Klebsiella pneumoniae infections after liver transplantation: Drug resistance and distribution of pathogens, risk factors, and influence on outcomes.

BACKGROUND: Liver transplantation (LT) is the only curative treatment for end-stage liver disease. However, LT recipients are susceptible to infection, which is the leading cause of early mortality after LT. Klebsiella pneumoniae infections (KPIs) in the bloodstream are common in LT recipients. We hypothesized that KPIs and carbapenem-resistant Klebsiella pneumoniae (CRKP) infections may affect the outcomes of LT recipients. AIM: To assess KPI incidence, timing, distribution, drug resistance, and risk factors following LT and its association with outcomes. METHODS: This retrospective study included 406 patients undergoing LT at The Third Xiangya Hospital of Central South University, a tertiary hospital, from January 2015 to January 2023. We investigated the risk factors for KPIs and assessed the impact of KPIs and CRKP infections on the prognosis of LT recipients using logistic regression analysis. RESULTS: KPI incidence was 7.9% (n = 32), with lung/thoracic cavity the most frequent site of infection; the median time from LT to KPI onset was 7.5 d. Of 44 Klebsiella pneumoniae isolates, 43 (97.7%) and 34 (77.3%) were susceptible to polymyxin B or ceftazidime/avibactam and tigecycline, respectively; > 70% were resistant to piperacillin/ tazobactam, ceftazidime, cefepime, aztreonam, meropenem, and levofloxacin. Female sex [odds ratio (OR) = 2.827, 95% confidence interval (CI): 1.256-6.364; P = 0.012], pre-LT diabetes (OR = 2.794, 95%CI: 1.070-7.294; P = 0.036), day 1 post-LT alanine aminotransferase (ALT) levels ≥ 1500 U/L (OR = 3.645, 95%CI: 1.671-7.950; P = 0.001), and post-LT urethral catheter duration over 4 d (OR = 2.266, 95%CI: 1.016-5.054; P = 0.046) were risk factors for KPI. CRKP infections, but not KPIs, were risk factors for 6-month all-cause mortality post-LT. CONCLUSION: KPIs occur frequently and rapidly after LT. Risk factors include female sex, pre-LT diabetes, increased post-LT ALT levels, and urethral catheter duration. CRKP infections, and not KPIs, affect mortality.

Nomogram to predict gas-related complications during transoral endoscopic resection of upper gastrointestinal submucosal lesions: Clinical significance.

Transoral endoscopic resections in treating upper gastrointestinal submucosal lesions have the advantages of maintaining the integrity of the gastrointestinal lumen, avoiding perforation and reducing gastrointestinal fistulae. They are becoming more widely used in clinical practice, but, they may also present a variety of complications. Gas-related complications are one of the most common, which can be left untreated if the symptoms are mild, but in severe cases, they can lead to rapid changes in the respiratory and circulatory systems in a short period, which can be life-threatening. Therefore, it is important to predict the occurrence of gas-related complications early and take preventive measures actively. Based on the authors' results in the prepublication of the article "Nomogram to predict gas-related complications during transoral endoscopic resection of upper gastrointestinal submucosal lesions," and in conjunction with our evaluation and additions to the relevant content, radiographs may help screen patients at high risk for gas-related complications. Controlling blood glucose levels, shortening the duration of surgery, and choosing the most appropriate surgical resection may positively impact the prognosis of patients at high risk for gas-related complications during transoral endoscopic resection of upper gastrointestinal submucosal lesions.

Insulin reverses impaired alveolar fluid clearance in ARDS by inhibiting LPS-induced autophagy and inflammatory.

