Maternal obesity and perinatal oxidative stress: the strength of the association.

Maternal obesity is a chronic inflammatory state, which has been shown to induce increased levels of free fatty acids, reactive oxygen species and inflammatory cells. Recent evidence reveals increased levels of lipid peroxidation products in the plasma of obese women during pregnancy. The aim of this study was to test the hypothesis that maternal overweight or obesity is associated with increased oxidative stress (OS) in offspring. Two hundred and forty-five pregnant women and their newborns were prospectively enrolled. Mothers were divided in two groups: lean control - LC (n=175, Group I); overweight or obese (n=70, Group II) according to BMI ≥ 25 before pregnancy. Cord blood F2-isoprostanes (F2-IsoPs), as reliable markers of OS, were measured in all newborns. Lower 1 minute APGAR score and higher weight at discharge were found in Group II neonates, compared to those of Group I (p less than 0.05). Small for gestational age (SGA) newborns of both groups showed increased levels of F2-IsoPs than appropriate (AGA) or large (LGA) for gestational age (GA) (p less than 0.01). SGA newborns of Group II had higher F2-IsoPs levels compared to SGA of Group I (p less than 0.01), which were significantly correlated to maternal BMI at the end of pregnancy (r=0.451, p less than 0.01). Multivariate regression analysis corrected for confounding factors, showed that maternal overweight or obesity was significantly associated with high F2-IsoPs levels in SGA offspring (p less than 0.01). Maternal overweight or obesity is associated with increased OS in their SGA newborns. Data suggest the need of antioxidant protection for both mothers during pregnancy and infants soon after birth.

Neonatal oxidative stress depends on oxygen blood pressure in umbilical artery.

With advancing gestation, partial pressure of oxygen (pO2) and pH fall significantly. Hypoxia is a main factor inducing free radical generation and thereby oxidative stress (OS). Placental and fetal tissue response when oxygen becomes restricted is complex and partially known. We tested the hypothesis that changes in umbilical artery and vein blood gas concentrations modulate OS occurrence in the newborn. Seventy umbilical artery and vein plasma samples were collected from healthy term newborns immediately after delivery. F2 Isoprostanes (F2-Isop) were measured in all samples as reliable markers of lipid peroxidation. Significantly lower pCO2 and higher pO2 and pH were found in umbilical vein than in artery, as expected. A positive correlation was detected between pH and pO2 only in umbilical artery (p=0.019). F2-Isop levels were no different between artery and vein in cord blood. Significant correlations were found between F2-Isop and pCO2 (p=0.025) as well as between F2-Isop and pH in umbilical vein (p=0.027). F2-Isop correlated with pCO2 (p=0.007) as well as with pO2 values (p=0.005) in umbilical artery blood. Oxidative stress (OS) in newborns depends on oxygen concentrations in umbilical artery. OS biomarkers significantly correlate with pO2 and in umbilical artery but not in umbilical vein. In normoxic conditions fetal-maternal gas exchanges occurring in placenta re-establish normal higher oxygen levels in umbilical vein than artery, with a normal production of free radicals without any deleterious effects.

Resuscitating preterm infants with 100% oxygen is associated with higher oxidative stress than room air.

AIM: The starting fraction of inspired oxygen for preterm resuscitation is a matter of debate, and the use of room air in full-term asphyxiated infants reduces oxidative stress. This study compared oxidative stress in preterm infants randomised for resuscitation with either 100% oxygen or room air titrated to internationally recommended levels of preductal oxygen saturations. METHODS: Blood was collected at birth, two and 12 hours of age from 119 infants <32 weeks of gestation randomised to resuscitation with either 100% oxygen (n = 60) or room air (n = 59). Oxidative stress markers, including advanced oxidative protein products (AOPP) and isoprostanes (IsoP), were measured with high-performance liquid chromatography and mass spectrometry. RESULTS: Significantly higher levels of AOPP were found at 12 hours in the 100% oxygen group (p < 0.05). Increases between two- and 12-hour AOPP (p = 0.004) and IsoP (p = 0.032) concentrations were significantly higher in the 100% oxygen group. CONCLUSION: Initial resuscitation with room air versus 100% oxygen was associated with lower protein oxidation at 12 hour and a lower magnitude of increase in AOPP and IsoP levels between two and 12 hours of life. Correlations with clinical outcomes will be vital to optimise the use of oxygen in preterm resuscitation.

Strongyloides stercoralis infection in allogeneic stem cell transplant: a case report and review of the literature.

