Multidrug-resistant bacterial infections after liver transplantation: Prevalence, impact, and risk factors.

BACKGROUND & AIMS: Infections by multidrug-resistant bacteria (MDRB) are an increasing healthcare problem worldwide. This study analyzes the incidence, burden, and risk factors associated with MDRB infections after liver transplant(ation) (LT). METHODS: This retrospective, multicenter cohort study included adult patients who underwent LT between January 2017 and January 2020. Risk factors related to pre-LT disease, surgical procedure, and postoperative stay were analyzed. Multivariate logistic regression analysis was performed to identify independent predictors of MDRB infections within the first 90 days after LT. RESULTS: We included 1,045 LT procedures (960 patients) performed at nine centers across Spain. The mean age of our cohort was 56.8 ± 9.3 years; 75.4% (n = 782) were male. Alcohol-related liver disease was the most prevalent underlying etiology (43.2.%, n = 451). Bacterial infections occurred in 432 patients (41.3%) who presented with a total of 679 episodes of infection (respiratory infections, 19.3%; urinary tract infections, 18.5%; bacteremia, 13.2% and cholangitis 11%, among others). MDRB were isolated in 227 LT cases (21.7%) (348 episodes). Enterococcus faecium (22.1%), Escherichia coli (18.4%), and Pseudomonas aeruginosa (15.2%) were the most frequently isolated microorganisms. In multivariate analysis, previous intensive care unit admission (0-3 months before LT), previous MDRB infections (0-3 months before LT), and an increasing number of packed red blood cell units transfused during surgery were identified as independent predictors of MDRB infections. Mortality at 30, 90, 180, and 365 days was significantly higher in patients with MDRB isolates. CONCLUSION: MDRB infections are highly prevalent after LT and have a significant impact on prognosis. Enterococcus faecium is the most frequently isolated multi-resistant microorganism. New pharmacological and surveillance strategies aimed at preventing MDRB infections after LT should be considered for patients with risk factors. IMPACT AND IMPLICATIONS: Multidrug-resistant bacterial infections have a deep impact on morbidity and mortality after liver transplantation. Strategies aimed at improving prophylaxis, early identification, and empirical treatment are paramount. Our study unveiled the prevalence and main risk factors associated with these infections, and demonstrated that gram-positive bacteria, particularly Enterococcus faecium, are frequent in this clinical scenario. These findings provide valuable insights for the development of prophylactic and empirical antibiotic treatment protocols after liver transplantation.

Recent outcomes of liver transplantation for Budd-Chiari syndrome: A study of the European Liver Transplant Registry (ELTR) and affiliated centers.

BACKGROUND AND AIMS: Management of Budd-Chiari syndrome (BCS) has improved over the last decades. The main aim was to evaluate the contemporary post-liver transplant (post-LT) outcomes in Europe. APPROACH AND RESULTS: Data from all patients who underwent transplantation from 1976 to 2020 was obtained from the European Liver Transplant Registry (ELTR). Patients < 16 years, with secondary BCS or HCC were excluded. Patient survival (PS) and graft survival (GS) before and after 2000 were compared. Multivariate Cox regression analysis identified predictors of PS and GS after 2000. Supplemental data was requested from all ELTR-affiliated centers and received from 44. In all, 808 patients underwent transplantation between 2000 and 2020. One-, 5- and 10-year PS was 84%, 77%, and 68%, and GS was 79%, 70%, and 62%, respectively. Both significantly improved compared to outcomes before 2000 ( p < 0.001). Median follow-up was 50 months and retransplantation rate was 12%. Recipient age (aHR:1.04,95%CI:1.02-1.06) and MELD score (aHR:1.04,95%CI:1.01-1.06), especially above 30, were associated with worse PS, while male sex had better outcomes (aHR:0.63,95%CI:0.41-0.96). Donor age was associated with worse PS (aHR:1.01,95%CI:1.00-1.03) and GS (aHR:1.02,95%CI:1.01-1.03). In 353 patients (44%) with supplemental data, 33% had myeloproliferative neoplasm, 20% underwent TIPS pre-LT, and 85% used anticoagulation post-LT. Post-LT anticoagulation was associated with improved PS (aHR:0.29,95%CI:0.16-0.54) and GS (aHR:0.48,95%CI:0.29-0.81). Hepatic artery thrombosis and portal vein thrombosis (PVT) occurred in 9% and 7%, while recurrent BCS was rare (3%). CONCLUSIONS: LT for BCS results in excellent patient- and graft-survival. Older recipient or donor age and higher MELD are associated with poorer outcomes, while long-term anticoagulation improves both patient and graft outcomes.

