Phlebotomy resulting in controlled hypovolaemia to prevent blood loss in major hepatic resections (PRICE-1): a pilot randomized clinical trial for feasibility.

BACKGROUND: Major liver resection is associated with blood loss and transfusion. Observational data suggest that hypovolaemic phlebotomy can reduce these risks. This feasibility RCT compared hypovolaemic phlebotomy with the standard of care, to inform a future multicentre trial. METHODS: Patients undergoing major liver resections were enrolled between June 2016 and January 2018. Randomization was done during surgery and the surgeons were blinded to the group allocation. For hypovolaemic phlebotomy, 7-10 ml per kg whole blood was removed, without intravenous fluid replacement. Co-primary outcomes were feasibility and estimated blood loss (EBL). RESULTS: A total of 62 patients were randomized to hypovolaemic phlebotomy (31) or standard care (31), at a rate of 3·1 patients per month, thus meeting the co-primary feasibility endpoint. The median EBL difference was -111 ml (P = 0·456). Among patients at high risk of transfusion, the median EBL difference was -448 ml (P = 0·069). Secondary feasibility endpoints were met: enrolment, blinding and target phlebotomy (mean(s.d.) 7·6(1·9) ml per kg). Blinded surgeons perceived that parenchymal resection was easier with hypovolaemic phlebotomy than standard care (16 of 31 versus 10 of 31 respectively), and guessed that hypovolaemic phlebotomy was being used with an accuracy of 65 per cent (20 of 31). There was no significant difference in overall complications (10 of 31 versus 15 of 31 patients), major complications or transfusion. Among those at high risk, transfusion was required in two of 15 versus three of nine patients (P = 0·326). CONCLUSION: Endpoints were met successfully, but no difference in EBL was found in this feasibility study. A multicentre trial (PRICE-2) powered to identify a difference in perioperative blood transfusion is justified. Registration number: NCT02548910 ( http://www.clinicaltrials.gov).

ANTECEDENTES: La resección hepática mayor se asocia con pérdida de sangre y necesidad de transfusión. Datos observacionales sugieren que la flebotomía hipovolémica (hypovolaemic phlebotomy, HP) puede reducir estos riesgos. Este ensayo clínico aleatorizado (randomised clinical trial, RCT) de factibilidad comparó HP con el tratamiento estándar con el fin de proporcionar información para un futuro ensayo multicéntrico. MÉTODOS: Se reclutaron pacientes sometidos a resecciones hepáticas mayores entre junio 2016 y enero 2018. La aleatorización se realizó durante el intraoperatorio y los cirujanos eran ciegos al resultado de la asignación. Para la HP, se extrajeron 7-10 mL/kg de sangre total, sin reposición de líquidos intravenosos. Los resultados primarios fueron la factibilidad y la pérdida de sangre estimada (estimated blood loss, EBL). RESULTADOS: Un total de 62 pacientes se aleatorizaron a HP (n = 31) y a tratamiento estándar (n = 31), a un ritmo de 3,1 pacientes/mes, cumpliendo el co-objetivo primario de la factibilidad. La mediana de la diferencia de EBL fue 11 mL (P = 0,46). Entre los pacientes con alto riesgo de transfusión, la mediana de la diferencia de EBL fue 448 mL (P = 0,069). Los objetivos secundarios de factibilidad se consiguieron: reclutamiento (89%), cegamiento (98%), y objetivo de la flebotomía (7,6 ± 1,9 mL/kg). Los cirujanos que fueron cegados percibieron que la resección fue más fácil con la HP (52% versus 32%) y acertaron el uso de HP con una exactitud del 65%. No hubo diferencia significativa en las complicaciones globales (32% versus 48%), complicaciones mayores y transfusión. Entre aquellos pacientes de alto riesgo, la trasfusión se realizó en un 13% versus 33% (P = 0,33). CONCLUSIÓN: Se cumplieron los objetivos, pero no se identificó diferencia en EBL en este estudio de factibilidad. Ello justifica un ensayo multicéntrico (PRICE-2) con poder estadístico para identificar una diferencia en la transfusión de sangre perioperatoria.

Validation study of a transcutaneous carbon dioxide monitor in patients in the emergency department.