Until now, acute respiratory distress syndrome (ARDS) has been a difficult clinical condition with a high mortality and morbidity rate, and is characterized by a build-up of alveolar fluid and impaired clearance. The underlying mechanism is not yet fully understood and no effective medications available. Autophagy activation is associated with ARDS caused by different pathogenic factors. It represents a new direction of prevention and treatment of ARDS to restrain autophagy to a reasonable level through pharmacological and molecular genetic methods. Na, K-ATPase is the main gradient driver of pulmonary water clearance in ARDS and could be degraded by the autophagy-lysosome pathway to affect its abundance and enzyme activity. As a normal growth hormone in human body, insulin has been widely used in clinical for a long time. To investigate the association of insulin with Na, K-ATPase, autophagy and inflammatory markers in LPS-treated C57BL/6 mice by survival assessment, proteomic analysis, histologic examination, inflammatory cell counting, myeloperoxidase, TNF-α and IL-1ß activity analysis etc. This was also verified on mouse alveolar epithelial type II (AT II) and A549 cells by transmission electron microscopy. We found that insulin restored the expression of Na, K-ATPase, inhibited the activation of autophagy and reduced the release of inflammatory factors caused by alveolar epithelial damage. The regulation mechanism of insulin on Na, K-ATPase by inhibiting autophagy function may provide new drug targets for the treatment of ARDS.

[Risk Factors and Prognosis of Delirium After Liver Transplantation].

Objective: To analyze the incidence, the onset time, and the risk factors of delirium after liver transplantation (LT). Methods: The clinical data of 211 patients who underwent LT at Third Xiangya Hospital, Central South University between January 2019 and December 2021 were collected to investigate the incidence and the onset time of postoperative delirium. Univariate analysis and multivariate logistic regression analysis were conducted to analyze the risk factors of delirium and to analyze the effect of delirium on clinical outcomes. Results: The incidence of delirium was 20.4% (43/211) and the median interval between LT and the onset of delirium was 19 hours. Univariate analysis showed that the preoperative Model for End-Stage Liver Disease (MELD) score≥22, preoperative length-of-stay≥7, liver cancer, preoperative hepatic encephalopathy, infections within 2 months before LT, preoperative lymphocyte value<0.5×10 9 L －1, massive amount of intraoperative red blood cell infusion, and carbapenem antibiotics use for 3 days or longer were associated with postoperative delirium. Multivariate logistic regression analysis showed that preoperative infections within 2 months before LT (odds ratio [ OR]=2.597, 95% confidence interval [ CI]: 1.135-5.944, P=0.024), preoperative MELD score≥22 ( OR=2.967, 95% CI: 1.104-7.975, P=0.031), and preoperative hepatic encephalopathy ( OR=4.700, 95% CI: 2.043-10.602, P<0.001) were independent risk factors for delirium after LT, while carbapenems antibiotics use for 3 days or longer ( OR=0.192, 95% CI: 0.083-0.441, P<0.001) was a protective factor for postoperative delirium among LT recipients. Regarding clinical outcomes, patients with delirium had longer postoperative ICU length-of-stays than those without delirium did ( P=0.025). Conclusion: There is a high incidence of postoperative delirium among patients who undergo LT and the onset time of delirium after LT is early. Risk factors include preoperative infections, high MELD score, and hepatic encephalopathy. On the other hand, the use of carbapenems can help prevent delirium.

Identification of different proteins binding to Na, K-ATPase α1 in LPS-induced ARDS cell model by proteomic analysis.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is characterized by refractory hypoxemia caused by accumulation of pulmonary fluid, which is related to inflammatory cell infiltration, impaired tight junction of pulmonary epithelium and impaired Na, K-ATPase function, especially Na, K-ATPase α1 subunit. Up until now, the pathogenic mechanism at the level of protein during lipopolysaccharide- (LPS-) induced ARDS remains unclear. METHODS: Using an unbiased, discovery and quantitative proteomic approach, we discovered the differentially expressed proteins binding to Na, K-ATPase α1 between LPS-A549 cells and Control-A549 cells. These Na, K-ATPase α1 interacting proteins were screened by co-immunoprecipitation (Co-IP) technology. Among them, some of the differentially expressed proteins with significant performance were identified and quantified by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Data are available via ProteomeXchange with identifier PXD032209. The protein interaction network was constructed by the related Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis. Several differentially expressed proteins were validated by Western blot. RESULTS: Of identified 1598 proteins, 89 were differentially expressed proteins between LPS-A549 cells and Control-A549 cells. Intriguingly, protein-protein interaction network showed that there were 244 significantly enriched co-expression among 60 proteins in the group control-A549. while the group LPS-A549 showed 43 significant enriched interactions among 29 proteins. The related GO and KEGG analysis found evident phenomena of ubiquitination and deubiquitination, as well as the pathways related to autophagy. Among proteins with rich abundance, there were several intriguing ones, including the deubiquitinase (OTUB1), the tight junction protein zonula occludens-1 (ZO-1), the scaffold protein in CUL4B-RING ubiquitin ligase (CRL4B) complexes (CUL4B) and the autophagy-related protein sequestosome-1 (SQSTM1). CONCLUSIONS: In conclusion, our proteomic approach revealed targets related to the occurrence and development of ARDS, being the first study to investigate significant differences in Na, K-ATPase α1 interacting proteins between LPS-induced ARDS cell model and control-A549 cell. These proteins may help the clinical diagnosis and facilitate the personalized treatment of ARDS.

