute liver failure (ALF) and acute-on-chronic liver failure (AoCLF) are associated with a high mortality. In these patients an accumulation of both water-soluble and water-insoluble, protein-bound, metabolic waste products occurs. Conventional extracorporeal blood purification techniques based on diffusion and/or convection such as hemodialysis or hemofiltration may only eliminate small molecular weight, water-soluble compounds. In recent years, fractionated plasma separation and adsorption (FPSA) with the Prometheus system has been introduced for extracorporeal liver support therapy. To date, however, only limited data is available regarding the effect of this treatment on mortality and outcome of patients with advanced liver disease. Here we report on our experience with 23 patients with severe liver failure who were treated with Prometheus in our medical intensive care unit. Fourteen patients had AoCLF, and nine patients experienced ALF. The median bilirubin level at the start of Prometheus therapy was 30.5 mg/dL and the median Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 26. During 40 individual treatment sessions lasting 5-6 h, Prometheus therapy reduced serum bilirubin levels from 23.7 mg/dL to 15.0 mg/dL (median values) (P < 0.001), and the overall survival was 26%. ALF patients had a better survival compared to AoCLF patients (44% vs. 22%; P = 0.022). Apart from one patient who developed hemodynamic instability during a treatment session, Prometheus therapy was well tolerated without relevant side-effects. In conclusion, extracorporeal liver support therapy with Prometheus is a novel and safe treatment option in patients with severe liver failure. In this series, patients with ALF showed a significantly better outcome with Prometheus therapy compared to AoCLF patients.

CD40-activated B cells can be generated in high number and purity in cancer patients: analysis of immunogenicity and homing potential

Cellular adjuvants such as dendritic cells (DC) are in the focus of tumour immunotherapy. In DC-vaccine trials, induction of tumour antigen-specific immunity is observed frequently and well-documented clinical responses have been reported. However, the overall response rate is less than 3%, therefore alternative strategies are being investigated. CD40-activated B cells (CD40-B) have been characterized previously as an interesting alternative because they present antigen efficiently and can be expanded by several logs from small amounts of peripheral blood. To determine the central technical challenges of cell-based vaccines we performed a single-patient analysis of 502 patients from DC-based tumour vaccine trials and identified at least three factors contributing to their limited efficiency: (1) lack of cell numbers; (2) lack of documented purity thus high contamination of bystander cells; and (3) lack of quality control and thus heterogeneous or unknown expression of important surface molecules such as major histocompatibility complex (MHC) and chemokine receptors. Based on these findings we re-evaluated the CD40-B approach in cancer patients. Here, we show that proliferation of B cells from cancer patients is equivalent to that observed in healthy donors. Purity is always > 90% after 2 weeks and remains stable for several weeks. They have comparable antigen-presenting capability determined phenotypically and by allogeneic mixed lymphocyte reaction. Expression of CCR7 and CD62L was detected in all samples and B cells migrated towards the relevant homing chemokines. Taken together, CD40-B cells from cancer patients can be expanded in virtually unlimited numbers at high purity and full function concerning antigen-presentation and migratory properties.

Genetic loci contribute to the progression of vascular and cardiac hypertrophy in salt-sensitive spontaneous hypertension

OBJECTIVE

The salt-sensitive Dahl rat and the spontaneously hypertensive rat develop comparable spontaneous hypertension on a low-salt diet, whereas only the salt-sensitive Dahl rat strain develops a striking increase in blood pressure and cardiovascular hypertrophy on a high-salt diet. We set out to identify quantitative trait loci (QTLs) contributing to the progression of salt-induced organ damage in hypertension by studying an F2 population derived from both strains.

METHODS AND RESULTS

We determined systolic blood pressure (SBP), vascular aortic hypertrophy (AH), cardiac left ventricular (LV) hypertrophy (LVH), and LV fibrosis in 230 male F2-animals on a high-salt diet. A strong correlation between AH and LVH was found (r=0.58, P<0.0001), and genome-wide QTL mapping detected suggestive or significant QTLs in overlapping chromosomal fragments for AH and LVH on chromosomes 1, 3, and 19, respectively. A significant influence of SBP on the extent of LVH and AH was evident at all QTLs, although significant linkage to SBP (together with LVH) was only found on chromosome 9. No QTLs for LV fibrosis were detected.