Frecuentación del servicio de urgencias y reingresos no programados durante el primer año del trasplante de hígado y su repercusión en la supervivencia / Emergency department frequentation and unscheduled readmissions within the first year after liver transplantation, and their impact on survival

El objetivo de este estudio fue evaluar la frecuentación de la sala de emergencias, las causas de las visitas y los reingresos no programados dentro del primer año después del alta hospitalaria después del trasplante de hígado. También se evaluó su impacto en la supervivencia del injerto y del paciente. Se trata de un estudio retrospectivo de las historias clínicas de 98 pacientes (edad media, 55,6 ± 8,59 años, 77,6 % varones) que fueron dados de alta hospitalaria de forma consecutiva tras someterse a un primer trasplante hepático en nuestra institución durante 2012-2015. Se analizaron todas las visitas a urgencias durante los primeros años tras el trasplante y se calculó la supervivencia a los dos años tras el trasplante. Cincuenta y seis de los 98 pacientes (57,15 %) acudieron a urgencias en 117 ocasiones durante el primer año postrasplante. Fiebre (n = 34; 29,05 %) y síntomas digestivos (n = 32; 27. 35 %) fueron las causas más comunes de consulta y dieron lugar a más de la mitad de las visitas. Treinta y cinco de estos 56 pacientes (62,5 %) requirieron un reingreso urgente durante 50 de las 117 (42,7 %) visitas. Esto se debió principalmente a complicaciones infecciosas (44 %) de diversas causas (neumonía bacteriana, colangitis, colitis por Clostridium difficile) y problemas relacionados con las vías biliares. La probabilidad de reingreso aumentó del 11,22 % a los 30 días del alta al 22,4 % a los 90 días del alta. La supervivencia de los pacientes al año y 2 años después del trasplante fue menor para los pacientes que reingresaron (88,4 % y 80,7 %, respectivamente) en comparación con los que no reingresaron (95,56 % y 91,17 %, respectivamente, p = 0,002). (AU)

Prevalence and progression of chronic kidney disease after liver transplant: a prospective, real-life, observational, two-year multicenter study

Introduction: chronic kidney disease is a frequent complication after liver transplantation. The use of calcineurin inhibitors is one of the causes of this complication. Current immunsuppression regimens that reduce the use of calcineurin inhibitors may be associated with an improved preservation of renal function. Objective: the study aimed to assess the evolution of renal function after liver transplantation in the current routine clinical practice. Methods: an observational, prospective, multicenter study in adult liver transplant recipients was performed. Two hundred and thirty patients with a good renal function before transplantation were assessed six months post-transplantation (baseline) and every six months until month 30. Results: at baseline, 32% of the patients had a reduction in the glomerular filtration rate below < 60 ml/min/1.73 m2. The mean glomerular filtration rate increased from 72.3 to 75.6 ml/min/1.73 m2 at baseline and month 30 respectively (p < 0.01). The mean serum creatinine levels (mg/dl) decreased from 1.13 to 1.09 (p < 0.01). The percentage of patients with stage 3 chronic kidney disease decreased from 31.7% to 26.4%, whereas the percentage of patients with stage 4 remained unchanged (0.4% at baseline and 0.5% at month 30). No patients progressed to end-stage kidney disease that required dialysis or renal transplantation. Conclusion: in the routine clinical practice, a moderate deterioration of renal function is frequent after liver transplantation. However, advanced chronic kidney disease is infrequent in patients with a good pre-transplant renal function

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Prevalence and outcome of portal thrombosis in a cohort of cirrhotic patients undergoing liver transplantation

