RESUMO
This observational retrospective study aimed to investigate the usefulness of Sequential Organ Failure Assessment (SOFA), Quick SOFA (qSOFA), National Early Warning Score (NEWS), and quick NEWS in predicting respiratory failure and death among patients with COVID-19 hospitalized outside of intensive care units (ICU). We included 237 adults hospitalized with COVID-19 who were followed-up on for one month or until death. Respiratory failure was defined as a PaO2/FiO2 ratio ≤200mmHg or the need for mechanical ventilation. Respiratory failure occurred in 77 patients (32.5%), 29 patients (12%) were admitted to the ICU, and 49 patients (20.7%) died. Discrimination of respiratory failure was slightly higher in NEWS, followed by SOFA. Regarding mortality, SOFA was more accurate than the other scores. In conclusion, sepsis scores are useful for predicting respiratory failure and mortality in COVID-19 patients. A NEWS score ≥4 was found to be the best cutoff point for predicting respiratory failure.
Assuntos
COVID-19 , Insuficiência Respiratória , Sepse , Adulto , COVID-19/complicações , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Escores de Disfunção Orgânica , Prognóstico , Curva ROC , Estudos RetrospectivosRESUMO
This observational retrospective study aimed to investigate the usefulness of Sequential Organ Failure Assessment (SOFA), Quick SOFA (qSOFA), National Early Warning Score (NEWS), and quick NEWS in predicting respiratory failure and death among patients with COVID-19 hospitalized outside of intensive care units (ICU). We included 237 adults hospitalized with COVID-19 who were followed-up on for one month or until death. Respiratory failure was defined as a PaO2/FiO2 ratio ≤ 200 mmHg or the need for mechanical ventilation. Respiratory failure occurred in 77 patients (32.5%), 29 patients (12%) were admitted to the ICU, and 49 patients (20.7%) died. Discrimination of respiratory failure was slightly higher in NEWS, followed by SOFA. Regarding mortality, SOFA was more accurate than the other scores. In conclusion, sepsis scores are useful for predicting respiratory failure and mortality in COVID-19 patients. A NEWS score ≥ 4 was found to be the best cutoff point for predicting respiratory failure.
RESUMO
OBJECTIVES: There is increasing evidence that ferritin is a key marker of macrophage activation, but its potential role in influenza infection remains unexplored. Our aim was to assess whether hyperferritinaemia (ferritin ≥500 ng/mL) could be a marker of poor prognosis in hospitalized patients with confirmed influenza A infection. METHODS: We prospectively recruited all hospitalized adult patients who tested positive for the influenza A rRT-PCR assay performed on respiratory samples in two consecutive influenza periods (2016-17 and 2017-18). Poor outcome was defined as the presence of at least one of the following: respiratory failure, admission to the intensive care unit, or in-hospital mortality. RESULTS: Among 494 patients, 68 (14%) developed poor outcomes; 112 patients (23%) had hyperferritinaemia (39/68, 57% in the poor-outcome group versus 73/426, 17% in the remaining patients, p < 0.0001). Median serum ferritin levels were significantly higher in the subgroup of patients with poor outcomes (609 ng/mL, range 231-967 versus 217 ng/mL, range 140-394, p < 0.0001). In multivariate analysis, hyperferritinaemia was associated with a five-fold increase in the odds ratio of developing poor outcome. After adjusting for classic influenza risk factors, ferritin remained as a significant predictive factor in all exploratory models. Ferritin levels had a good discriminative capacity with an area under the ROC curve of 0.72 (95% confidence interval (CI) 0.65-0.8, p < 0.001) and an overall diagnostic accuracy for predicting poor outcome of 79.3% (95%CI 75.4-82.7%). CONCLUSIONS: Serum ferritin may discriminate a subgroup of patients with influenza infection who have a higher risk of developing a poor outcome.
