C-reactive protein at ICU admission as a marker of early graft dysfunction after liver transplant. A prospective, single-center cohort study / Proteína C reactiva al ingreso en UCI como marcador de disfunción temprana del injerto tras trasplante hepático. Estudio unicéntrico, prospectivo y de cohortes

OBJECTIVE: To explore the behavior of C-reactive protein (CRP) after orthotopic liver transplantation (OLT) during the first postoperative days, and its usefulness as a marker of severe early allograft dysfunction (EAD). DESIGN: A prospective, single-center cohort study was carried out. SETTING: The Intensive Care Unit (ICU) of a regional hospital with a liver transplant program since 1997. PATIENTS: The study comprised a total of 183 patients admitted to our ICU immediately after liver transplantation between 2009 and 2015. VARIABLES OF INTEREST: C-reactive protein levels upon ICU admission and after 24 and 48h, severe EAD and hospital mortality. RESULTS: The CRP levels after OLT were: upon ICU admission 57.5 (51.6-63.3) mg/L, after 24h 80.1 (72.9-87.3)mg/L and after 48h 69.9 (62.5-77.4) mg/L. Severe EAD patients (14.2%) had higher mortality (23.1 vs 2.5; OR 11.48: 2.98-44.19) and lower CRP upon ICU admission (39.3 [29.8-48.7] mg/L) than the patients without EAD (0.5 [53.9-67.0]; p < 0.05] - the best cut-off point being 68mg/L (sensitivity 92.3%; specificity 40.1%; Youden index 0.33). Lower CRP upon ICU admission was correlated to higher mortality (24.5 [9.2-39.7] vs 59.4 [53.4-65.4]; p < 0.01, AUC 0.79 [0.65-0.92]). CONCLUSIÓN: Liver transplant is a strong inflammatory stimulus accompanied by high levels of C-reactive protein. A blunted rise in CRP on the first postoperative day after OLT may be a marker of poor allograft function and is related to hospital mortality

OBJETIVO: Explorar el comportamiento de la proteína C reactiva (PCR) en el postoperatorio inmediato de trasplante hepático y su utilidad como marcador de disfunción grave del injerto hepático. DISEÑO: Estudio de cohortes prospectivo, unicéntrico. ÁMBITO: Unidad de cuidados intensivos (UCI) de un hospital regional. PACIENTES: Ciento ochenta y tres pacientes ingresados en nuestra UCI inmediatamente después del trasplante hepático entre 2009-2015. VARIABLES DE INTERÉS: Niveles de PCR al ingreso en UCI, 24 y 48h, disfunción grave del injerto hepático, mortalidad intrahospitalaria. RESULTADOS: Los niveles de PCR en el postoperatorio inmediato de trasplante fueron: al ingreso en UCI 57,5 (51,6-63,3) mg/L, a las 24h 80,1 (72,9-87,3) mg/L y a las 48h 69,9 (62,5-77,4) mg/L. Los pacientes con disfunción grave del injerto (14,2%) tuvieron una mayor mortalidad (23,1 vs. 2,5; OR 11,48: 2,98-44,19) y PCR más baja al ingreso en UCI (39,3 [29,8-48,7]mg/L) que los pacientes sin disfunción grave (0,5 [53,9-67]; p < 0,05), siendo el mejor punto de corte para la PCR de 68mg/L (sensibilidad 92,3%; especificidad 40,1%; índice de Youden 0,33). La PCR baja al ingreso tuvo correlación directa con la mortalidad (24,5 [9,2-39,7] vs. 59,4 [53,4-65,4]; p < 0,01, AUC 0,79 [0,65-0,92]). CONCLUSIÓN: El trasplante hepático es un estímulo inflamatorio intenso que se acompaña de niveles elevados de PCR. Un ascenso truncado de la PCR, en el primer día del postoperatorio de trasplante hepático, puede ser un marcador de funcionamiento inadecuado del injerto hepático y está relacionado con la mortalidad intrahospitalaria

Early graft dysfunction after liver transplant: Comparison of different diagnostic criteria in a single-center prospective cohort / Disfunción temprana del injerto tras trasplante hepático: Comparación de varios criterios diagnósticos en un estudio unicéntrico, prospectivo y de cohorte