Introduction: The prevalence of portal vein thrombosis (PVT) in patients that have undergone liver transplantation (LT) is 9.7% (SD 4.5). The aim of our study was to determine the prevalence, assess the factors that are associated with PVT and clarify their association with prognosis in patients with liver cirrhosis (LC) and LT. Aims and methods: From 2005 to 2014, laboratory, radiological and surgical data were collected from patients with LC in our center who had undergone LT for the first time. esults: One hundred and ninety-one patients were included. The mean age was 55 (SD 9), 75.4% of patients were male and 48.7% had HCV. The Child-Pugh scores were A/B/C 41.9%/35.9%/25.5% and the MELD score was 15 (SD 6). Previous decompensations were: ascites (61.4%), hepatic encephalopathy (34.4%), variceal bleeding (25.4%), hepatocellular carcinoma (48.9%) and spontaneous bacterial peritonitis (SPB) (14.3%). The mean post-transplant follow-up was 42 months (0-113). PVT was diagnosed at LT in 18 patients (9.4%). Six patients were previously diagnosed using imaging tests (33.3%): 2 patients (11.1%) by DU and 4 patients (22.2%) by CT scan. All patients with PVT had DU in a mean time of 6 months before LT (0-44) and 90 patients (47.1%) had a CT scan in a median time of 6 months before LT (0-45). PVT was significantly related to the presence of SBP (33.3% vs 12.6%; p = 0.02) and lower levels of albumin (3.1g/dl vs 3.4g/ dl; p = 0.05). MELD was higher in patients with PVT (16.6 vs 14.9; p = 0.3). There were no significant differences with regard to the need for transfusion of blood components. Moreover, the surgery time was similar in both groups. PVT correlated with a higher mortality in the first 30 days (8.8% vs 16.7%; p = 0.2). Conclusion: Prior history of SBP and lower levels of albumin were identified as factors associated with PVT. The pre-transplant diagnosis rate is very low and the presence of PVT may have implications for short-term mortality (AU)

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Trasplante de heces como tratamiento de diarrea recurrente asociada a infección por Clostridium difficile en un paciente con trasplante hepático / Fecal transplantation for the treatment of relapsing diarrhea associated with Clostridium difficileinfection in a liver transplantation patient

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Actividad y resultados del trasplante hepático durante el período 1984-2012. Análisis del Registro Español de Trasplante Hepático / Activity and results of liver transplantation in Spain during 1984-2012. Analysis of the Spanish Liver Transplant Registry

Fundamento y objetivo: El trasplante hepático (TH) es un tratamiento de eficacia contrastada de la enfermedad hepática grave. El objetivo de este trabajo es analizar los resultados del TH en España durante el período 1984-2012. Pacientes y método: Se analizó la base de datos del Registro Español de Trasplante Hepático. Resultados: Se realizaron 20.288 trasplantes en 18.568 pacientes. La mediana de edad del donante y del receptor aumentó durante el período de análisis, desde 25 años (intervalo de confianza del 95% [IC 95%] 18-40) y 47 años (IC 95% 34-55), respectivamente, en el período 1984-1994, hasta 59 años (IC 95% 33-65; p < 0,05) y 55 años (IC 95% 48-61; p < 0,01), respectivamente, en el período 2010-2012. Las indicaciones más frecuentes fueron cirrosis hepática (63,18%) y hepatocarcinoma (19,62%). La supervivencia global del paciente y del injerto fueron, respectivamente, del 85,1 y 77,8% en el primer año, del 72,6 y 63,5% a los 5 años, y del 62 y 52,6% a los 10 años del TH. La supervivencia del paciente y del injerto al primer año aumentó, respectivamente, desde el 77,8 y 66,3% en el período 1984-1994 al 88,5 y 83% en el período 2010-2012 (p < 0,01). La edad del donante y del receptor, la etiología de la enfermedad de base y la serología positiva para el virus de la hepatitis C del receptor se asociaron a menor supervivencia en los análisis univariado y multivariado. Conclusiones: Los resultados del TH mejoraron significativamente a lo largo del período analizado, a pesar de un progresivo aumento en la edad del donante y del receptor (AU)