Assuntos
Ferritinas/sangue , Vírus da Influenza A/genética , Influenza Humana/diagnóstico , Regulação para Cima , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Influenza Humana/sangue , Influenza Humana/complicações , Influenza Humana/mortalidade , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/etiologiaRESUMO
BACKGROUND: Hip fracture usually occurs in frail elderly patients and is associated with an important morbi-mortality in the first year. The objective of the study is to describe the prognostic factors that would allow maintaining functionality at 12 months. METHOD: From June 1, 2010 to May 31, 2013, all patients older than 69 years with hip fracture due to bone fragility admitted to the Geriatric Acute Unit of our hospital were included. We define as functional maintenance those patients who have lost between 0-15 points in the Barthel Index with respect to the previous to the fracture. Prospective study of bivariate data analysis for related and multivariate prognostic factors for predictive predictors. RESULTS: 271 patients were included, of them, 146 (54.8%), maintained functionality at 12 months and 122 (45.2%) no. Patients who maintain functional status are younger: average age 83.4 vs 85.80 years (P=.002); with better scores in the indexes of: Lawton prior to fracture 4.42 vs 2.40 (P<.001) and Barthel at discharge 34.2 vs. 27.1 (P=.002). There are also differences in the score of the "Geriatric Dementia Scale" 2.59 vs. 3.13 (P=.009), in the score of the "American Society Anesthesiologist"Assuntos
Atividades Cotidianas
, Fraturas do Quadril/cirurgia
, Recuperação de Função Fisiológica
, Fatores Etários
, Idoso
, Idoso de 80 Anos ou mais
, Análise de Variância
, Feminino
, Idoso Fragilizado
, Avaliação Geriátrica/métodos
, Fraturas do Quadril/epidemiologia
, Mortalidade Hospitalar
, Humanos
, Masculino
, Prognóstico
, Estudos Prospectivos
, Fatores de Tempo
RESUMO
A poorer functional status at the time of fracture is a predictor of non-adherence to oral bisphosphonates initiated after a hip fracture, and suggests further opportunities for optimization of secondary fracture prevention in this high-risk population. INTRODUCTION: Low adherence to treatment is a problem in post-fracture secondary prevention. We aimed to analyze the prognostic factors (related and predictive) associated with non-adherence to oral bisphosphonate prescription for hip fracture due to bone fragility (HFBF) 12 months after discharge from an acute geriatric unit. METHODS: Prospective study of bivariate data analyzing related and multivariate factors predicting non-adherence of oral bisphosphonates at 12 months after treatment for HFBF. The statistical study was performed with SPSS 19.0.0. RESULTS: We attended 368 patients with HFBF. At discharge, oral bisphosphonates were prescribed to 226 (61.42%) patients. At 12 months, we followed up 160 (70.7%) patients, 104 (65%) of whom had non-adherence to oral bisphosphonates. Bivariate analysis (adherent vs. non-adherent): age (83.79 ± 5.82 vs. 85.78 ± 5.80, p = .029); Lawton and Brody Index (4.29 ± 3.40 vs. 2.67 ± 3.31, p = .004); baseline Barthel Index (BI) (85.89 ± 21.99 vs. 74.18 ± 26.70) (p = .004); BI at admission (18.84 ± 10.00 vs. 14.47 ± 11.71, p = .004); BI at discharge (34.20 ± 15.40 vs. 27.45 ± 16.71, p = .011); baseline Functional Ambulation Classification (5.66 ± 0.98 vs. 5.43 ± 0.99, p = .025). Multivariate analysis: BI 0.980 (0.965-0.995, p = .007). Discriminatory capacity of the AUC model (± 95% CI): 0.634 (0.545-0.722). CONCLUSIONS: At 12 months, there was low adherence to treatment with oral bisphosphonates in our model. A lower BI prior to treatment is a predictive factor for non-adherence treatment with oral bisphosphonate.