Strongyloides stercoralis infections may be documented in low-endemicity areas, particularly in immigrants from endemic areas. The case of a patient from Bangladesh, an immigrant to Italy who developed a S. stercoralis infection after allogeneic stem cell transplant, is described, and 7 further cases are reviewed. Because of the atypical clinical presentation, the low predictive role of the eosinophil count, and the low sensitivity of the microbiological tests, diagnosis of strongyloidiasis is a challenging problem. When a case of S. stercoralis infection is suspected, previous exposure may be the only clue to guide the diagnostic approach.

[Delivery induction with slow-release dinoprostone in clinical practice: results of a clinical protocol]. / L'induzione del parto con prostaglandine a lento rilascio nella pratica clinica: risultati di un protocollo clinico.

AIM: The aim of this paper was to evaluate the feasibility of a protocol for the induction of delivery with slow-release dinoprostone in women with unfavourable cervix. METHODS: Indications for the induction were: pregnancy beyond 40 weeks, amniotic fluid index (AFI) <5, premature rupture of membranes, intrauterine growth retardation, or adverse maternal conditions. Eligibility criteria were: single pregnancy, cephalic presentation, Bishop Score <4, no previous uterine scar. Slow-release vaginal insert containing dinoprostone 10 mg was used to induce delivery according to a dedicated protocol agreed between clinicians and midwifes. Dinoprostone induction failure was defined as no cervical dilation >3 cm at the removal of the insert. RESULTS: One-hundred-nineteen patients were enrolled. The onset of labour was obtained in 102 (85.7%) patients, 98 (82.3%) with the insert only, and in 4 (3.3%) after the sequential administration of prostaglandins and oxitocin. The mean interval between insert application and delivery was 16.85±11.48 hours. Vaginal delivery was reported in 87 (73.1%) women, whereas Cesarean was necessary in 32 (26.9%) patients [29 nulliparous]. Cesarean section was also required in 15/98 (15.3%) women who responded to prostaglandins and in 17/21 (80.9) non-responders. Protocol violations occurred in 11 (9.2%) patients. Uterine hyperstimulation occurred in 4 (3.3%) patients. CONCLUSION: Induction of delivery with slow-release dinoprostone seems a feasible option, characterized by high efficacy, good adherence to protocol, low incidence of adverse events and easy management. In our opinion the high compliance of the gynecologists and midwifes is based on the insert handiness.

[Fetal and neonatal outcomes in infants of mothers with TSH receptor antibody positivity in pregnancy]. / Esiti feto-neonatali nei figli di madri con positivita' degli anticorpi anti-recettore del tsh in gravidanza.

OBJECTIVES: To know the mother's frequency with TRAb (TSH receptor antibodies) positivity during pregnancy in the population afferent to Agostino Gemelli Hospital in the five years 2002-2007 and the itself antibodies's role determining fetal and neonatal symptoms. MATERIALS AND METHODS: We performed a prospective analysis with maternal and neonatal variables detection in 16 couples mother-newborn with TRAb positivity during the pregnancy. The method to dose neonatal TRAb is ELISA (enzyme linked immunosorbant assay). RESULTS: The prevalence of newborns of mothers with TRAb positivity during pregancy results 0.1 per thousand (16/16783). The prevalence of neonatal hyperthyroidism, clinical and biochemical, in the studied population results especially elevated equal to about 30% (5/16). The 5 newborns are born to mothers with Basedow disease with TRAb serum levels greater than TRAb levels of newborn without hyperthyroidism: 2 are showed the symptoms of clinical hyperthyroidism and 3 a transient biochemical hyperthirodism. 3 newborns with hyperthyroidism among 5 are born to mother undergo thyroidectomy with L-tiroxina teraphy during the pregnancy. Then the newborns of thyroidectomized mothers also many years before the pregnancy must be considered high risk of developing neonatal hyperthyroidism because of long-lasting persistence of mother's TRAb. The neonatal hyperthyroidism, clinical and biochemical, appears later in newborns of mothers using antithyroid drugs. The pharmacological treatment of neonatal hyperthyroidism was difficult to standardize and highly individualized. CONCLUSIONS: Although the neonatal hyperthyroidism is a very rare disease it is essential to apply specific protocol assistance, both during pregnancy and the neonatal period, in the presence of maternal TRAb positive for the risk of serious cardiovascular complications.

Early oxidative stress in amniotic fluid of pregnancies with Down syndrome.