Insulin alleviates LPS-induced ARDS via inhibiting CUL4B-mediated proteasomal degradation and restoring expression level of Na,K-ATPase α1 subunit through elevating HCF-1.

Acute respiratory distress syndrome (ARDS) is a critical disease with a high mortality rate, characterized by obstinate hypoxemia caused by accumulation of alveolar fluid and excessive uncontrolled inflammation. Na,K-ATPase α1 (ATP1A1) subunit is an important component of Na,K-ATPase that transports Na+ and K+ and scavenges alveolar fluid. The function of Na,K-ATPase is always impaired during ARDS and results in more severe symptoms of ARDS. However, the regulatory mechanism of Na,K-ATPase after ARDS remains unclear. Here, we revealed ATP1A1 was downregulated post-transcriptionally by an E3 ligase component CUL4B mediated proteasomal degradation. Moreover, we found insulin could inhibit the upregulation of CUL4B in an insulin receptor cofactor HCF-1-dependent manner. Our study resolved the molecular mechanism underlying the clearance impairment of alveolar fluid and provided a clue for the usage of insulin as a potential therapeutic medicine for ARDS.

Regulatory effect of insulin on the structure, function and metabolism of Na+/K+-ATPase (Review).

Na+/K+-ATPase is an ancient enzyme, the role of which is to maintain Na+ and K+ gradients across cell membranes, thus preserving intracellular ion homeostasis. The regulation of Na+/K+-ATPase is affected by several regulatory factors through a number of pathways, with hormones serving important short-term and long-term regulatory functions. Na+/K+-ATPase can also be degraded through activation of the ubiquitin proteasome and autophagy-lysosomal pathways, thereby affecting its abundance and enzymatic activity. As regards the regulatory effect of insulin, it has been found to upregulate the relative abundance of Na+/K+-ATPase and restore the transport efficiency in multiple in vitro and in vivo experiments. Therefore, elucidating the role of insulin in the regulation Na+/K+-ATPase may help uncover new drug targets for the treatment of related diseases. The aim of the present study was to review the structure and function of Na+/K+-ATPase and to discuss the possible mechanisms through which it may be regulated by insulin, in order to investigate the possibility of designing new therapies for related diseases.

Non-targeted proteomics of acute respiratory distress syndrome: clinical and research applications.

Acute respiratory distress syndrome (ARDS) is characterized by refractory hypoxemia caused by accumulation of pulmonary fluid with a high mortality rate, but the underlying mechanism is not yet fully understood, causing absent specific therapeutic drugs to treat with ARDS. In recent years, more and more studies have applied proteomics to ARDS. Non-targeted studies of proteomics in ARDS are just beginning and have the potential to identify novel drug targets and key pathways in this disease. This paper will provide a brief review of the recent advances in the application of non-targeted proteomics to ARDS.

Candidate Genes as Biomarkers in Lipopolysaccharide-Induced Acute Respiratory Distress Syndrome Based on mRNA Expression Profile by Next-Generation RNA-Seq Analysis.