Assuntos
Conservadores da Densidade Óssea/administração & dosagem , Difosfonatos/administração & dosagem , Fraturas do Quadril/prevenção & controle , Adesão à Medicação/estatística & dados numéricos , Fraturas por Osteoporose/prevenção & controle , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Conservadores da Densidade Óssea/uso terapêutico , Difosfonatos/uso terapêutico , Prescrições de Medicamentos , Feminino , Seguimentos , Serviços de Saúde para Idosos , Fraturas do Quadril/etiologia , Humanos , Masculino , Osteoporose/complicações , Osteoporose/tratamento farmacológico , Estudos Prospectivos , Prevenção Secundária/métodosRESUMO
Although hematological abnormalities have been described among patients with influenza virus infection, little is known about their impact on the outcome of the patients. The aim of this study was to assess the frequency and clinical impact of severe hematological abnormalities in patients with confirmed influenza virus infection. This was an observational retrospective study including all adult patients with diagnosis of influenza virus infection hospitalized from January to May 2016 in our institution. Influenza virus infection was diagnosed by means of rRT-PCR assay performed on respiratory samples. Poor outcome was defined as a composite endpoint in which at least one of the following criteria had to be fulfilled: (a) respiratory failure, (b) SOFA ≥2, or (c) death. Two hundred thirty-nine patients were included. Applying the HLH-04 criteria for the diagnosis of hemophagocytic syndrome, cytopenias (hemoglobin ≤9 g/dl, platelets <100,000/µl or neutrophils <1,000/µl) were present in 51 patients (21%). Patients with hematological abnormalities showed higher SOFA scores, respiratory failure, septic shock and in-hospital mortality than the remaining patients. The composite endpoint was present in 33.3% in the cytopenias group vs. 13.3% in the group without cytopenias (p=0.001). In a multivariate analysis, variables associated with the composite endpoint were: use of steroids prior to present admission (OR: 0.12; 95% CI: 0.015-0.96, p=0.046), presence of any hematological abnormality (OR: 3.54; 95% CI:1.66-7.51, p= 0.001), and LDH>225 U/l (OR:4.45; CI:1-19.71, p=0.049). Hematological abnormalities are not uncommon among hospitalized patients with influenza virus infection, and they are associated with a poorer outcome.
Assuntos
Doenças Hematológicas/complicações , Influenza Humana/mortalidade , Influenza Humana/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Gravidez , Insuficiência Respiratória , Estudos Retrospectivos , Análise de Sobrevida , Resultado do TratamentoRESUMO
Risk factors for invasive pulmonary aspergillosis (IPA) after kidney transplantation have been poorly explored. We performed a multinational case-control study that included 51 kidney transplant (KT) recipients diagnosed with early (first 180 posttransplant days) IPA at 19 institutions between 2000 and 2013. Control recipients were matched (1:1 ratio) by center and date of transplantation. Overall mortality among cases was 60.8%, and 25.0% of living recipients experienced graft loss. Pretransplant diagnosis of chronic pulmonary obstructive disease (COPD; odds ratio [OR]: 9.96; 95% confidence interval [CI]: 1.09-90.58; p = 0.041) and delayed graft function (OR: 3.40; 95% CI: 1.08-10.73; p = 0.037) were identified as independent risk factors for IPA among those variables already available in the immediate peritransplant period. The development of bloodstream infection (OR: 18.76; 95% CI: 1.04-339.37; p = 0.047) and acute graft rejection (OR: 40.73, 95% CI: 3.63-456.98; p = 0.003) within the 3 mo prior to the diagnosis of IPA acted as risk factors during the subsequent period. In conclusion, pretransplant COPD, impaired graft function and the occurrence of serious posttransplant infections may be useful to identify KT recipients at the highest risk of early IPA. Future studies should explore the potential benefit of antimold prophylaxis in this group.
Assuntos
Função Retardada do Enxerto/etiologia , Rejeição de Enxerto/etiologia , Aspergilose Pulmonar Invasiva/etiologia , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Estudos de Casos e Controles , Função Retardada do Enxerto/patologia , Feminino , Seguimentos , Taxa de Filtração Glomerular , Rejeição de Enxerto/patologia , Sobrevivência de Enxerto , Humanos , Aspergilose Pulmonar Invasiva/patologia , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Prognóstico , Fatores de Risco , TransplantadosRESUMO
Microbiological spectrum and outcome of infectious complications following small bowel transplantation (SBT) have not been thoroughly characterized. We performed a retrospective analysis of all patients undergoing SBT from 2004 to 2013 in Spain. Sixty-nine patients underwent a total of 87 SBT procedures (65 pediatric, 22 adult). The median follow-up was 867 days. Overall, 81 transplant patients (93.1%) developed 263 episodes of infection (incidence rate: 2.81 episodes per 1000 transplant-days), with no significant differences between adult and pediatric populations. Most infections were bacterial (47.5%). Despite universal prophylaxis, 22 transplant patients (25.3%) developed cytomegalovirus disease, mainly in the form of enteritis. Specifically, 54 episodes of opportunistic infection (OI) occurred in 35 transplant patients. Infection was the major cause of mortality (17 of 24 deaths). Multivariate analysis identified retransplantation (hazard ratio [HR]: 2.21; 95% confidence interval [CI]: 1.02-4.80; p = 0.046) and posttransplant renal replacement therapy (RRT; HR: 4.19; 95% CI: 1.40-12.60; p = 0.011) as risk factors for OI. RRT was also a risk factor for invasive fungal disease (IFD; HR: 24.90; 95% CI: 5.35-115.91; p < 0.001). In conclusion, infection is the most frequent complication and the leading cause of death following SBT. Posttransplant RRT and retransplantation identify those recipients at high risk for developing OI and IFD.