BACKGROUND: Transcutaneous carbon dioxide tension (TcPco(2)) monitors offer a non-invasive method of continuously measuring arterial carbon dioxide tensions. The concordance between the TcPco(2) measurement and the value obtained from arterial blood gas sampling (Paco(2)) was measured in patients attending the emergency department. METHODS: A prospective observational cohort study was performed in 49 adult patients who were undergoing arterial blood gas sampling as part of their assessment. Blood gas sampling and recording of the TcPco(2) level from the monitor was done simultaneously. Concordance between the two values (Paco(2) and TcPco(2)) was demonstrated using the method described by Bland and Altman. RESULTS: The mean difference was 0.02 kPa (95% CI -0.11 to 0.15). The Pearson's correlation coefficient was 0.94 (p<0.001) and the Bland-Altman limits of agreement were +/-0.9 kPa. CONCLUSIONS: In adult patients, concordance between carbon dioxide measurements by transcutaneous monitor and arterial blood sampling is good. Using the transcutaneous method, patients may be monitored non-invasively which may reduce the need for repeated blood gas sampling.

Predictive value of pretransplant inflammatory markers in renal allograft survival and rejection in children.

Pretransplant (pre-Tx) inflammation has been associated with acute rejection (AR) in adult Tx recipients. Our study was performed to determine whether a single pre-Tx serum C-reactive protein (CRP), Neopterin (Neo), and IL-12 determination could predict outcome in pediatric renal Tx recipients. Pre-Tx sera from 51 children transplanted between 1985 and 2000 were analyzed for serum CRP, Neo, and IL-12 for correlation with Tx-related variables. Endpoints were graft loss and AR. Kaplan-Meier and log-rank statistics were used to compare rejection-free and overall graft survival at different quartiles for each marker. Cox regression analysis was performed to determine the independent effects of various pre-Tx variables on the endpoints. The mean age of the children at Tx was 11 years. The mean CRP, Neo, and IL-12 were 1.3 mg/L, 1.78 ng/mL and 123 pg/mL, respectively. At last-follow-up (mean 4.9 years after Tx), 50% of the children had experienced AR and 29% had lost their grafts. The mean CRP, Neo, and IL-12 were not different between the patients with versus without AR or graft loss (P > .4 for all). Neither rejection-free survival nor graft survival was affected by CRP, Neo, or IL-12 quartiles (log-rank test). Cox regression analysis demonstrated no predictive value of any marker on the outcomes. Unlike adults, a single pre-Tx determination of inflammatory markers was not predictive of AR or graft loss in children. The pathogenesis of AR may be different in children with a lesser contribution of alloantigen-independent factors such as chronic infections.

First-pass metabolism of midazolam by the human intestine.

The in vivo intestinal metabolism of the CYP3A probe midazolam to its principal metabolite, 1'-hydroxymidazolam, was investigated during surgery in 10 liver transplant recipients. After removal of the diseased liver, five subjects received 2 mg midazolam intraduodenally, and the other five received 1 mg midazolam intravenously. Simultaneous arterial and hepatic portal venous blood samples were collected during the anhepatic phase; collection of arterial samples continued after reperfusion of the donor liver. Midazolam, 1'-hydroxymidazolam, and 1'-hydroxymidazolam glucuronide were measured in plasma. A mass balance approach that considered the net change in midazolam (intravenously) or midazolam and 1'-hydroxymidazolam (intraduodenally) concentrations across the splanchnic vascular bed during the anhepatic phase was used to quantitate the intestinal extraction of midazolam after each route of administration. For the intraduodenal group, the mean fraction of the absorbed midazolam dose that was metabolized on transit through the intestinal mucosa was 0.43 +/- 0.18. For the intravenous group, the mean fraction of midazolam extracted from arterial blood and metabolized during each passage through the splanchnic vascular bed was 0.08 +/- 0.11. Although there was significant intersubject variability, the mean intravenous and intraduodenal extraction fractions were statistically different (p = 0.009). Collectively, these results show that the small intestine contributes significantly to the first-pass oxidative metabolism of midazolam catalyzed by mucosal CYP3A4 and suggest that significant first-pass metabolism may be a general phenomenon for all high-turnover CYP3A4 substrates.

Renal disease in hepatitis C-positive liver transplant recipients.