Up until now, the regulation mechanism at the level of gene during lipopolysaccharide- (LPS-) induced acute respiratory distress syndrome (ARDS) remains unclear. The discovery of differentially expressed genes (DEGs) between LPS-induced ARDS rats and normal rats by next-generation RNA sequencing analysis is of particular interest for the current study. These DEGs may help clinical diagnosis of ARDS and facilitate the selection of the optimal treatment strategy. Randomly, 20 rats were equally divided into 2 groups, the control group and the LPS group. Three rats from each group were selected at random for RNA sequencing analysis. Sequence reads were obtained from Illumina HiSeq4000 and mapped onto the rat reference genome RN6 using Hisat2. We identified 5244 DEGs (Fold_Change > 1.5, and P < 0.05) in the lung tissues from LPS-treated rats compared with normal rats, including 1413 upregulated and 3831 downregulated expressed genes. Lots of chemokine family members were among the most upregulated genes in LPS group. Gene ontology (GO) analysis revealed that almost all of the most enriched and meaningful biological process terms were mainly involved in the functions like immune-inflammation response and the pathways like cytokine-cytokine receptor interaction. We also found that, as for GO molecular function terms, the enriched terms were mainly related to chemokines and cytokines. DEGs with fold change over 100 were verified by quantitative real-time polymerase chain reaction and reanalyzed by gene-gene coexpression network, and the results elucidated central roles of chemokines in LPS-induced ARDS. Our results revealed some new biomarkers for uncovering mechanisms and processes of ARDS.

The expression profiles of circRNAs in lung tissues from rats with lipopolysaccharide-induced acute respiratory distress syndrome: A microarray study.

The development of circular RNA (circRNA) microarray has facilitated the study of the role of circRNAs in regulating gene expression through a circRNA-miRNA-mRNA network. In our study, microarray was performed to detect the expression profiles of circRNAs during lipopolysaccharide (LPS)-induced acute respiratory distress syndrome (ARDS). Twenty rats were randomly divided into 2 groups, the control group and the LPS group, 10 rats in each group. Three rats each from both groups were randomly selected. Using circRNA microarray data, we compared the circRNA expression profiles in lung tissues between these 6 rats. The most differentially expressed circRNA species from these profiles were validated and optimized as ARDS biomarkers and potential therapeutic targets. Overall, 395 and 562 circRNAs were significantly up- and down-regulated in LPS group vs. control group, respectively. Six up-regulated and 4 down-regulated circRNAs from the top 10 candidates were eventually selected to be validated. Among them, only 4 up-regulated circRNAs (mmu_circRNA_19423, rno_circRNA_010489, rno_circRNA_011426, mmu_circRNA_30664) and 1 down-regulated circRNA (rno_circRNA_005564) exhibited significant validation. The 5 highest ranking target miRNAs of these 5 validated circRNAs were predicted according to the miRNA support vector regression method. This is the first study to investigate circRNA expression profile and a large number of aberrantly expressed circRNAs were revealed during ARDS. The significantly over- or under-expressed circRNA may represent a novel biomarker and be developed as a novel therapeutic target for the clinical management of ARDS. The results are preliminary and need to be confirmed in further well-designed studies with larger sample size.

Donor-derived infections among Chinese donation after cardiac death liver recipients.

AIM: To investigate blood cultures of deceased donors and report the confirmed transmission of bacterial infection from donors to liver recipients. METHODS: We retrospectively studied the results of blood cultures among our donation after cardiac death (DCD) donors and calculated the donor-derived bacterial infection rates among liver recipients. Study participants underwent liver transplantation between January 1, 2010 and February 1, 2017. The study involved a total of 67 recipients of liver grafts from 67 DCD donors. We extracted the data of donors' and patients' characteristics, culture results and clinical outcomes, especially the post-transplant complications in liver recipients, from electronic medical records. We analyzed the characteristics of the donors and the corresponding liver recipients with emphasis put on donor-derived infections. RESULTS: Head trauma was the most common origin of death among our 67 DCD donors (46.3%). Blood taken prior to the procurement operation was cultured for 53 of the donors, with 17 episodes of bloodstream infections developing from 13 donors. The predominant organism isolated from the blood of donors was Gram-positive bacteria (70.6%). Only three (4.5%) of 67 liver recipients developed confirmed donor-derived bacterial infections, with two isolates of multidrug-resistant Klebsiella pneumoniae and one isolate of multidrug-resistant Enterobacter aerogenes. The liver recipients with donor-derived infections showed relation to higher crude mortality and graft loss rates (33.3% each) within 3 mo post transplantation, as compared to those without donor-derived infections (9.4% and 4.7%, respectively). All three liver recipients received appropriate antimicrobial therapy. CONCLUSION: Liver recipients have high occurrence of donor-derived infections. The liver recipients with donor-derived multidrug-resistant Enterobacteriaceae infections can have good outcome if appropriate antimicrobial therapy is given.