Assuntos
Rejeição de Enxerto/microbiologia , Enteropatias/cirurgia , Intestino Delgado/transplante , Micoses/microbiologia , Infecções Oportunistas/microbiologia , Complicações Pós-Operatórias , Adulto , Criança , Pré-Escolar , Feminino , Seguimentos , Rejeição de Enxerto/epidemiologia , Sobrevivência de Enxerto , Humanos , Incidência , Enteropatias/complicações , Enteropatias/microbiologia , Masculino , Micoses/epidemiologia , Infecções Oportunistas/epidemiologia , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
OBJECTIVES: Evaluate the protective effect against late CMV disease of delaying antiviral prophylaxis initiation in D+/R- patients receiving solid organ transplant (SOT). METHODS: Prospective multicenter study in D+/R- SOT recipients in Spain (Sept/09-Sept/12). Whole blood specimens were prospectively collected after Tx for CMV-specific cell-mediated immunity (CMI) determination. Two prophylaxis strategies were compared: early prophylaxis (EP; starting within the first 3 days after Tx) and delayed prophylaxis (DP; starting 14 days after Tx). Risk factors for the occurrence of CMV disease were determined by survival analysis and proportional risk Cox regression models. RESULTS: We included 95 patients (50 EP V 45 DP). Twenty six patients (27.4%) developed CMV disease: 32.7% EP vs. 20% DP; (p = 0.2). No cases of CMV disease were reported previously to beginning delayed prophylaxis. The percentage of individuals with detectable CMI response was higher in patients with DP although differences did not reach statistic significance (42% vs 29.6% at day 200 after Tx; p = 0.4). There was a clear trend towards less end-organ CMV disease in patients receiving DP (18.2% EP vs 5% DP; p = 0.09) and DP was the only protective factor in the multivariate analysis (HR: 0.26; CI: 0.05-1.2; p = 0.09). CONCLUSIONS: A 14-day delay in CMV prophylaxis in D+/R- SOT recipients is safe and may reduce the incidence of late CMV end-organ disease although correlation of this effect with CMI responses was not complete.
Assuntos
Antivirais/uso terapêutico , Infecções por Citomegalovirus/imunologia , Infecções por Citomegalovirus/prevenção & controle , Citomegalovirus/imunologia , Ganciclovir/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Transplantados , Citomegalovirus/efeitos dos fármacos , Infecções por Citomegalovirus/tratamento farmacológico , Infecções por Citomegalovirus/epidemiologia , Infecções por Citomegalovirus/virologia , Feminino , Humanos , Imunidade Celular , Incidência , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Risco , Espanha/epidemiologia , Análise de SobrevidaRESUMO
BACKGROUND: This study aimed to characterize the dynamics of acquisition of cytomegalovirus (CMV)-specific cell-mediated immunity (CMI) in CMV donor positive/recipient negative solid organ transplant (SOT) patients receiving long-term antiviral prophylaxis, and to determine whether development of CMI confers protection against CMV disease. METHODS: A prospective multicenter study was conducted in Spain from September 2009 to September 2012. Whole blood specimens were prospectively collected at 30, 90, 120, 200, and 365 days after SOT, and CMI was determined by enumeration of CMV pp65 and IE-1-specific CD69(+) /interferon-γ-producing CD8(+) and CD4(+) T cells by flow cytometry for intracellular cytokine staining. As part of a simultaneous clinical trial, patients received either early prophylaxis (in the first 3 days after transplantation) in the first period of the study or delayed prophylaxis (initiated at day 14) during the second period of the study. The impact of the dynamics of acquisition of CMV-specific CMI on the incidence of CMV disease was evaluated by Kaplan-Meier survival analysis. RESULTS: A total of 95 SOT recipients were recruited. CMV infection and disease occurred in 38 (40%) and 26 (27.4%) patients, respectively. The proportion of patients achieving any detectable CMV-specific CMI response at each of the different monitoring points was higher in liver transplant recipients, as compared to kidney or heart transplant recipients. The presence of any detectable response at day 120 or 200 was protective against the development of CMV disease (positive predictive values 92% and 93%, respectively). CONCLUSIONS: The rate of acquisition of CMV-specific CMI in SOT recipients undergoing antiviral prophylaxis differed significantly between different SOT populations. Patients developing any detectable CMI response were protected against the occurrence of CMV disease.