OBJECTIVE: Comparison of different diagnostic criteria for early liver allograft dysfunction (EAD) and their capability to predict mortality. DESIGN: Single-center, prospective, cohort study. SETTINGS: ICU in a Regional Hospital with a liver transplant program since 1997. PATIENTS: 253 consecutive patients admitted to our ICU immediately after liver transplantation between 2009 and 2015. Variables of interest: Differences in the incidence of EAD and its relation with ICU, Hospital and 2-year mortality depending on the definition applied using as comparator the UNOS (United Network for Organ Sharing) primary non-function criterion. RESULTS: The incidence of early liver allograft dysfunction according to UNOS was 13.8%, to Makowka 6.3%, to Ardite 10.7%, to Nanashima 20.6%, to Dhillon 30.8% and to MEAF 13.4%. Kappa test did not show a good correlation among these criteria. EAD was related with ICU mortality for all diagnostic criteria except Dhillon but only UNOS, Makowka and MEAF were associated with 2-year mortality. Hospital mortality was poorly predicted by all criteria except for the MEAF score. CONCLUSIÓN: We found a poor agreement between different criteria analyzed for the diagnosis of EAD. In our population, the MEAF score showed the best relationship with short- and long-term mortality

OBJETIVO: Comparar diferentes criterios diagnósticos de disfunción temprana del aloinjerto hepático y su capacidad para predecir mortalidad. DISEÑO: Estudio de cohortes prospectivo, unicéntrico. Ámbito: Unidad de Cuidados Intensivos de un Hospital Regional con programa de trasplante hepático desde 1997. PACIENTES: 253 pacientes consecutivos ingresados en nuestra UCI inmediatamente después del trasplante entre 2009-2015. Variables de interés: Incidencia de disfunción temprana del aloinjerto hepático según cada criterio diagnóstico, relación entre disfunción grave acorde a cada criterio y mortalidad en UCI, mortalidad hospitalaria y a los 2 años utilizando como comparador el criterio para fallo primario de la UNOS (United Network for Organ Sharing). RESULTADOS: La incidencia de disfunción temprana según UNOS fue 13.8%, Makowka 6.3%, Ardite 10.7%, Nanashima 20.6%, Dhillon 30.8% y MEAF 13.4%. El coeficiente kappa mostró una pobre correlación entre ellos. Todos los criterios, excepto el de Dhillon, mostraron relación con la mortalidad en la UCI, pero solo los criterios de UNOS, Makowka y MEAF se asociaron con la mortalidad a 2 años. Finalmente, la capacidad predictiva de la mortalidad hospitalaria fue baja para todos, excepto para MEAF. CONCLUSIÓN: Existe una pobre correlación entre diferentes criterios diagnósticos de disfunción temprana del injerto hepático. El MEAF muestra la mejor relación con el pronóstico a corto y largo plazo en nuestra población

C-reactive protein at ICU admission as a marker of early graft dysfunction after liver transplant. A prospective, single-center cohort study.

OBJECTIVE: To explore the behavior of C-reactive protein (CRP) after orthotopic liver transplantation (OLT) during the first postoperative days, and its usefulness as a marker of severe early allograft dysfunction (EAD). DESIGN: A prospective, single-center cohort study was carried out. SETTING: The Intensive Care Unit (ICU) of a regional hospital with a liver transplant program since 1997. PATIENTS: The study comprised a total of 183 patients admitted to our ICU immediately after liver transplantation between 2009 and 2015. VARIABLES OF INTEREST: C-reactive protein levels upon ICU admission and after 24 and 48h, severe EAD and hospital mortality. RESULTS: The CRP levels after OLT were: upon ICU admission 57.5 (51.6-63.3)mg/L, after 24h 80.1 (72.9-87.3)mg/L and after 48h 69.9 (62.5-77.4)mg/L. Severe EAD patients (14.2%) had higher mortality (23.1 vs 2.5; OR 11.48: 2.98-44.19) and lower CRP upon ICU admission (39.3 [29.8-48.7]mg/L) than the patients without EAD (0.5 [53.9-67.0]; p<0.05] - the best cut-off point being 68mg/L (sensitivity 92.3%; specificity 40.1%; Youden index 0.33). Lower CRP upon ICU admission was correlated to higher mortality (24.5 [9.2-39.7] vs 59.4 [53.4-65.4]; p<0.01, AUC 0.79 [0.65-0.92]). CONCLUSION: Liver transplant is a strong inflammatory stimulus accompanied by high levels of C-reactive protein. A blunted rise in CRP on the first postoperative day after OLT may be a marker of poor allograft function and is related to hospital mortality.

