Graft factors as determinants of postoperative delirium after liver transplantation.

Post-operative delirium (POD) is a frequent complication after surgery, occurring in 15-20% of patients. POD is associated with a higher complications rate and mortality. Literature on POD after liver transplantation (LT) is limited, with the few available studies reporting an incidence of 10-47%. The aim of this study was analyzing pattern, risk factors and clinical impact of POD after LT. Data on donor and recipient characteristics, postoperative course and POD of consecutive adult LT recipients from March 2016 to May 2018 were prospectively collected and retrospectively analyzed. Risk factors for POD were analyzed using univariable logistic regression and Lasso regression. Kaplan-Meier method was used for survival analysis. 309 patients underwent LT during study period; 3 were excluded due to perioperative death. Incidence of POD was 13.4% (n = 41). The median day of onset was 5th (IQR [4-7]) with a median duration of 4 days (IQR [3-7]). Several risk factors, related to the severity of liver disease and graft characteristics, were identified. Graft macrovesicular steatosis was the only factor independently associated with POD at multivariable analysis (OR 1.27, CI 1.09-1.51, p = 0.003). POD was associated with a higher rate of severe postoperative complications and longer intensive care unit and hospital stay, but did not significantly impact on patient and graft survival. Incidence of POD after LT is comparable to that observed after general surgery and graft factors are strongly associated with its onset. These results help identifying a subset of patients to be considered for preventive interventions.

Cruzipaína, la principal cisteín proteasa de trypanosoma cruzi en la interrelación huésped-parásito / Cruzipain, a major Trypanosoma cruzi cystein protease in the host-parasite interplay

La enfermedad de Chagas, causada por el parásito protozoarioTrypanosoma cruzi, es endémica en América Central y Sudaméricay representa la miocarditis más frecuente a nivel mundial.El establecimiento de la infección crónica conduce a una patologíacardíaca debilitante por la cual mueren más de 50,000 personascada año. No existe consenso sobre si la causa del daño tisulares ocasionada por el parásito o está exacerbada por una respuestaautoinmune. En ambos escenarios, ha sido sugerido quecruzipaína- la principal cisteín proteasa del T. cruzi- cumple unrol importante en la progresión de la enfermedad.Cruzipaína, miembro de la superfamilia de las papaínas, seexpresa como una mezcla compleja de isoformas en los diferentesestadíos de desarrollo de todas las cepas del parásito. Esta glicoproteínaparticipa en la internalización del T. cruzi en las célulasmamíferas, lo que ha sido demostrado con inhibidores específicosde la enzima que interfieren en la invasión celular y la replicacióndel parásito. Además, cruzipaína genera una fuerte respuestaimmune en individuos infectados. Estas característicashacen de cruzipaína un potencial blanco de drogas terapéuticas.La presente revisión resume el conocimiento actual sobre elrol de cruzipaína en la patogénesis de la enfermedad, su compromisoen la invasión de células del huésped así como su participaciónen la activación y evasión de la respuesta inmune enmodelos experimentales y en pacientes chagásicos. El avance enesta área de investigación, proveerá nuevas estrategias terapéuticastendientes a incrementar la respuesta inmunoprotectiva yprevenir la respuesta deletérea producida por el parásito

The protozoan parasite Trypanosoma cruzi, etiological agentof Chagas disease, is endemic in Central and South America andproduces the most common myocarditis worldwide.Parasite persistence eventually leads to a debilitating heartdisease that kills more than 50,000 people every year. There is noconsensus as to whether tissue damage is caused entirely by theparasite or is exacerbated by an autoimmune response. In bothmodels of disease progression, cruzipain- the major cysteine proteinaseof T. cruzi- has been suggested to play an important role.Cruzipain is a member of the papain superfamily, and it isexpressed as a complex mixture of isoforms by different strains ofthe parasite, as well as in all its developmental stages. This parasiteglycoprotein plays a role in the process of T. cruzi internalizationinto mammalian cells, as proved by specific enzyme inhibitors, whichinterfere with cell invasion and inhibit parasite replication.In addition, cruzipain not only is essential for parasite survivalbut also generates a strong immune response in infected individuals.These characteristics point to cruzipain as a potential targetfor drug therapy and for the generation of immune responses.This review analyses our present knowledge of the role ofcruzipain in the disease pathogenesis, its involvement in host cellinvasion, immune activation and evasion by T. cruzi in experimentalmodels and human infection. Ongoing studies in this researcharea may provide novel therapeutic strategies that couldenhance the immunoprotective response while preventing thedeleterious parasite elicited responses observed during Chagasdisease

Anti-galectin-1 autoantibodies in human Trypanosoma cruzi infection: differential expression of this beta-galactoside-binding protein in cardiac Chagas' disease.