OBJECTIVE: Some evidence suggests that oxidative stress, due to an imbalance between oxidants and antioxidants, occurs in babies with Down syndrome (DS). This study tests the hypothesis that oxidative stress occurs early in DS pregnancies. DESIGN AND METHODS: Isoprostanes (IPs), a new marker of free radical-catalyzed lipid peroxidation, were measured in amniotic fluid from pregnancies with normal, growth restricted and DS fetuses, diagnosed by karyotype analysis of amniotic cells cultured. RESULTS: A nine-fold increase in IP concentrations was found in amniotic fluid of pregnancies with DS fetuses. This increase (595.15; 542.96-631.64 pg/ml, median; 95% CI), was greater than in pregnancies with fetal growth-restricted fetuses (155; 130.57-172.23 pg/ml, median; 95% CI) and normal fetuses (67; 49.82-98.38 pg/ml, median; 95% CI; p<0.0001). CONCLUSIONS: The study reveals that oxidative stress occurs early in pregnancy and supports the idea of testing whether prenatal antioxidant therapy may prevent or delay the onset of oxidative stress diseases in the DS population.

Is prenatal bonding enhanced by prenatal education courses?

AIM: Prenatal education courses (PEC) are a way of allaying anxiety in pregnancy. PEC consist of a series of five 1-hour lessons in the first and second trimesters of pregnancy. Conducted by nurses or midwives, the course syllabus includes the basics of fetal physiology and development, singing sessions, dance sessions, massage-through-the-womb sessions. Here we investigated whether they can enhance feto-maternal bonding. METHODS: We studied 77 pregnant women (mean age: 31.5+/-4.1 years), 36 of whom attended PEC. We used the Prenatal Attachment Inventory (PAI), a validated 21-item questionnaire, to score prenatal bonding and compared the scores of the two groups. Three months after delivery, we asked the mothers to fill in another questionnaire to assess infant and maternal well-being. RESULTS: The PEC group showed a higher PAI score than the control group (65.5+/-6.9 vs. 59.9+/-6.1; P<0.05). Babies born to the PEC group had a higher frequency of unexplained crying. CONCLUSION: PEC positively influenced prenatal attachment. More studies are needed to assess whether this may be useful for the development of the mother-infant relationship.

Oxidative Stress as a Physiological Pain Response in Full-Term Newborns.

This research paper aims to investigate if oxidative stress biomarkers increase after a painful procedure in term newborns and if nonpharmacological approaches, or sex, influence pain degree, and the subsequent OS. 83 healthy term newborns were enrolled to receive 10% oral glucose or sensorial saturation (SS) for analgesia during heel prick (HP). The ABC scale was used to score the pain. Advanced oxidation protein products (AOPP) and total hydroperoxides (TH) as biomarkers of OS were measured at the beginning (early-sample) and at the end (late-sample) of HP. The early-sample/late-sample ratio for AOPP and TH was used to evaluate the increase in OS biomarkers after HP. Higher levels of both AOPP and TH ratio were observed in high degree pain (4-6) compared with low degree pain score (0-3) (AOPP: p = 0.049; TH: p = 0.001). Newborns receiving SS showed a significantly lower pain score (p = 0.000) and AOPP ratio levels (p = 0.021) than those without. Males showed higher TH levels at the end of HP (p = 0.005) compared to females. The current study demonstrates that a relationship between pain degree and OS exists in healthy full-term newborns. The amount of OS is gender related, being higher in males. SS reduces pain score together with pain-related OS in the newborns.

Recommendations for use of everolimus after heart transplantation: results from a Latin-American Consensus Meeting.

Despite improvements during the last decades, heart transplantation remains associated with several medical complications, which limit clinical outcomes: acute rejection with hemodynamic compromise, cytomegalovirus (CMV) infections, allograft vasculopathy, chronic renal failure, and neoplasias. Everolimus, a proliferation signal inhibitor, represents a new option for adjunctive immunosuppressive therapy. Everolimus displays better efficacy in de novo heart transplant patients than azathioprine for prophylaxis of biopsy-proven acute rejection episodes of at least ISHLT grade 3A (P < .001), of allograft vasculopathy (P < .01), and of CMV infections (P < .01). These findings suggest that everolimus potentially play an important role as part of immunosuppressive therapy in heart transplant recipients. Heart transplant investigators from Latin America produced recommendations for everolimus use in daily practice based on available data and their own experience.

Neonatal pain analyzer: development and validation.