Background and objective: Liver transplantation (LT) is a proven effective treatment of severe liver disease. The aim of this paper is to analyze the results of LT in Spain during the period 1984-2012. Patients and method: We analyze the results of the database of Spanish Liver Transplant Registry. Results: A total of 20,288 transplants were performed in 18,568 patients. The median age of the donor and recipient increased during the analysis period: 25 years (95% confidence interval [95% CI] 18-40) and 47 years (95% CI 34-55), respectively, in the period 1984-1994 compared to 59 years (95% CI 33-65; P < .05) and 55 years (95% CI 48-61; P < .01), respectively, in the period 2010-2012. The most frequent indications were liver cirrhosis (63.18%) and hepatocellular carcinoma (19.62%). The overall patient and graft survival was respectively 85.1 and 77.8% in the first year, 72.6 and 63.5% the fifth year and 62 and 52.6% in the tenth year. First year patients and graft survival increased respectively from 77.8 and 66.3% in the period 1984-1994 to 88.5 and 83% in 2010-2012 (P < .01). Donor and recipient age, etiology of underlying disease, and hepatitis C virus serological status, were factors associated with decreased survival in univariate and multivariate analysis. Conclusions: Results of LT improved significantly over the review period, despite a progressive increase in donor and recipient age (AU)

Contraindicaciones absolutas del retrasplante hepático / No disponible

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Fiebre sin foco y trasplante hepático: infección por virus del herpes humano tipo 6 en pacientes trasplantados / Fever without an infectious focus and liver transplantation: Infection due to human herpes virus type 6 in transplanted patients

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Infección precoz en el paciente con trasplante hepático: incidencia, gravedad, factores de riesgo y sensibilidad antibiótica de los aislados bacterianos / Early infection in liver transplant recipients: incidence, severity, risk factors and antibiotic sensitivity of bacterial isolate

OBJETIVOS. Estudio descriptivo y análisis de factores de riesgo de infección precoz. Estudio de resistencias de los aislados bacterianos. PACIENTES Y MÉTODOS. Se estudiaron 149 trasplantados hepáticos. Se definió infección precoz en 0-90 días postrasplante. Se analizaron variables preoperatorias, intraoperatorias y postoperatorias. Se estudiaron los microorganismos aislados. Se utilizó descontaminación intestinal selectiva (DIS) con quinolonas y profilaxis perioperatoria y antifúngica en todos los pacientes. RESULTADOS. La incidencia de infección fue del 73,1 por ciento: bacterianas (49,7 por ciento), virales (35,5 por ciento), fúngicas (10,1 por ciento) y mixtas (4,5 por ciento). Las más frecuentes en el primer mes fueron bacterianas y en el segundo y tercero, virales (p = 0,001). Factores de riesgo en el análisis multivariante: días de nutrición parenteral, cirugía más de 5 h, rechazo y estado seronegativo para citomegalovirus. En 1.278 cultivos se aislaron microorganismos: 77,9 por ciento cocos grampositivos y 19 por ciento bacilos gramnegativos aerobios. La sensibilidad a vancomicina (VAN) de Staphylococcus fue del 99,6-100 por ciento y a teicoplanina (TEI) del 97,9-100 por ciento. El 1,2 por ciento de Enterococcus faecalis y el 4,5 por ciento de Enterococcus faecium fueron resistentes a VAN. El 68,7 por ciento de los S. aureus fueron SAMR. La tasa de resistencias de bacilos gramnegativos a quinolonas fue del 38,8 por ciento. CONCLUSIONES. La mayor incidencia de infección fue observada en los primeros 30 días postrasplante, siendo la bacteriana la más frecuente. La duración de la cirugía de más de 5 h fue el factor de riesgo más importante de infección bacteriana. Los grampositivos fueron las bacterias más frecuentes. El tratamiento empírico de la infección bacteriana precoz debe incluir VAN o TEI. La DIS condicionó escasa incidencia de infecciones por bacilos gramnegativos, de los cuales el 38,8 por ciento presentaban resistencia a quinolonas (AU)