Early graft dysfunction after liver transplant: Comparison of different diagnostic criteria in a single-center prospective cohort.

OBJECTIVE: Comparison of different diagnostic criteria for early liver allograft dysfunction (EAD) and their capability to predict mortality. DESIGN: Single-center, prospective, cohort study. SETTINGS: ICU in a Regional Hospital with a liver transplant program since 1997. PATIENTS: 253 consecutive patients admitted to our ICU immediately after liver transplantation between 2009 and 2015. VARIABLES OF INTEREST: Differences in the incidence of EAD and its relation with ICU, Hospital and 2-year mortality depending on the definition applied using as comparator the UNOS (United Network for Organ Sharing) primary non-function criterion. RESULTS: The incidence of early liver allograft dysfunction according to UNOS was 13.8%, to Makowka 6.3%, to Ardite 10.7%, to Nanashima 20.6%, to Dhillon 30.8% and to MEAF 13.4%. Kappa test did not show a good correlation among these criteria. EAD was related with ICU mortality for all diagnostic criteria except Dhillon but only UNOS, Makowka and MEAF were associated with 2-year mortality. Hospital mortality was poorly predicted by all criteria except for the MEAF score. CONCLUSION: We found a poor agreement between different criteria analyzed for the diagnosis of EAD. In our population, the MEAF score showed the best relationship with short- and long-term mortality.

Concordancia en pacientes críticos entre las ecuaciones diseñadas para la estimación del filtrado glomerular y el aclaramiento de creatinina en orina de 24h / Concordance in critical patients between the equations designed for the calculation of glomerular filtration rate and 24-hour creatinine clearance

Objetivo: Estudiar el comportamiento de las ecuaciones empleadas para estimar el filtrado glomerular cuando se aplican a pacientes críticos y comparar con el método actualmente más aceptado: el aclaramiento de creatinina (ClCr) en orina de 24h (ClCr-24h). Diseño: Estudio retrospectivo de una base de datos procedente de un estudio prospectivo observacional previo. Ámbito: Una unidad de cuidados intensivos polivalente en un hospital de tercer nivel. Participantes: Todos los pacientes adultos ingresados en nuestra unidad con sondaje vesical. Se excluyó a los pacientes en anuria. Intervenciones: A los pacientes seleccionados se les midió el ClCr-24h y aplicamos las ecuaciones Modified Diet in Renal Disease (MDRD), Jelliffe modificada (JF), Clínica Mayo (CM) y Cockroft-Gault (C-G) para estimar el filtrado glomerular. Variables de interés: Para valorar el grado de acuerdo, agrupamos a los pacientes según el ClCr-24h como normales (>70 ml/min/1,73m2), con disfunción moderada (69-50 ml/min/1,73m2) y con disfunción renal grave (<50ml/min/1,73m2). Resultados: Trescientos siete pacientes de 54±18 años, el 69,7% varones. El ClCr-24h fue de 109,2±78,2ml/min/1,73m2 y el estimado de 95,5±56,7 ml/min/1,73m2 para JF, de 87,4±53,4 ml/min/1,73m2 para C-G, de 86,9±55,9 ml/min/1,73m2 para MDRD y de 85,6±39,9 ml/min/1,73m2 para CM. La diferencia fue significativa (p<0,001) para todas las medidas, pero menor para JF (13,7±53,2 ml/min/1,73m2) que para C-G (21,9±58,3 ml/min/1,73m2), CM (23,6±59,6 ml/min/1,73m2) o MDRD (22,3±60,4 ml/min/1,73m2). El coeficiente de correlación fue 0,73 para JF; 0,67 para C-G y CM y 0,64 para MDRD. El grado de acuerdo fue discreto en todos los casos (estadístico κ de 0,55 para JF y MDRD; 0,51 para C-G, y 0,5 para CM). Conclusiones: La ecuación de JF muestra mayor concordancia con el ClCr que las de C-G, MDRD o CM cuando se aplica a pacientes de unidad de cuidados intensivos. Sin embargo, cuando se requiere una medición fiable, ninguna de ellas es adecuada y es necesario en estos casos calcular el ClCr (AU)