Assuntos
Antivirais/uso terapêutico , Infecções por Citomegalovirus/prevenção & controle , Citomegalovirus/imunologia , Ganciclovir/análogos & derivados , Imunidade Celular , Transplante de Órgãos , Complicações Pós-Operatórias/prevenção & controle , Adulto , Idoso , Infecções por Citomegalovirus/etiologia , Infecções por Citomegalovirus/imunologia , Infecções por Citomegalovirus/virologia , Feminino , Seguimentos , Ganciclovir/uso terapêutico , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/imunologia , Complicações Pós-Operatórias/virologia , Estudos Prospectivos , Resultado do Tratamento , ValganciclovirRESUMO
BACKGROUND: Safety concerns have been raised about the use of adjuvanted vaccines after kidney transplantation. METHODS: We retrospectively analyzed 65 kidney transplant (KT) recipients who received ≥1 dose of influenza vaccine (pandemic or seasonal) during the 2009-2010 campaign. Participants were classified into 2 groups: those who received a squalene-based AS03- or MF59-adjuvanted vaccine ("adjuvanted vaccination" [AV] group, n = 37) and those who exclusively received non-adjuvanted vaccines ("non-adjuvanted vaccination" [NAV] group, n = 28). Primary outcomes included occurrence of biopsy-proven acute graft rejection (BPAR) and graft function at months 6 and 12 after vaccination. Patients were followed up until graft loss, death, or October 2010. RESULTS: Four episodes of BPAR occurred during post-vaccination follow-up, with no differences between the AV and NAV groups, in terms of cumulative incidence (5.4% vs. 7.1%, respectively; P = 0.581), incidence rate (0.22 vs. 0.18 episodes per 1000 transplant-days; P = 0.950), or occurrence of severe episodes (T-cell-mediated BPAR of grade ≥2a) (2.7% vs. 3.6%; P = 0.680). No between-group differences were seen in graft function after vaccination. CONCLUSION: Adjuvanted influenza vaccination in KT recipients seems to be safe regarding graft outcome.
Assuntos
Adjuvantes Imunológicos/uso terapêutico , Rejeição de Enxerto/epidemiologia , Vacinas contra Influenza/uso terapêutico , Influenza Humana/prevenção & controle , Falência Renal Crônica/cirurgia , Transplante de Rim , Esqualeno/uso terapêutico , Adulto , Idoso , Estudos de Coortes , Feminino , Rejeição de Enxerto/patologia , Rejeição de Enxerto/prevenção & controle , Humanos , Imunossupressores/uso terapêutico , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , TransplantadosRESUMO
In the context of solid organ transplantation, screening of recipients and organ donors is crucial, and should be performed with great rigour to minimize the reactivation or the risk of transmission of certain infectious processes. This review aims to update understanding of the possible pathologies involved, as well as of emerging infections that, as a result of globalization, are gaining increasing prominence on a daily basis.