We developed a pain analyzer (ABC analyzer) to perform automatic acoustic analysis of neonatal crying and to provide an objective estimate of neonatal pain. The ABC analyzer uses a validated pain scale (ABC scale) based on three acoustic parameters: pitch frequency, normalized RMS amplitude, and presence of a characteristic frequency- and amplitude-modulated crying feature, defined as "siren cry". Here we assessed the reliability of the analyzer. We enrolled 57 healthy neonates. Each baby was recorded with a video camera during heel prick. Pain intensity was evaluated using a validated scale [Douleur Aigue du Nouveau-Né (DAN) scale] and the analyzer and the two scores were compared. We found a statistically significant concordance between the DAN score and ABC analyzer score (p < 0.0001). The ABC analyser is a novel approach to cry analysis that should now have its properties carefully evaluated in a series of studies, just as is necessary in the development of any other pain measurement tool.

Heart rate is a marker of amiodarone mortality reduction in severe heart failure. The GESICA-GEMA Investigators. Grupo de Estudio de la Sobrevida en la Insuficiencia Cardiaca en Argentina-Grupo de Estudios Multicéntricos en Argentina.

OBJECTIVES: The impact of amiodarone on mortality in patients with severe congestive heart failure (CHF) (New York Heart Association functional classes II [advanced], III and IV; left ventricular ejection fraction < 35%) In the Grupo de Estudio de la Sobrevida en la Insuficiencia Cardiaca en Argentina (GESICA) trial was analyzed in relation to initial mean baseline heart rate (BHR) and its change after 6 months of follow-up. BACKGROUND: Trials of amiodarone therapy in CHF have produced discordant results, suggesting that the effect is not uniform in all patient subgroups with regard to survival. METHODS: The present analysis was carried out in 516 patients randomized to receive amiodarone, 300 mg/day (n = 260), or nonantiarrhythmic therapy (n = 256, control group) and followed up for 2 years. Survival was evaluated for patients with a BHR > or = 90 beats/min (control: n = 132; amiodarone: n = 122) and < 90 beats/min (control: n = 124; amiodarone: n = 138). Survival was also analyzed according to heart rate reduction at 6 months for 367 patients. RESULTS: For patients with a BHR > or = 90 beats/min, amiodarone therapy reduced mortality to 38.4% compared with 62.4% in control patients (relative risk [RR] 0.55, 95% confidence interval [CI] 0.35 to 0.95, p < 0.002). Both sudden death (RR 0.46, 95% CI 0.24 to 0.90, p < 0.02) and progressive heart failure death (RR 0.60, 95% CI 0.30 to 1.03, p < 0.06) were reduced, and functional capacity was improved. In patients with a BHR < 90 beats/min, amiodarone did not alter survival. Among 367 patients who completed 6 months of follow-up, amiodarone reduced 2-year mortality only in those with a BHR > or = 90 beats/min, which was reduced at 6 months. CONCLUSIONS: Elevated rest heart rates in severe CHF identify a subgroup of patients who benefit from treatment with amiodarone. Amiodarone-induced heart rate slowing may be an important benefit for patients.

Amrinone stimulation test: ability to predict improvement in left ventricular ejection fraction after coronary bypass surgery in patients with poor baseline left ventricular function.

OBJECTIVES: This study sought to determine whether the response to amrinone in patients with severe baseline left ventricular dysfunction can predict improvement in left ventricular ejection fraction after coronary artery bypass graft surgery. BACKGROUND: Previous studies have suggested that the inotropic response to dobutamine can identify viable myocardium in the setting of chronic coronary disease and left ventricular dysfunction. However, increased oxygen demand stimulated by dobutamine can lead to superimposition of ischemia on the hibernating state, potentially confounding interpretation of results. Amrinone is an inotropic agent that does not critically augment myocardial oxygen demand and may be useful for identification of hibernating myocardium in the chronically ischemic state. METHODS: Forty-four consecutive patients with coronary artery disease and left ventricular ejection fraction < 40% referred for coronary artery bypass graft surgery underwent amrinone stimulation (1 mg/kg body weight). Left ventricular ejection fraction was determined before amrinone stimulation, 20 min after infusion and 21 days after bypass surgery. RESULTS: Baseline ejection fraction was 28 +/- 7% (mean +/- SD). Ejection fraction increased to 35 +/- 5% after amrinone stimulation (p < 0.0001) and to 33 +/- 6% after bypass surgery (p < 0.0001). Postbypass ejection fraction was significantly correlated with postamrinone ejection fraction (r = 0.65, p < 0.0001). Furthermore, the change in ejection fraction from baseline to after bypass surgery was highly correlated with the change in ejection fraction after amrinone stimulation (r = 0.75, p < 0.0001). Of 13 patients with an increase in ejection fraction > or = 10% after amrinone, all 13 had an increase of at least 8% and 11 (85%) of 13 had an increase > or = 10% after bypass surgery. In contrast, of 31 patients with an increase in ejection fraction < 10% after amrinone, only 2 (6%) had an increase > or = 10% (p < 0.0001) and 28 (90%) of 31 had an increase < 5% after bypass surgery. CONCLUSIONS: Augmentation of myocardial contraction by amrinone in patients with chronic coronary artery disease and severe baseline left ventricular dysfunction predicts improvement in left ventricular ejection fraction after coronary artery bypass graft surgery.

