Regular monitoring of cytomegalovirus-specific cell-mediated immunity in intermediate-risk kidney transplant recipients: predictive value of the immediate post-transplant assessment.

OBJECTIVE: Previous studies on monitoring of post-transplant cytomegalovirus (CMV)-specific cell-mediated immunity (CMI) are limited by single-centre designs and disparate risk categories. We aimed to assess the clinical value of a regular monitoring strategy in a large multicentre cohort of intermediate-risk kidney transplant (KT) recipients. METHODS: We recruited 124 CMV-seropositive KT recipients with no T-cell-depleting induction pre-emptively managed at four Spanish institutions. CMV-specific interferon-γ-producing CD4+ and CD8+ T cells were counted through the first post-transplant year by intracellular cytokine staining after stimulation with pp65 and immediate early-1 peptides (mean of six measurements per patient). The primary outcome was the occurrence of any CMV event (asymptomatic infection and/or disease). Optimal cut-off values for CMV-specific T cells were calculated at baseline and day 15. RESULTS: Twelve-month cumulative incidence of CMV infection and/or disease was 47.6%. Patients with pre-transplant CMV-specific CD8+ T-cell count <1.0 cells/µL had greater risk of CMV events (adjusted hazard ratio (aHR) 2.84; p 0.054). When the CMI assessment was performed in the immediate post-transplant period (day 15), the presence of <2.0 CD8+ T cells/µL (aHR 2.18; p 0.034) or <1.0 CD4+ T cells/µL (aHR 2.43; p 0.016) also predicted the subsequent development of a CMV event. In addition, lower counts of CMV-specific CD4+ (but not CD8+) T cells at days 60 and 180 were associated with a higher incidence of late-onset events. CONCLUSIONS: Monitoring for CMV-specific CMI in intermediate-risk KT recipients must be regular to reflect dynamic changes in overall immunosuppression and individual susceptibility. The early assessment at post-transplant day 15 remains particularly informative.

[The early prognostic assessment of heat stroke]. / Evaluación pronóstica precoz del golpe de calor.

We study the clinical characteristics of 21 heat strokes at admittance, to analyze the clinical features in relationship with prognosis. 15 patients (71%) suffered a classical heat stroke and 6 (29%) an active heat stroke. Global mortality was 33%. Sun exposition was more frequent in patients who survived (p less than 0.05), fact that we relate with earlier withdrawal from noxa. Patients with worse prognosis were showing more frequently coma (p less than 0.05); photomotor (p less than 0.01), oculocephalic (p less than 0.01) and corneal (p less than 0.01) reflexes abolition; together with disorders in spontaneous and induced motility of members (p less than 0.05); areflexia (p less than 0.01) and plantar extensor response (p less than 0.05). However the most discriminatory parameter between the two groups was the response to cooling, because the outcome was always fatal when cooling did not take place (p less than 0.01). From the analytical standpoint, serum bicarbonate was lower in the patients who died (p less than 0.05). We insist in the need to start prevention and treatment programs in those communities with high incidence of this syndrome.