Assuntos
Doenças Transmissíveis/transmissão , Transmissão de Doença Infecciosa/prevenção & controle , Controle de Infecções/métodos , Programas de Rastreamento/métodos , Transplante de Órgãos/efeitos adversos , Doadores de Tecidos , Doenças Transmissíveis Emergentes/prevenção & controle , Humanos , TransplantadosAssuntos
Infecções por Citomegalovirus/epidemiologia , Infecções por Citomegalovirus/prevenção & controle , Infecções Oportunistas/epidemiologia , Infecções Oportunistas/prevenção & controle , Transplante de Órgãos , Transplantados , Infecções por Citomegalovirus/diagnóstico , Infecções por Citomegalovirus/terapia , Humanos , Hospedeiro Imunocomprometido , Imunossupressores/uso terapêutico , Infecções Oportunistas/diagnóstico , Infecções Oportunistas/terapiaRESUMO
BACKGROUND: The impact of iron metabolism on the risk of infectious complications has been demonstrated in various immunosuppressed populations. However, no previous studies have assessed this potential association in kidney transplant (KT) recipients. METHODS: We prospectively analyzed 228 patients undergoing KT at our institution from November 2008 to February 2011. Serum iron parameters (iron level, ferritin, total iron-binding capacity, unsaturated iron-binding capacity, transferrin, and transferrin saturation) were assessed within the first 2 weeks after transplantation (median interval, 3 days; interquartile [Q1 -Q3 ] range, 1-6 days), and before the occurrence of the first infectious episode (median interval, 26 days; Q1 -Q3 range, 11-76 days). Primary outcome was the occurrence of any episode of infection during the first year. Multivariate-adjusted hazard ratios (aHRs) were estimated by Cox regression models. RESULTS: Patients with ferritin level ≥ 500 ng/mL had higher incidence rates (per 1000 transplant-days) of overall infection (P = 0.017), bacterial infection (P = 0.002), and bloodstream infection (P = 0.011) during the first post-transplant year. One-year infection-free survival rate was lower in these recipients (26% vs. 41%; P = 0.004). On multivariate analysis, after adjusting for potential confounders, ferritin emerged as an independent predictor of overall infection (aHR [per unitary increment], 1.001; P = 0.006), and bacterial infection (aHR [per unitary increment], 1.001; P = 0.020). CONCLUSION: Monitoring of serum iron parameters in the early post-transplant period may be useful in predicting the occurrence of infection in KT recipients, although further studies should be carried out to confirm this preliminary finding.
Assuntos
Infecções Bacterianas/epidemiologia , Ferritinas/sangue , Ferro/sangue , Transplante de Rim/efeitos adversos , Sepse/epidemiologia , Transferrina/metabolismo , Adulto , Idoso , Infecções Bacterianas/sangue , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Sepse/sangueRESUMO
BACKGROUND: Uncontrolled donations after circulatory death (DCD) present 2 well-established risk factors for infection after kidney transplantation (KT): greater rates of delayed graft function (DGF) and antithymocyte globulin (ATG)-containing sequential therapies. METHODS: We performed a prospective cohort study of our 291 KT patients between November 2008 and July 2011 to compare the incidences of infection between DCD (n = 87) and donation after brain death (DBD; n = 204) recipients. Most DCD donors were uncontrolled Maastricht categories 1 or 2. Backward stepwise Cox proportional hazards models were used to assess the impact of DCD on the primary study outcome. RESULTS: As compared to the DBD group, DCD recipients were younger, less likely to have undergone previous transplantations, exhibited lower dialysis vintage, and displayed a greater incidence of DGF and graft loss, but lower incidence of acute rejection episodes. There were no differences in the non-death-censored graft survival at 2 years (log-rank P = .835). The DCD group showed lower cumulative incidences of overall, bacterial, cytomegalovirus (CMV), and non-CMV viral infections (P < .05 for all). Multivariate analysis, associated DCD with a lower risk of overall infection (hazard ratio: 0.41; 95% confidence interval: 0.28-0.60; P = .012), an effect that remained when the analysis was restricted to patients receiving ATG induction therapy. Finally, there were no differences in the cumulative incidence of overall infection when DCD recipients were compared with age-matched DBD controls: 43.7% vs 47.1% respectively (P = .648). CONCLUSION: Despite the higher rate of DGF and the use of ATG-containing sequential therapy, uncontrolled DCD policies were safe in terms of the risk of post-transplant infection.