The pathogenesis of Chagas' disease has been subject of active research and still remains to be ascertained. Galectin-1 (Gal-1), a member of a conserved family of animal beta-galactoside-binding proteins, localized in human heart tissue, has been suggested to play key roles in immunological and inflammatory processes. In the present study we demonstrated the occurrence of anti-Gal-1 autoAb in sera from patients in the acute and chronic stages of Chagas' disease (ACD and CCD) by means of ELISA and Western blot analysis. We found a marked increase in the level and frequency of Ig E anti-Gal-1 antibodies in sera from patients with ACD, but a low frequency of Ig M anti-Gal-1 immunoreactivity. Moreover, Ig G immunoreactivity to this beta-galactoside-binding protein was found to be correlated with the severity of cardiac damage in CCD, but was absent in nonrelated cardiomyopathies. We could not detect immunoreactivity with Trypanosoma cruzi antigens using a polyclonal antibody raised to human Gal-1 and no hemagglutinating activity could be specifically eluted from a lactosyl-agarose matrix from parasite lysates. Moreover, despite sequence homology between Gal-1 and shed acute phase antigen (SAPA) of T. cruzi, anti-Gal-1 antibodies eluted from human sera failed to cross-react with SAPA. In an attempt to explore whether Gal-1 immunoreactivity was originated from endogenous human Gal-1, we finally investigated its expression levels in cardiac tissue (the main target of Chagas' disease). This protein was found to be markedly upregulated in cardiac tissue from patients with severe CCD, compared to cardiac tissue from normal individuals.

Induction of antibodies reactive to cardiac myosin and development of heart alterations in cruzipain-immunized mice and their offspring.

Human and murine infection with Trypanosoma cruzi parasite is usually accompanied by strong humoral and cellular immune response to cruzipain, a parasite immunodominant antigen. In the present study we report that the immunization of mice with cruzipain devoid of enzymatic activity, was able to induce antibodies which bind to a 223-kDa antigen from a mouse heart extract. We identified this protein as the mouse cardiac myosin heavy chain by sequencing analysis. The study of IgG isotype profile revealed the occurrence of all IgG isotypes against cruzipain and myosin. IgG1 showed the strongest reactivity against cruzipain, whereas IgG2a was the main isotype against myosin. Anti-cruzipain antibodies purified by immunoabsorption recognized the cardiac myosin heavy chain, suggesting cross-reactive epitopes between cruzipain and myosin. Autoimmune response in mice immunized with cruzipain was associated to heart conduction disturbances. In addition, ultrastructural findings revealed severe alterations of cardiomyocytes and IgG deposit on heart tissue of immunized mice. We investigated whether antibodies induced by cruzipain transferred from immunized mothers to their offsprings could alter the heart function in the pups. All IgG isotypes against cruzipain derived from transplacental crossing were detected in pups' sera. Electrocardiographic studies performed in the offsprings born to immunized mothers revealed conduction abnormalities. These results provide strong evidence for a pathogenic role of autoimmune response induced by a purified T. cruzi antigen in the development of experimental Chagas' disease.

Cruzipain induces autoimmune response against skeletal muscle and tissue damage in mice.

The goal of the current study was to investigate whether cruzipain, a major Trypanosoma cruzi antigen, is able to induce in mice an autoimmune response and skeletal muscle damage. We demonstrate that immunization with cruzipain triggers immunoglobulin G antibody binding to a 210-kDa antigen from a syngeneic skeletal muscle extract. The absorption of immune sera with purified myosin completely eliminated this reactivity, confirming that the protein identified is really myosin. We also found that spleen cells from immunized mice proliferated in response to a skeletal muscle extract rich in myosin and to purified myosin. Cells from control mice did not proliferate against any of the antigens tested. In addition, we observed an increase in plasma creatine kinase activity, a biochemical marker of muscle damage. Histological studies showed inflammatory infiltrates and myopathic changes in skeletal muscle of immunized animals. Electromyographic studies of these mice revealed changes such as are found in inflammatory or necrotic myopathy. Altogether, our results suggest that this experimental model provides strong evidence for a pathogenic role of anticruzipain immune response in the development of muscle tissue damage.