MicroRNA­144 suppresses tumorigenesis of hepatocellular carcinoma by targeting AKT3.

Aberrant expression of microRNAs (miRNAs) has been shown to be associated with the progression and metastasis of cancer. Dysregulation of miR­144 has been observed in numerous types of cancer; however, the exact role of miR­144 in hepatocellular carcinoma (HCC) remains unclear. The present study observed that miR­144 was downregulated in HCC tissues and cell lines. Forced overexpression of miR­144 suppressed proliferation, migration and invasion of HCC cells. AKT3 was identified as a direct target of miR­144 in HCC, and this was confirmed by a luciferase activity assay and western blot analysis. Overexpression of AKT3 in miR­144 transfected HCC cells effectively reversed the tumor suppressive effects of miR­144. Furthermore, AKT3 expression levels were inversely correlated with miR­144 expression levels in HCC tissues. In conclusion, the results of the present study suggest that miR­144 may act as a tumor suppressor in HCC by targeting AKT3, and miR­144 may be a potential therapeutic candidate for HCC.

miR-24 promotes the proliferation and invasion of HCC cells by targeting SOX7.

Accumulating evidence shows that microRNAs (miRNAs) are involved in the development and progression of multiple tumors, including hepatocellular carcinoma (HCC). Recent studies have found that miR-24 acts as an oncogene in several tumors; however, the function of miR-24 in HCC remains unclear. In this study, we found that miR-24 was increased in HCC tissues and cell lines. Inhibition of miR-24 by inhibitor significantly suppressed HCC cells proliferation, migration, and invasion. Furthermore, the sex-determining region Y (SRY)-box 7 (SOX7), a putative tumor suppressor, was found to be a target of miR-24 in HCC cells. Forced expression of SOX7 substantially attenuated the oncogenic effects of miR-24. Those results strongly suggest that miR-24 plays important role in HCC development partially by targeting SOX7.

Correlation of tumor necrosis factor-ß and interleukin-1 gene cluster polymorphism with susceptibility to bacteremia in patients undergoing kidney transplantation.

BACKGROUND: Bacteremia remains a significant cause of morbidity and mortality after kidney transplantation. This study was conducted to investigate whether the polymorphisms of tumor necrosis factor (TNF)-ß, interleukin (IL)-1ß, and IL-1 receptor antagonist (IL-1ra) gene predicted the susceptibility to bacteremia within the first 6 months after kidney transplantation. METHODS: Subjects comprised 82 infected kidney transplant recipients and 60 non-infected kidney transplant recipients. Bacteremia was diagnosed in 16 of the 82 infected recipients. Genomic DNA from these 142 kidney transplant recipients was extracted from peripheral blood leukocytes. Regions containing the NcoI polymorphic site at position +252 of TNF-ß gene and the AvaI polymorphic site at position -511 of IL-1ß gene were amplified by polymerase chain reaction (PCR) and subsequently digested with NcoI and AvaI restriction enzymes, respectively. The polymorphic regions within intron 2 of IL-1ra gene containing variable numbers of a tandem repeat (VNTR) of 86 base pairs were amplified by PCR. RESULTS: Genotypic and allelic frequencies were similar between infected recipients and non-infected ones. Individual locus analysis showed that recipient TNF-ß and IL-1ra gene polymorphisms were not associated with the presence of bacteremia (P = 0.684 and P = 0.567, respectively). However, genotype analysis revealed that recipient IL-1ß-511CC genotype was strongly associated with susceptibility to develop bacteremia (P = 0.003). Recipient IL-1ß-511CC genotype (odds ratio 5.242, 95% confidence intervals 1.645-16.706, P = 0.005) independently predicted the risk for bacteremia within the first 6 months after kidney transplantation. CONCLUSIONS: These findings indicate a critical role of IL-1ß gene polymorphisms in susceptibility to bacteremia after kidney transplantation, which may be useful to screen for patients at higher risk for post-transplant bacteremias. Thus, the identified individuals can benefit from preventive treatment and a less potent immunosuppressive regimen.