Objective: To study the behavior of the different equations used to estimate glomerular filtration rate (GFR) applied to critical care patients compared to the standard method: 24-hour creatinine clearance (24-CrCl). Design: Retrospective analysis of data base from a previous observational prospective study. Setting: Polyvalent ICU in a tertiary Hospital. Population: All adult patients admitted to our Unit during the study who had a bladder catheter inserted. Anuric patients were excluded. Interventions: We measured 24-CrCl and estimated GFR by MDRD, modified Jelliffe (JF), Mayo-Clinic (CM) and Cockroft-Gault (C-G) equations. Variables: To evaluate degree of agreement, we grouped patients regarding 24-CrCl as normal (>70), moderate dysfunction (69-50) or severe renal dysfunction (< 50mL/min/1.73m2). Results: 307 patients, aged 54±18, 69.7% males. Measured 24-CrCl was 109.2±78.2mL/min/1.73m2 and the estimate one 95.5±56.7 for JF, 87.4±53.4 for C-G, 86.9±55.9 for MDRD and 85.6±39.9 for CM. The difference was significant (p<0.001) for all estimates but lower for (13.7±53.2mL/min/1.73m2) than C-G (21.9±58.3), CM (23.6±59.6) or MDRD (22.3±60.4). Correlation coefficient was 0.73 for JF, 0.67 C-G or CM and 0.64 for MDRD. The degree of agreement was only fair for all measures (Kappa 0.55 for JF or MDRD, 0.51 for C-G and 0.5 for CM). Conclusions: Modified Jelliffe equation showed higher agreement with 24-CrCl than Cockroft-Gault, MDRD or Mayo-Clinic equations when used in critically ill patients. However, when exact measurement is needed, none of the equations can be considered adequate and in these cases, the CrCl should be calculated (AU)

[Concordance in critical patients between the equations designed for the calculation of glomerular filtration rate and 24-hour creatinine clearance]. / Concordancia en pacientes críticos entre las ecuaciones diseñadas para la estimación del filtrado glomerular y el aclaramiento de creatinina en orina de 24h.

OBJECTIVE: To study the behavior of the different equations used to estimate glomerular filtration rate (GFR) applied to critical care patients compared to the standard method: 24-hour creatinine clearance (24-CrCl). DESIGN: Retrospective analysis of data base from a previous observational prospective study. SETTING: Polyvalent ICU in a tertiary Hospital. POPULATION: All adult patients admitted to our Unit during the study who had a bladder catheter inserted. Anuric patients were excluded. INTERVENTIONS: We measured 24-CrCl and estimated GFR by MDRD, modified Jelliffe (JF), Mayo-Clinic (CM) and Cockroft-Gault (C-G) equations. VARIABLES: To evaluate degree of agreement, we grouped patients regarding 24-CrCl as normal (>70), moderate dysfunction (69-50) or severe renal dysfunction (< 50 mL/min/1.73 m(2)). RESULTS: 307 patients, aged 54+/-18, 69.7% males. Measured 24-CrCl was 109.2+/-78.2 mL/min/1.73 m(2) and the estimate one 95.5+/-56.7 for JF, 87.4+/-53.4 for C-G, 86.9+/-55.9 for MDRD and 85.6+/-39.9 for CM. The difference was significant (p<0.001) for all estimates but lower for (13.7+/-53.2 mL/min/1.73 m(2)) than C-G (21.9+/-58.3), CM (23.6+/-59.6) or MDRD (22.3+/-60.4). Correlation coefficient was 0.73 for JF, 0.67 C-G or CM and 0.64 for MDRD. The degree of agreement was only fair for all measures (Kappa 0.55 for JF or MDRD, 0.51 for C-G and 0.5 for CM). CONCLUSIONS: Modified Jelliffe equation showed higher agreement with 24-CrCl than Cockroft-Gault, MDRD or Mayo-Clinic equations when used in critically ill patients. However, when exact measurement is needed, none of the equations can be considered adequate and in these cases, the CrCl should be calculated.