Non protein bound iron concentrations in amniotic fluid.

OBJECTIVES: To investigate whether amniotic fluid concentrations of non protein bound iron (NPBI) vary with growth in healthy fetuses and also offer a reference curve in the second trimester of pregnancy. DESIGN AND METHODS: Amniotic fluid concentrations of NPBI were measured by HPLC in 118 women with physiological singleton pregnancies, who underwent amniocentesis for fetal karyotype between weeks 15 and 18 of gestation. RESULTS: NPBI increased progressively from weeks 14--15 to weeks 15--16, peaking at 17--18 weeks of gestation. NPBI values regressed positively with gestational age (GA). Multiple linear regression analysis between NPBI, as dependent variable, and various fetal parameters, as independent variables, showed a statistically significant regression coefficient with GA, bi-parietal diameter and transverse cerebellar diameter. CONCLUSIONS: The present data constitutes the first quantification of NPBI concentrations in amniotic fluid under physiological conditions. Correlations with GA and ultrasound fetal biometry suggest that NPBI may play a role in fetal growth.

Nucleated red blood cell count in term and preterm newborns: reference values at birth.

The prognostic value of nucleated red blood cell count at birth in relation to neonatal outcome has been established. However, reference values were needed to usefully interpret this variable. The normal range of reference values for absolute nucleated red blood cell count in 695 preterm and term newborns is reported.

Cesarean 10-group classification: a tool for clinical management of the delivery ward.

AIM: Aim of the present study was to evaluate 10-group Robson classification for delivery ward clinical management. METHODS: To evaluate cesarean section (C-section) rate following the implementation firstly of recommendations, and then of 10-group reporting and medical audit, a retrospective cohort study was performed including all women who gave birth in the years 2001, 2006 and 2010. Data were analyzed by means of 10-group classification. RESULTS: C-section rate was 27.5% in 2001, 31.1% in 2006, and 30.5% in 2010. Ten-group analysis showed that from 2001 to 2006 group 1-2 size increased from 27.6% to 42.5% (P<0.01), and contribution to the overall cesarean rate from 22.3% to 29.9% (P<0.01), whereas the group 1 C-section sub-rate was reduced from 19.6% to 13.5% (P<0.05). Previous cesarean increased from 9.2% to 11.6% (P<0.05). Delivery ward 10-group monitoring showed that from January to May 2010 the C-section rate was consistently above 30%. The audit was started and the causes were analyzed. Subsequently, C-section rate dropped to the actual 30.5%. CONCLUSION: Ten-group analysis showed that the 2006 cesarean rate increase was related to a significant shift in obstetric population toward groups 5 to 9 at higher risk of C-section, whereas after recommendation implementation a significant reduction of C-section subrates was observed in groups 1, 2a, 3, 4a, and 10 which represented more than 80% of the hospital population. In 2010, 10-group monitoring of the cesarean subrates stabilized the C-section rate. Ten-group analysis should be implemented in clinical practice to control delivery ward clinical management. It only requires the involvement of a clinical manager and of a midwife for data collection.

Proton nuclear magnetic resonance spectroscopy of urine samples in preterm asphyctic newborn: a metabolomic approach.

In order to highlight differences in the metabolic profile of healthy (control) compared with asphyxiated newborns, by using untargeted metabolomic approach coupled with (1)H NMR spectroscopy, we evaluated the effects of asphyxia on newborn urine metabolites. Our results showed that lactate, glucose and TMAO, together with threonine plus 3-hydroxyisovalerate are the metabolites more characterizing the asphyxiated group; lower contribute to discrimination is related to other metabolites such as dimethylglycine, dimethylamine, creatine, succinate, formate, urea and aconitate. After 24-48h from resuscitation preterm asphyctic neonates showed their recovery pattern that still can be differentiated by the controls.