Glomerular abnormalities are frequent in patients undergoing liver transplantation; however, renal dysfunction following transplantation is mainly attributed to cyclosporine toxicity. Membranoproliferative glomerulonephritis (MPGN) is seen in patients infected with hepatitis C virus (HCV), the virus responsible for 30% of the end-stage liver disease leading to liver transplantation. To determine the incidence of renal abnormalities in liver transplant recipients and the association with HCV, we undertook a longitudinal study in HCV-positive (n=91) and HCV-negative (n=106) liver transplant recipients. Mean creatinine clearance before transplantation was 94 ml/min/1.73 m2 in HCV+ patients and 88 ml/min/1.73 m2 in HCV- patients. By 3 months after transplantation, the mean creatinine clearance decreased by approximately one third in both groups. A greater proportion of HCV+ patients excreted >2 g protein/day after transplantation (P=0.05) and had renal biopsies showing MPGN than did HCV- recipients (4/10 HCV+ patients vs. 0/7 HCV- patients; P=0.1). In the HCV+ group, proteinuria was not associated with recurrent HCV hepatitis, DQ matching, posttransplant diabetes, or hypertension. Treatment of HCV-related MPGN with interferon-alpha2b appeared to stabilize proteinuria and renal function but did not reverse renal dysfunction nor cause liver allograft rejection. After transplantation, HCV+ patients had similar renal function over 3 years after transplantation, compared with HCV- patients, but they had an increased risk of proteinuria and occurrence of MPGN that was only partially responsive to interferon.

Pretransplant systemic inflammation and acute rejection after renal transplantation.

BACKGROUND: There are presently no established pre-transplant tests that consistently identify patients who may be at increased risk for acute rejection episodes after renal transplantation. We studied whether pretransplant serum levels of C-reactive protein (CRP), a marker for the presence of systemic inflammation, would predict the occurrence of acute rejection episodes after renal transplantation. METHODS: Pretransplant serum was tested for CRP level in 97 consecutive renal transplant recipients. Time to acute rejection after transplantation was stratified by CRP level and compared using the Kaplan-Meier method. In addition, Cox regression multivariate analysis was performed to assess whether any pretransplant covariates could independently predict the subsequent occurrence of acute rejection episodes. RESULTS: Pretransplant mean CRP levels were higher in patients who subsequently had a rejection episode versus those who had no rejection (22.2+/-2.9 vs. 11.7+/-1.8 microg/ml, respectively, P=0.003). Patients less than the median CRP value had a significantly longer time to rejection compared to those with higher CRP levels (P=0.002). Similarly, patients within the lowest CRP quartile had longer times to rejection when compared with the highest quartile (P=0.006). Cox proportional hazards regression multivariate analysis identified CRP level as the only independent pretransplant risk factor for rejection identified (P=0.044). CONCLUSIONS: Pretransplant systemic inflammation as manifested by elevated serum CRP level independently predicts the risk of acute rejection after renal transplantation and may be useful in stratifying patients at the time of transplantation according to immunological risk. Thus, assessment of pretransplant systemic inflammatory status may be helpful in prospective individualization of immunosuppression therapy after renal transplantation.

Recombinant human tumor necrosis factor receptor Fc fusion protein therapy in kidney transplant recipients undergoing OKT3 induction therapy.

BACKGROUND: Initial doses of OKT3 are associated with a cytokine-induced acute clinical syndrome (ACS). This study assessed the safety of a recombinant human tumor necrosis factor receptor fusion protein (TNFR:Fc) given to minimize OKT3-ACS symptoms in renal allograft recipients undergoing induction therapy. METHODS: Sixteen patients were randomized into treatment or control groups. Treated patients received TNFR:Fc 1 hr before OKT3 on days 0 and 3. Patients were monitored after transplant for OKT3-ACS symptoms. Levels of cytokines, serum creatinine, and C-reactive protein were followed. RESULTS: Patients receiving TNFR:Fc had lower OKT3-ACS symptoms as measured by a scoring system. There was a higher incidence of infection in treated patients (10/12) compared to controls (1/4) in the 3 months after transplant, but the etiology of this difference was unclear. There were no significant differences in cytokine profiles. CONCLUSIONS: TNFR:Fc is well tolerated by renal transplant patients receiving OKT3 induction therapy and modestly decreases the symptoms associated with OKT3-ACS.

Increased transplantation of kidneys with multiple renal arteries in the laparoscopic live donor nephrectomy era: surgical technique and surgical and nonsurgical donor and recipient outcomes.