Assuntos
Infecções/epidemiologia , Transplante de Rim/efeitos adversos , Choque/mortalidade , Doadores de Tecidos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de RiscoRESUMO
INTRODUCTION: Severity of recurrent hepatitis C virus (HCV) infection in liver transplant recipients (LTR) is variable and the influence of different factors, including the administration of antiviral therapy in the long-term outcome is controversial. METHODS: We analyzed the outcome of a cohort of HCV-infected LTR who were transplanted in our institution. Patients were divided into 2 groups (severe and non-severe HCV disease) depending on the presence of a fibrosis score of F ≥ 2 in the Scheuer index and/or fibrosing cholestasic hepatitis (FCH) in a graft biopsy. Risk factors were studied using logistic regression analysis. Survival of patients was estimated using Kaplan-Meier plots. A total of 146 patients were followed for a mean of 58 months. RESULTS: Fifty-six (34%) patients developed severe HCV disease and showed shorter survival (P < 0.024). Donor age (odds ratio [OR]: 1.04; 95% confidence interval [CI]: 1.02-1.06) and pre-transplant viral load (VL) >10(6) UI/mL (OR: 3.5; 95% CI: 1.42-10.61) were the only factors associated with severe HCV infection. Over-immunosuppression (OR: 2.3; 95% CI: 1.2-4.41) was specifically associated with the development of FCH. Overall, patient survival in recipients who received a full course of anti-HCV therapy was higher than in patients who did not complete antiviral therapy (P = 0.004) or received no treatment (P = 0.007). Patients with non-severe HCV infection have a higher probability of receiving a full course of antiviral therapy (P = 0.033). CONCLUSION: In conclusion, donor age, pre-transplant VL, and over-immunosuppression were associated with the long-term development of severe HCV recurrence in liver grafts. Administration of a full course of antiviral therapy was associated with better survival.
Assuntos
Antivirais/uso terapêutico , Hepatite C/tratamento farmacológico , Transplante de Fígado/efeitos adversos , Adulto , Feminino , Hepacivirus/efeitos dos fármacos , Hepatite C/mortalidade , Hepatite C/patologia , Hepatite C/virologia , Humanos , Cirrose Hepática/tratamento farmacológico , Cirrose Hepática/mortalidade , Cirrose Hepática/patologia , Cirrose Hepática/virologia , Masculino , Pessoa de Meia-Idade , Recidiva , Fatores de Risco , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
Limited information exists about epidemiology and risk factors of infection following pancreas-kidney transplantation and its impact on long-term pancreatic graft function. A retrospective chart review of episodes of severe infection in consecutive pancreas-kidney transplantations in a single institution was performed to assess the epidemiology, risk factors for infection and their impact on the development of pancreatic graft dysfunction. Ninety-four (81%) of 116 recipients (median follow-up of 1492 days; mean 1594) developed 248 episodes of severe infection. Bacterial infections were present in 208 episodes, with 12% of the isolates resistant to antibiotics used in prophylaxis. There were 40 episodes of fungal infection in 32 patients (28%) (mostly Candida spp), and CMV disease appeared in 20 patients (17%), of which 50% appeared after the third month following surgery. The multivariate analysis identified that surgical re-intervention and the use of steroid pulses were independently associated with the development of any infection. Additionally, pre-transplant evidence of peripheral artery disease, a longer cold ischaemia time and high transfusional requirements were associated with fungal infections. Cytomegalovirus (CMV) mismatch was independently related to CMV disease and female sex, and bladder drainage of the exocrine pancreas was associated with urinary tract infection. At the end of follow-up, 29 patients (25%) had developed severe pancreatic graft dysfunction, and fungal infection was independently associated with it. Our study identifies a subset of pancreas-kidney transplant recipients at a higher risk of developing severe infection. Fungal infection is an independent risk factor for the development of severe pancreatic graft dysfunction.
Assuntos
Infecções Bacterianas/epidemiologia , Transplante de Rim/efeitos adversos , Micoses/epidemiologia , Transplante de Pâncreas/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Adulto , Infecções Bacterianas/complicações , Infecções Bacterianas/microbiologia , Feminino , Rejeição de Enxerto , Humanos , Imunossupressores/uso terapêutico , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Micoses/complicações , Micoses/microbiologia , Complicações Pós-Operatórias/microbiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
The usefulness of monitoring of complement levels in predicting the occurrence of infection in kidney transplant (KT) recipients remains largely unknown. We prospectively assessed serum complement levels (C3 and C4) at baseline and at months 1 and 6 in 270 patients undergoing KT. Adjusted hazard ratios (aHRs) for infection in each posttransplant period were estimated by Cox regression. The prevalence of C3 hypocomplementemia progressively decreased from 21.5% at baseline to 11.6% at month 6 (p = 0.017), whereas the prevalence of C4 hypocomplementemia rose from 3.7% at baseline to 9.2% at month 1 (p = 0.004). Patients with C3 hypocomplementemia at month 1 had higher incidences of overall (p = 0.002), bacterial (p = 0.004) and fungal infection (p = 0.019) in the intermediate period (months 1-6). On multivariate analysis C3 hypocomplementemia at month 1 emerged as a risk factor for overall (aHR 1.911; p = 0.009) and bacterial infection (aHR 2.130; p = 0.014) during the intermediate period, whereas C3 hypocomplementemia at month 6 predicted the occurrence of bacterial infection (aHR 3.347; p = 0.039) in the late period (>6 month). A simple monitoring strategy of serum C3 levels predicts the risk of posttransplant infectious complications in KT recipients.
