Continuous Renal Replacement Therapy with Low Dose Systemic Heparin in Liver Transplant Recipients.

INTRODUCTION: Continuous renal replacement therapy (CRRT) is an effective dialysis method in critically ill patients. Citrate and heparin are commonly used as anticoagulants to prevent premature circuit clotting. The aim of this study was to evaluate the safety and efficacy of using low dose systemic heparin while on CRRT in liver transplant recipients. METHODS: We retrospectively evaluated and analyzed data from 29 liver transplant recipients undergoing CRRT in the postoperative course in this cross-sectional study. Numerous variables were recorded, such as coagulation parameters, duration of intensive care unit (ICU) stay, duration of dialysis, heparin dose, circuit life span, and anticoagulant complications. RESULTS: Out of 29 recipients, there were 16 (55%) female and 13 (45%) male. All participants underwent whole organ liver transplantation with a median age of 45 years. Overall, 98 successful dialysis sessions were recorded in this study with a mean circuit life span of 36 hours. Mean ± SD duration of CRRT for each recipient was 4.8 ± 3.1 days. The median total dose of heparin used for each recipient was 25,000 units , and the median dose of heparin per-day for each recipient was about 3,300 units. There were no episodes of anticoagulant-related bleeding complications. Thirteen (13.2%) episodes of premature circuit clotting occurred. We found a significant association between the first dose and total dose of heparin usage with first postoperative INR and PTT level (P < .05, P < .05, P < .001, and P < .05). CONCLUSION: In liver transplant recipients, low dose heparin during CRRT for patency of circuit is well tolerated.

Prevalence of Postoperation Metabolic Syndrome in Pediatric Liver Transplant Patients: A Single Center Experience.

OBJECTIVES: Metabolic syndrome components, such as being overweight or having hypertension, hyperlipidemia, or diabetes mellitus, are common complications after liver transplant in pediatric patients with probable multifactorial causes and increase the risk of cardiovascular complications in adulthood. In this study, our aim was to evaluate the prevalence of these components both before and after transplant surgery. MATERIALS AND METHODS: Our study included all children having liver transplant at our institution over a period of 20 years who were under 18 years old and had at least 6 months of posttransplant follow-up. Prevalence of metabolic syndrome components and pretransplant and posttransplant laboratory data of patients were evaluated. RESULTS: Over the 20-year study period, 391 liver transplant patients were included in our study, in which 167 were girls (42.7%) and 224 were boys (57.3%). Patients showed a posttransplant hyperlipidemia rate of 7.5%, hyperglycemia rate of 22%, hypertension rate of 9.6%, and metabolic syndrome rate of 50.2%. Pretransplant, the rate of patients with metabolic syndrome was 10.5%. CONCLUSIONS: Our study confirmed that the prevalence of metabolic syndrome in patients after liver transplant increases dramatically and should be explored with further research.

Observational Study of Associations between Voriconazole Therapeutic Drug Monitoring, Toxicity, and Outcome in Liver Transplant Patients.

The aim of this study was to investigate the variability of the voriconazole plasma level and its relationships with clinical outcomes and adverse events among liver transplant recipients to optimize the efficacy and safety of their treatment. Liver transplant recipients treated with voriconazole were included, and voriconazole trough levels were quantified by a validated high-performance liquid chromatography method. Cytochrome P450 genotypes for CYP2C19 were evaluated in allograft liver tissues. A total of 832 voriconazole trough levels from 104 patients were measured. Proven, probable, and possible invasive fungal infections were reported for 8/104 (7.7%), 42/104 (40.4%), and 54/104 (51.9%) patients, respectively. Receiver operating characteristic (ROC) curve analysis indicated that trough concentrations of ≥1.3 µg/ml minimized the incidence of treatment failure (95% confidence interval [CI], 0.68 to 0.91 µg/ml) (P < 0.001) and that those of <5.3 µg/ml minimized the incidence of any adverse events (95% CI, 0.83 to 0.97 µg/ml) (P < 0.001). Voriconazole trough levels were significantly higher for heterozygous extensive metabolizers, poor metabolizers, and individuals receiving coadministration with proton pump inhibitors. For ultrarapid metabolizers, oral administration of voriconazole, and concomitant use of glucocorticoids, voriconazole blood concentrations were significantly reduced. Furthermore, there was no statistically significant association of patient age, weight, or gender or coadministration of tacrolimus and cyclosporine with the voriconazole trough level. In conclusion, the results of our analysis indicate large inter- and intraindividual variabilities of voriconazole concentrations in liver transplant recipients. Voriconazole trough concentrations of ≥1.3 µg/ml and <5.3 µg/ml are optimal for treatment and for minimization of adverse events. Optimization of drug efficacy and safety requires the use of rational doses for voriconazole therapy.

Antifungal Effects of Common Mouthwashes on Candida Strains Colonized in the Oral Cavities of Liver Transplant Recipients in South Iran in 2014.