CONCLUSIONS

This study demonstrates a strong correlation between AH and LVH in salt-sensitive hypertension and identifies QTLs contributing to the progression of cardiovascular hypertrophy in this condition.

A retrospective study of the addition of ciprofloxacin to clarithromycin and ethambutol in the treatment of disseminated Mycobacterium avium complex infection

Disseminated Mycobacterium avium complex (DMAC) infection is associated with increased morbidity and mortality in HIV-infected individuals. The combination antibiotic regimens containing clarithromycin can decrease symptoms and improve survival in patients with DMAC, however, optimal therapy remains to be defined. Quinolones have been widely used in the treatment of DMAC but their utility has not been established. A retrospective cohort study of DMAC infection was established in a metropolitan hospital providing comprehensive care to over 3000 HIV-infected individuals. Medical records of patients with DMAC diagnosed at the Parkland Memorial Hospital from 1991 to 1994 were reviewed for therapeutic regimens for DMAC, concomitant therapy for HIV and Pneumocystis carinii prophylaxis and date of death. Subjects were included if they were treated with clarithromycin and ethambutol. Cases were defined as those patients who received more than 30 days of ciprofloxacin as therapy for DMAC in addition to the other drugs that they received. The primary endpoint was the time to death from the data of DMAC diagnosis. Covariates effecting survival were analysed through the Cox proportional hazards model. Eighty-nine subjects with DMAC who were treated with clarithromycin and ethambutol were identified. Fifty-eight received ciprofloxacin in addition to clarithromycin and ethambutol. The time to death was significantly better in those subjects who were treated with ciprofloxacin than those who were not (489 days vs 281 days, P=0.01). The sole significant predictor of improved survival on Cox proportional hazards model was ciprofloxacin therapy. Subjects treated with combination of clarithromycin, ethambutol and ciprofloxacin had improved survival over those treated with clarithromycin and ethambutol alone.

G-CSF association with prolonged survival in HIV-infected patients with disseminated Mycobacterium avium complex infection

Clarithromycin can ameliorate symptoms and improve survival in disseminated Mycobacterium avium complex (DMAC) infection. Optimal combinations of this drug with other agents remain unknown. Granulocyte colony stimulating factor (G-CSF) is a cytokine that can improve phagocytosis of M. avium complex in vitro. We aim to determine if G-CSF administration is associated with improved survival in patients with DMAC in a retrospective, cohort study. Case records from 1991 to 1995 of 91 patients with DMAC at Parkland Memorial Hospital were reviewed for date of initial DMAC diagnosis, baseline CD4 count, race, sex, antiretroviral use, G-CSF use, therapy for DMAC (clarithromycin, ethambutol, ciprofloxacin and rifabutin) and date of death. Of 91 cases identified, 25 were treated with G-CSF and 66 never received this drug. Baseline characteristics were similar in each group including CD4 count (40 cells/mm3 vs 33 cells/mm3, P=0.68), clarithromycin use (18 patients vs 52 patients, P=0.90), and antiretroviral use (20 patients vs 42 patients, P=0.21). Subjects treated with G-CSF lived longer than those who did not receive this drug (355 days vs 211 days, P<0.01). In the subgroup treated with clarithromycin, G-CSF was also associated with increased survival (377 days vs 252 days, P<0.01). Cox proportional hazards model showed a decreased risk of death in patients treated with G-CSF (RH=0.22, P<0.01), clarithromycin (RH=0.13, P<0.01) and ethambutol (RH=0.51, P=0.02). Ciprofloxacin and rifabutin use did not influence survival. These data support the use of clarithromycin and ethambutol in the treatment of DMAC. Addition of G-CSF to a regimen of clarithromycin and ethambutol may increase survival in DMAC and should be studied prospectively.