Assuntos
Complemento C3/deficiência , Rejeição de Enxerto/etiologia , Infecções/etiologia , Nefropatias/complicações , Transplante de Rim/efeitos adversos , Complicações Pós-Operatórias , Feminino , Rejeição de Enxerto/mortalidade , Sobrevivência de Enxerto , Humanos , Infecções/mortalidade , Nefropatias/cirurgia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida , Centros de Atenção TerciáriaRESUMO
BACKGROUND: The strength of the assumed association of CMV and long term deleterious events in solid organ transplant recipients (SOT) is controversial. OBJECTIVES: The aim of the present study was to evaluate whether viral replication dynamics during CMV infection or CMV disease may correlate not only with graft dysfunction and survival, but also with other potentially related late events in a long-term followed cohort of kidney (KT) and liver (LT) transplant recipients. STUDY DESIGN: 162 SOT (104 kidney, 58 liver) at our institution (2003-2005) with survival over 180 days and a median follow-up of 71 months (9-86) were analyzed. Using a Cox proportional hazard model, CMV infection (including area under the curve of DNAemia[AUC]) and CMV disease in the first 180 days were evaluated as potential predictors of the following late events (>180 days): mortality, graft dysfunction (GD), graft loss (GL), cardiovascular events (CVE), malignant tumors (MT). RESULTS: CMV infection occurred in 59% and CMV disease in 8%. Late death occurred in 17%, GD in 45.6%, GL in 14.2%, CVE in 10.5% and MT in 9.9%. We found no significant association between the intensity or duration of CMV viremia (AUC, persistent viremia or untreated CMV viremia) or CMV disease and the development of evaluated late events. According multivariate analysis neither CMV infection (hazard ratio [HR] 2.18 95% CI 0.949-5 p = 0.066) nor CMV disease (HR: 1.72; 95% CI 0.59-5 p = 0.31) were significantly correlated with late mortality. CONCLUSIONS: Our data do not support that CMV infection or CMV disease contribute significantly to long-term deleterious events in SOT.
Assuntos
Infecções por Citomegalovirus/epidemiologia , Transplante de Rim/mortalidade , Transplante de Fígado/mortalidade , Adulto , Idoso , Área Sob a Curva , Intervalos de Confiança , Citomegalovirus , Feminino , Humanos , Rim/patologia , Fígado/patologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
Antimicrobial stewardship programmes promote excellence in the use of antimicrobials by selecting the appropriate antimicrobial agent and the correct dose, route of administration and duration of treatment. However, there is limited experience with such programmes targeting antifungal treatments. We present the results of a non-compulsory programme for the control of antifungals. For 12 months, prescriptions of oral voriconazole or intravenous voriconazole, caspofungin and liposomal amphotericin B were reviewed, and non-compulsory recommendations were made. The incidence and outcome of fungal infections were examined. The results for the dispensed defined daily doses (DDDs) and expenditure on antifungals were compared with those for the previous 12 months. The number of antifungal treatments reviewed was 662. A recommendation to change treatment was made in 29% of the cases, including a change from intravenous to oral treatment (15%), cessation of antifungal treatment (8%), and a change to fluconazole (6%). The DDDs of intravenous voriconazole and caspofungin were reduced by 31.4% and 20.2%, respectively. The DDDs of oral voriconazole and dispensed vials of liposomal amphotericin B were increased by 8.2% and 13.9%, respectively. Expenditure on antifungals was reduced by US$370681.78 (11.8% reduction). The programme was not related to significant increases in the incidence of candidaemia, percentage of persistent/relapsing candidaemia cases, percentage of fluconazole-resistant Candida species, incidence of infections by filamentous fungi, or 12-month mortality in patients with filamentous fungal infections. In conclusion, a stewardship programme targeting antifungals achieved a reduction in antifungal expenditure without reducing the quality of care provided.