Differences in willingness to donate cadaveric organ between young donor families and adult donor families: evidence from the Hunan Province, China.

BACKGROUND: The Red Cross of China and Ministry of Health jointly started a pilot program of organ donation after cardiac death to overcome the shortage of available organs since 2010. The purpose of this qualitative study were to compare the consent rate of organ donation between young donor families and adult donor families; to explore and determine factors associated with differences in willingness to donate organs between them. Research objective was to provide a rationale for further preparation of professionals involved in this sensitive work. METHODS: Between March 2010 and June 2012, 24 young deceased patients including donors and non-donors and 96 potential adult donors were collected, and consent rates of young donors' families and adult donors' families were calculated. A χ(2) test analysis to compare the consent rates of the two groups was conducted. We studied through semistructured interviews 15 parents of young donors and 15 relatives of old donors who were interviewed for petition of consent. Data collection and analysis of the overall study were performed according to the grounded theory methodology. Factors that influenced the families' decisions were identified and classified. We found the differences in willingness to donate organs between the two groups. RESULTS: The consent rate of young donor families was 66.67%, while the consent rate of adult donor families was 26.04%. Young donor families easily consented to organ donation than adult donor families (P < 0.005). The donors' families had been affected by various factors throughout the process of deciding to give consent for donation. The findings led to the formulation of an empirically based model of interlinking categories that influence families' decision-making process in organ donation. These factors are grouped into five main categories: (1) personal factors, (2) conditions of organ request, (3) interpersonal factors, (4) ethical factors, and (5) traditional views. The funeral tradition influenced the young donor parents' consent to donation, but had no relation with family decision of adult donors. And the family members of young donors are relatively less, who are more likely to reach a consensus. CONCLUSIONS: Young donor families influenced by traditional funeral beliefs are easier to consent to organ donation than adult donor families. Family members of young donors are relatively less who are more likely to reach a consensus. Acceptance of the expanded criteria donors may improve the organ donation rates, especially those of the advanced age.

[Experience in the use of bronchofibroscopy in the treatment for acute lung injury after liver transplantation].

OBJECTIVE: To evaluate retrospectively the clinical therapeutic effects of the application of bronchofibroscopy(BFS) in the treatment of acute lung injury (ALI) after liver transplantation. METHODS: Fifty-eight patients with ALI caused by various kinds of reasons after liver transplantation were divided into two groups depending on whether the BFS was undertaken (group A, n=36) or not (group B, n=22), and the clinical therapeutic effects were evaluated by comparing the length of intensive care unit (ICU) stay and mechanical ventilation, mortality rate of ALI, morbidity and mortality rate of acute respiratory distress syndrome (ARDS) and changes in arterial blood gas analysis before and after BFS treatment. RESULTS: The length of ICU stay [(11+/-4) days vs. (16+/-4) days] and mechanical ventilation [(9+/-5) days vs. (14+/-5) days, both P<0.01] in group A were shorter, and mortality rate of ALI (11.1% vs. 36.4%), morbidity rate (27.8% vs. 54.5%, P<0.05 and P<0.01) and mortality rate of ARDS [40.0% (4/10) vs. 66.7% (8/12)] were lower in group A compared with group B (P>0.05). Arterial partial pressure of oxygen (PaO(2)), partial pressure of carbon dioxide (PaCO(2)), arterial oxygen saturation (SaO(2)), and oxygenation index (PaO(2)/FiO(2)) after treatment were much better than those before BFS in group A and the differences were significant (all P<0.01). CONCLUSION: BFS is a kind of safe and effective treatment measure for ALI after liver transplantation and is worthwhile to recommend.