BACKGROUND: For anatomical and technical reasons, many transplant centers restrict laparoscopic live donor nephrectomy (in contrast with open live donor nephrectomy) to left kidneys. HYPOTHESIS: This change in surgical practice increases procurement and transplantation rates of live donor kidneys with multiple renal arteries (RAs), without affecting donor and recipient outcomes. DESIGN AND SETTING: Retrospective review at an academic tertiary care referral center comparing laparoscopically procured single vs multiple-RA kidney grafts (April 1997 to October 2000). PATIENTS: Seventy-nine consecutive left laparoscopic live kidney donors and 78 transplant recipients. MAIN OUTCOME MEASURES: Donor and recipient complications and postoperative length of stay; cold and warm ischemia time; operating time; short-term and long-term graft function; and survival. RESULTS: We noted multiple RAs in 21 (27%) of all kidneys. The proportion of donors with 1 or more perioperative complications was 19% in the single-RA group vs 10% in the multiple-RA group (P was not significant). For the recipients, we noted no significant differences between groups with respect to surgical complications, quality of early and late graft function, rejection rates, graft losses (all immunologic), and graft survival. Cold and warm ischemia time and length of stay were similar for donors and recipients in both groups. Median operating times were significantly longer for the multiple-RA vs single-RA group (difference, 41 minutes for donors and 45 minutes for recipients; P<.02). CONCLUSIONS: While the introduction of laparoscopic live donor nephrectomy has significantly increased the number of grafts with multiple RAs (compared with historical open controls), this change in practice is safe for both donors and recipients from a patient outcome-based perspective. However, from an economic perspective, the longer operating time associated with multiple-RA grafts provides strong added rationale for optimization of surgical instruments and techniques to make right-sided laparoscopic nephrectomy a routine intervention.

Management of spinal cord injury in the critical care setting.

Approximately 12,000 Americans suffer traumatic spinal cord injuries each year. This article discusses the management of their neurologic, respiratory, cardiovascular, gastroenterologic, and genitourinary complications in the critical care setting.

Improved results with combined donor-specific transfusion (DST) and sequential therapy protocol.

A combined DST-sequential CyA therapy protocol has been described that results in optimum graft survival for 1- and 2-haplotype mismatched living related donor-recipient combinations. In addition to the excellent graft survival obtained through 4 years, lower prednisone and CyA dosage levels are achieved with significantly decreased infection rates during the posttransplant period.

Embryo transfer as a means of controlling the transmission of viral infections. VII. The in vitro exposure of bovine and porcine embryos to foot-and-mouth disease virus.

When 169 zona pellucida-intact bovine embryos were exposed to 10(6) pfu/ml of foot-and-mouth disease virus and then washed, no infectious virus was detected on any of the embryos. FMD viral infectivity was found, however, in association with 14 of 42 hatched (zona pellucida-free) bovine embryos and in a small number of zona pellucida-intact porcine embryos. The porcine embryos were assayed individually and in groups of 8 embryos. Four of the 124 individual embryos and 2 of the 9 groups of embryos carried the infectious virus.

Embryo transfer as a means of controlling the transmission of viral infections. VIII. Failure to detect foot-and-mouth disease viral infectivity associated with embryos collected from infected donor cattle.

Foot-and-mouth disease (FMD) viral infectivity detectable in cell cultures or by animal inoculation was not found to be associated with any of 48 washed zona pellucida-intact (ZPI) embryos collected from 8 cattle during the acute stages of disease. Similarly, infectivity was not found to be associated with any of 42 washed ZPI embryos collected from 3 cattle 21 d after infection with FMD.

Quantitative aspects of the transmission of African swine fever.

The contagiousness of pigs during different stages of infection with African swine fever virus was assessed by measuring the amount of virus excreted and the amounts of virus in the blood and other tissues, as well as determining the infectious dose of the virus by various routes. The virus was present in substantial amounts in secretions and excretions of acutely infected pigs for only 7 to 10 days after the onset of fever and was present in the greatest amount in the feces. Virus persisted in the blood of some recovered and clinically normal pigs for 8 weeks and in the lymphoid tissues for at least 12 weeks. The intranasal/oral ID50, and the IV/IM ID50 of a moderately virulent isolate of African swine fever virus were determined to be 18,500 and 0.13, 50% headsorbing units, respectively. A highly virulent isolate required approximately 10-fold more virus to cause infection by the intranasal/oral route.