BACKGROUND: Among the opportunistic microorganisms, fungi, particularly Candida, play an important role in the mortality of transplant recipients. Thus, controlling and preventing fungal colonizations in various parts of the body, including the oral cavity, can reduce the possibility of post-transplant invasive fungal infections. This can be done simply by using mouthwashes. OBJECTIVES: The current study aimed to determine the prevalence of fungal species of Candida within the oral cavities of liver transplant recipients, and to evaluate the effects on Candida colonization of different exposure times to common mouthwashes. PATIENTS AND METHODS: Specimens were taken from the oral cavities of 101 liver transplant recipients who were referred to our clinic for their first monthly examination. After cultivation and DNA extraction, yeast strains were identified with the RFLP technique. Each strain's susceptibility to 0.2% chlorhexidine, Vi-One, Oral-B, Nanosil D1, and Nystatin mouthwashes was determined based on the CLSI M27-A2 standard method. RESULTS: The obtained data were analyzed using SPSS. Out of 101 samples from liver transplant recipients, 68 cases showed fungi growing within the culture media (67.4%). C. albicans and C. glabrata, respectively, were the first and second most frequent types. Mouthwash susceptibility tests revealed that their antifungal effects over 60 seconds were significantly higher than with an exposure time of 30 seconds. At both 30 and 60 seconds, chlorhexidine was significantly the most efficient. CONCLUSIONS: Chlorhexidine mouthwash with an exposure time of 60 seconds or more is suggested as an effective antifungal agent to be included in the medication regimen of liver transplant patients pre- and postoperatively, in order to prevent fungal colonization and subsequent systemic infections.

Invasive fungal infection in renal transplant recipients demonstrated by panfungal polymerase chain reaction.

OBJECTIVES: Invasive fungal infections following renal transplant are associated with high morbidity and mortality rates. This study reports our experience using molecular assay to diagnose invasive fungal infections in renal graft recipients. PATIENTS AND METHODS: One hundred twenty patients who had undergone renal transplant at the Organ Transplant Unit of Nemazi Hospital in Shiraz, Iran, between September 2004 and January 2006 were followed up for fungal infections for 6 months following transplant. Blood samples were cultured by bedside inoculation to BACTEC fungal medium. Whole blood specimens were collected prospectively once per week and were evaluated for any invasive fungal infections using panfungal polymerase chain reaction and polymerase chain reaction-enzyme-linked immunosorbent assay. The female-to-male ratio was 44.2% to 55.8%, the mean age of the recipients was 34.7 years, and the mean length of hospitalization was 10.92 days. RESULTS: The sensitivity and specificity for proven and probable infections were 80% and 95.6%, respectively. Using panfungal polymerase chain reaction- enzyme-linked immunosorbent assay, 4 recipients were diagnosed as having invasive fungal infections. The etiologic agents were C. albicans in 3 patients, and C. albicans and A. fumigatus in 1 patient. The mean interval of polymerase chain reaction-enzyme-linked immunosorbent assay positivity in blood samples before clinical signs was 27 days (range, 7-60 days). CONCLUSIONS: Polymerase chain reaction-enzyme-linked immunosorbent assay may improve early diagnosis of invasive fungal infections; however, correlating the results of polymerase chain reaction-enzyme-linked immunosorbent assay with clinical outcomes in renal transplant recipients will require further evaluation.

Arteriovenous fistula thrombosis in patients on regular hemodialysis: a report of 171 patients.

BACKGROUND: Fistula thrombosis in patients on maintenance hemodialysis is an important morbidity factor. Arterial or venous thrombotic events have been described as complications in patients on regular hemodialysis. This study was designed to evaluate the risk factors for arteriovenous fistula thrombosis. METHODS: One hundred and seventy-one patients with arteriovenous fistula on maintenance hemodialysis were studied prospectively during a period of 14 months for any episode of arteriovenous fistula thrombosis, after anticardiolipin antibodies were assayed by ELISA. Other risk factors for thrombosis such as the presence of diabetes or hypertension, the use of erythropoietin (rhEPO), fistula site, gender, age, ultrafiltration, hypotension during dialysis, and the number of dialysis visits in a week were assessed. RESULTS: Fifty-six percent of patients had IgG-anticardiolipin antibodies > or = 10GPL, which was significantly correlated with dialysis duration (23.18 +/- 24.56 months in patients with anticardiolipin antibodies < or = 10GPL vs. 37.73 +/- 36.35 months in patients with 20 < or = IgG-anticardiolipin antibodies < 40GPL). Within the 14 months of follow-up, 36 episodes of arteriovenous fistula thrombosis occurred in 31 patients (18.1%). Considering anticardiolipin antibodies and other risk factors in a Cox proportional hazard model, only fistula site (P = 0.021, RR = 2.48, Cl = 1.14 - 5.37) and erythropoietin (Eprex) use (P = 0.021, RR = 10.92, Cl = 1.43 - 83.02) seemed to have an influence on fistula patency. According to fistula site, the survival of brachiocephalic fistulas were significantly (P = 0.007) better than radiocephalic ones (1- and 3-year survival were 95% and 87% for upper, and 88% and 72% for lower ones, respectively). CONCLUSION: Although the incidence of the anticardiolipin antibody was high in our patients, in the presence of other risk factors for thrombosis, we found no correlation between IgG-anticardiolipin antibodies and arteriovenous fistula thrombosis. Instead, erythropoietin (Eprex) use and fistula site seem to have an important role in the correlation between IgG-anticardiolipin antibodies and arteriovenous fistula thrombosis.