Intraerythrocyte nonprotein-bound iron and plasma malondialdehyde in the hypoxic newborn.

Intraerythrocyte nonprotein-bound iron (INPBI), malondialdehyde (MDA), and hypoxanthine plasma levels (HxPL), were determined by high-pressure liquid chromatography in 138 randomly selected newborn infants with gestational ages ranging from 23 to 42 weeks at birth and on fourth day of life. MDA plasma levels were significantly higher in cord and fourth-day blood samples of preterm babies than term infants as well as babies born by emergency Caesarean section than babies born by vaginal delivery and in intubated than in nonintubated newborns. Highly significant correlations both in cord blood and fourth-day blood samples were observed between MDA plasma levels and gestational age, birth weight, Apgar score at 1 min and 5 min, HxPL, pH, base deficit, and INPBI content. Multiple regression analysis identified HxPL as the best single predictor of MDA plasma levels in cord blood, and INPBI content in fourth-day blood as the best single predictor of MDA plasma levels in fourth-day blood. The results indicate that red cells and plasma lipoproteins are a common target of free radical-induced oxidative stress during hypoxia.

Anti-skeletal muscle glycolipid antibodies in human heart transplantation as markers of acute rejection. Correlation with endomyocardial biopsy.

In seventeen patients the result of the histological study of 153 endomyocardial biopsies (EMB) was compared with the ELISA titer of anti-human skeletal muscle glycolipid antibodies (AGA) present in serum samples collected simultaneously with the EMB procedure during the first four months following cardiac transplantation. The glycolipids were extracted from the quadriceps femoralis of blood group O patients. In the serum samples corresponding to the histological rejection grades with myocyte necrosis (greater than or equal to 2, International Society for Heart and Lung Transplantation grading) the AGA titer was significantly higher (P<0.005) than in the less severe rejection grades. The follow-up in each patient showed that the AGA titer raised in the serum samples collected immediately after, before, or coincidentally with a histological diagnosis of rejection grade 2 or 3A. In only one rejection grade 3A case was a false-negative result observed. Determination of the cut-off of the AGA level versus rejection grades 2 and 3A was determined by a relative-operating characteristic curve. An optical density (OD) of 0.040 showed maximum efficiency with sensitivity 53% and specificity 79%. Four patients who had AGA with an OD above 0.040 at the time of transplant had a significantly higher number of rejection grade 2 and 3A episodes than eleven patients with low pre-transplant AGA titers (P<0.05). These results indicate that search of anti-skeletal muscle glycolipid antibodies may represent a useful noninvasive method for monitoring heart rejection, and suggest that its investigation prior transplant may be a predictor of the number of grades 2 and 3A rejection episodes.

Anti-skeletal muscle glycolipid antibodies in human heart transplantation as predictors of acute rejection: comparison with other risk factors.

In forty-five patients who underwent orthotopic heart transplantation, the titer of anti-human skeletal muscle glycolipid antibodies (AGA) present in the sera at the moment of transplantation was correlated with the number of histologically diagnosed cellular grade 3A and humoral acute rejection episodes during the first 120 days after transplantation. Determination of a cutoff value of 0.800 for the AGA level was determined by a receiver operating characteristic curve. Thirteen of 19 patients (68.4%) with an AGA titer above 0.800 developed 24 severe rejection episodes, and of the 26 patients with an AGA titer below 0.800, only 4 (15.3%) presented 6 severe rejection episodes during that time. This was especially evident for the humoral rejection episodes, which were diagnosed in only 1 of the 26 patients with AGA below 0.800 and in 7 of the 19 with AGA above 0.800. Comparison by univariate analysis of other well-known risk factors for a greater number of rejection episodes during the early posttransplant period with the AGA level at the moment of transplantation revealed that the latter distinguished a greater number of patients at risk than the other factors, such as a female donor, the lymphocyte direct cross-match, or the status of the patients at transplantation; the odds ratios were 6.33 for the AGA level, 3.17 for the direct cross-match, and 2.76 for the status at transplantation. By multiple logistic regression analysis, the only relevant risk factors in our group of patients were the AGA level (P=0.0009) and the status at transplantation (P=0.0285). These results indicate that determination of the AGA level at the moment of transplantation could represent a useful method for distinguishing which patients are at risk for a greater number of rejection episodes during the early posttransplant period, with a greater sensitivity than other risk factors.