African swine fever convalescent sows: subsequent pregnancy and the effect of colostral antibody on challenge inoculation of their pigs.

The effect of African swine fever (ASF) virus infection on reproductive performance of recovered sows and their pigs was investigated. Six sows were inoculated with a 1979 ASF isolate from the Dominican Republic. One sow was bred on postinoculation day (PID) 58 and killed on PID 148. Four sows were bred between PID 368 and 419 and were allowed to farrow. One sow did not conceive. Samples collected during pregnancy, at farrowing, and during lactation were tested for virus by tissue culture and animal inoculations to determine whether ASF virus recrudesced during these natural stresses. Virus was recovered only from tissues of the sow killed on PID 148. Virus was not detected in tissue samples from the 4 other sows or from any fetus or neonate. Sow and neonatal pig sera, colostral whey, and milk whey were assayed for antibodies against ASF viral antigens, using an enzyme-linked immunosorbent assay. Antibody values in sows' sera did not change appreciably during pregnancy, farrowing, or lactation. One litter of pigs was raised with their sow. Weekly serum samples were tested for passively acquired antibodies. At 7 weeks of age, the litter was challenge inoculated with the same virus as that used initially to infect their dam. Viremia titers, duration of viremias, and clinical course were reduced. One young pig did not develop fever, viremia, clinical disease, or antibody response to virus challenge exposure. The altered course of infection was attributed to protective effect of passively acquired antibodies.

African swine fever in neonatal pigs: passively acquired protection from colostrum or serum of recovered pigs.

The effect of passively acquired antibodies on the course of African swine fever (ASF) virus infection was investigated in hysterotomy-derived neonatal pigs fed colostrum from an ASF-recovered sow or given ASF virus antiserum. Thirty neonatal pigs were assigned to 5 study groups: (i) colostrum-deprived, (ii) fed colostrum from a normal sow, (iii) fed colostrum from an ASF-recovered sow, (iv) given ASF virus antiserum, and (v) noninoculated controls. Pigs were inoculated oronasally with 10(6.1) median hemadsorption units (HAd50) of a Dominican Republic ASF virus isolate. The progression of ASF infection was monitored by measure of rectal temperature, viremia titers, antibody response, and observation of attitude. The clinical course of ASF infection was markedly different in young pigs in the various study groups. On postinoculation day (PID) 4, ASF viremia titers for pigs receiving colostrum from an ASF-recovered sow or ASF virus antiserum (mean = 3.2 +/- 1.88 log10 HAd50, n = 10 pigs) were significantly lower (P < 0.001) than viremia titers of colostrum-deprived pigs or of those fed normal colostrum (mean viremia titer = 7.8 +/- 0.55 log10 HAd50, n = 14 pigs). All pigs not given colostrum or serum (n = 15 pigs) from swine recovered from ASF were dead by PID 16. By PID 30, only 1 pig that received colostrum or antiserum (n = 10 pigs) from the sow recovered from ASF had died. To determine whether the protective effect of ASF antiserum resided within the immunoglobulin (Ig) fraction, 4 pigs that had acted as noninoculated controls for the 1st experiment were given 125 mg of ammonium sulfate precipitated Ig from the ASF virus antiserum used in the initial study (intraperitoneally). The 5th pig was not given Ig (nontreated-inoculated control). All 5 pigs were inoculated oronasally with 10(6.1) HAd50 of Dominican Republic ASF virus. The nontreated control pig died on PID 10 and 3 Ig-treated pigs died on PID 17, 23, and 24. The 4th Ig-treated pig survived. Although administration of precipitated ASF Ig did not completely protect against clinical ASF infection or death, the course of infection was markedly altered.

Induced African swine fever in feral pigs.

Feral pigs trapped in Florida were exposed by intranasal/oral inoculation or contact to African swine fever virus isolants from the Iberian peninsula and the Dominican Republic. All exposed pigs became sick and died or were killed after becoming moribund. Necropsy revealed lesions typical of African swine fever, but several pigs had marked hemorrhage surrounding the kidneys or rectum or in the gastric, hepatic, or ventral abdominal region that, in the field, might have suggested trauma or poisoning as a cause of death. Most pigs had severe lesions associated with kidney worms. Virus was detected in the blood and selected tissues of each pig, using the hemadsorption reaction in porcine monocyte cultures; direct or indirect immunofluorescence was used to confirm the diagnosis.