Granulocyte colony-stimulating factor use is associated with decreased bacteremia and increased survival in neutropenic HIV-infected patients

BACKGROUND

Neutropenia occurs in up to 17% of human immunodeficiency virus (HIV)-infected individuals. Although granulocyte colony-stimulating factor (G-CSF) can reverse HIV-related neutropenia, it is not established that this therapy can reduce bacterial infections and affect survival.

METHODS

A retrospective cohort study of 152 neutropenic, HIV-infected patients was performed to determine the therapeutic utility of G-CSF. Medical records of 71 patients who received G-CSF and 81 patients who never received G-CSF, during the years of 1991 to 1994 at Parkland Memorial Hospital, were reviewed for the incidence of bacteremia, G-CSF use, antiretroviral therapy (AR), Pneumocystis carinii pneumonia prophylaxis (PCPP), and opportunistic infections (OI).

RESULTS

The two patient groups had similar baseline characteristics including CD4 count (37 cells/mm3 versus 40 cells/ mm3, P=0.7). Univariate analysis revealed and trend toward decreased rates of all bacteremias in the G-CSF-treated group compared with the controls (0.54 bacteremias/100 patient months versus 2.2 bacteremias/100 patient months, P=0.064) and a marked decrease in the rates of gram-negative rod bacteremias in the G-CSF-treated group compared with the untreated group (0.09 gram-negative rod bacteremias/100 patient months versus 1.7 gram-negative rod bacteremias/100 patient months, P=0.002). In a multivariate analysis, significant decreased risk for bacteremia was found with G-CSF use (odds ratio [OR]=0.15, P=0.02). Survival was longer in patients treated with G-CSF than in the untreated group (median: 397 days versus 165 days). Multivariate analysis using Cox Proportional Hazards Model showed decreased risk of death in patients treated with G-CSF, ARs, PCPP.

CONCLUSIONS

We conclude that G-CSF use is associated with decreased bacteremias and is associated with prolonged survival in neutropenic, HIV-infected patients.

Adjunctive corticosteroid therapy for tuberculosis: a critical reappraisal of the literature

An extensive, although largely forgotten, literature addresses the utility of adjunctive corticosteroid therapy in the management of tuberculosis. Corticosteroid therapy probably improves neurological outcomes of, and decreases mortality due to, tuberculous meningitis of moderate severity. Although therapy for tuberculous pericarditis is simplified (with less need for operative intervention) by adjunctive corticosteroid administration and there are fewer deaths, the incidence of subsequent constriction is not changed. The signs and symptoms of typical reactivation tuberculous pneumonia, tuberculous pleurisy, and probably primary tuberculous disease (with lymphadenopathy) seem to decrease rapidly with corticosteroid therapy, although no differences in final outcomes have been observed. Corticosteroid regimens used in most studies varied greatly in duration and dosage and generally caused significant side effects. Corticosteroids do not appear to diminish the efficacy of adequate antimycobacterial therapy. Adjunctive corticosteroid therapy appears to offer significant short-term but (other than for tuberculous meningitis and effusive pericarditis) minimal long-term benefit for patients with tuberculosis.

Utility of bone marrow culture and biopsy in the diagnosis of disseminated infections in AIDS

Bone marrow examination (BME) has been used as a diagnostic test of last resort in HIV infected patients. Identifying factors that would increase the diagnostic yield of BME would be useful. A retrospective cohort study was done to determine the predictive value of BME for disseminated infection in 133 patients with HIV infection in a 4-year period at an active HIV clinical center. Thirty-two percent of the cases had evidence of a disseminated infection on BME but only 10% of cases had a diagnosis made exclusively by BME. Multivariate analysis demonstrated that a positive result was more likely in those patients with fewer than 50 CD4 cells/mm3 and those with a hematocrit of less than 25% (P<0.01). BME can be a useful, low-risk diagnostic procedure in selected patients with HIV infection who are ill with a low CD4 count and/or have a hematocrit less than 25%. A diagnosis can usually be made by other means, suggesting that this test should be limited to those in whom other diagnostic modalities have been exhausted.