Isoniazid prophylaxis in liver transplant recipient with latent tuberculosis: Is it harmful for transplanted liver?

BACKGROUND: Liver transplantation (LT) is considered the only treatment for patients with end-stage liver disease and, despite its incredible impacts on the patients' health status, places them in an immunocompromised state in which opportunistic infection would find a way to present. Latent tuberculosis infection (LTBI) is the most common form of TB and can be diagnosed through tuberculin skin test (TST) or Interferon-Gamma Release Assays (IGRA). LT recipients are at significant risk of TB activation. There is no strict guideline to approaching these cases though, in most centers, Isoniazid (INH) would be prescribed prophylactically. INH is a hepatotoxic medication and can have adverse effects on the transplanted liver. There is no consensus on this issue; therefore, we aimed to survey the potential hepatotoxic effects of INH among LT recipients in Shiraz, Iran. METHODS: A retrospective cohort study was conducted among LT candidates and recipients at Abu Ali Sina Organ Transplantation Center between 1993 and 2019. All the cases underwent TST and chest X-ray to detect LTBI. All the LTBI were treated with INH from 6-9 months and followed by the level of liver enzymes for quick detection of hepatotoxicity. A control group was selected among LT recipients and matched for age, gender, MELD score, and donor age. RESULTS: Among 4895 medical records reviewed, 55 (1.12%) cases had LTBI. Neither INH-related hepatotoxicity, nor signs and symptoms that were suspicious to TB reactivation were reported. Overall, three deaths were reported, two because of myocardial infarction and one due to pneumonia. Ten patients (18.2%) experienced acute rejection as confirmed with pathology and responded to methylprednisolone. Aspartate aminotransferase (AST) was diminished from pre-LT time to the first time after transplantation; after that, it showed a steady pattern. Meanwhile, Alanine transaminase (ALT) was constant before and one stage later and decreased after that. Statistical analyses only showed significant changes in the total bilirubin titer between the case and control groups. CONCLUSION: This survey showed prophylactic management of LTBI with INH in LT candidates and recipients was associated with no hepatotoxicity or related death. It seems that INH prophylaxis is safe in LT settings and can efficiently prevent TB activation; however, careful monitoring for adverse effects and liver enzymes elevation is highly recommended.

Evaluation of the appropriate use of chest CT-Scans in the diagnosis of hospitalized patients in shiraz teaching hospitals, Southern Iran.

PURPOSE: During recent years, overuse of medical imaging especially computed tomography has become a serious concern. We evaluated the suitable usage of chest computed tomography (CT)-scan, in patients hospitalized in emergency and medical wards of two teaching hospitals of Shiraz University of Medical Science. METHODS: Medical records of 216 patients admitted in two major teaching hospitals (Namazi and Shahid Faghihi), who had undergone chest radiography and at least one type of chest CT were investigated. The clinical and paraclinical manifestations were independently presented to three pulmonologists and their opinion regarding the necessity and type of CT prescription were documented. Also, the patient's history was presented to an expert chest radiologist and asked to rate the appropriateness of chest CT according to American colleague of radiologist (ACR) criteria. RESULTS: In 127 cases (59%), at least 2 out of 3 pulmonologists had the same opinion on the necessity of performing CT scan regardless of CT scan type, in 89 cases (41%) the same CT type and in 38 (17.5%) cases other CT type was supposed. Based on ACR criteria, of total prescribed CTs, 49.5% were "usually not appropriate" and 31.5% of cases were "usually appropriate". Among 109 pulmonary CT angiography, 54 (49.5%) was usually not appropriate base on ACR criteria, which was the most frequent inappropriate requested CT type. CONCLUSION: Considering the high rates of inappropriate utilization of chest CT scan in our teaching hospitals, implementation of the standard guideline at a different level and consulting with a pulmonologist, may prevent unnecessary chest CTs prescription and reduce harm to patients and the health system.

Effects of pentoxifylline on oxygenation and exercise tolerance in patients with severe chronic obstructive pulmonary disease.

BACKGROUND: It was hypothesized that the use of Pentoxifylline would increase arterial O2 saturation and increase exercise tolerance in patients with Chronic Obstructive Pulmonary Disease (COPD). METHODS: We tested this hypothesis in 23 patients with COPD and pulmonary hypertension. Patients were randomized to receive Pentoxifylline or placebo, each for a 12-week period, in a prospective, double-blind study to assess the effects of Pentoxifylline on oxygen saturation and exercise tolerance via pulse oximetry and the 6-Minute Walk Test (6MWT). RESULTS: At the end of the 12 weeks, the six-minute walk distance rose from 351.9±65 meters to 393±67 meters in the Pentoxifylline group (10 patients) and increased from 328±79 meters to 353±66 meters in the placebo group (10 patients) (P=0.142). Resting oxygen saturation by pulse oximetry changed from 87±4% to 85±14% in the Pentoxifylline group and from 88±3% to 88±2% in the placebo group (P=0.676). There were no significant changes in dyspnea severity index and heart rate before and after the 6MWT. CONCLUSION: Pentoxifylline does not seem to improve exercise capacity and dyspnea in patients with severe and very severe COPD.

KIR-HLA gene diversities and susceptibility to lung cancer.

Killer-cell immunoglobulin-like receptors (KIR) are essential for acquiring natural killer (NK) cell effector function, which is modulated by a balance between the net input of signals derived from inhibitory and activating receptors through engagement by human leukocyte antigen (HLA) class I ligands. KIR and HLA loci are polygenic and polymorphic and exhibit substantial variation between individuals and populations. We attempted to investigate the contribution of KIR complex and HLA class I ligands to the genetic predisposition to lung cancer in the native population of southern Iran. We genotyped 16 KIR genes for a total of 232 patients with lung cancer and 448 healthy controls (HC), among which 85 patients and 178 HCs were taken into account for evaluating combined KIR-HLA associations. KIR2DL2 and 2DS2 were increased significantly in patients than in controls, individually (OR 1.63, and OR 1.42, respectively) and in combination with HLA-C1 ligands (OR 1.99, and OR 1.93, respectively). KIR3DS1 (OR 0.67) and 2DS1 (OR 0.69) were more likely presented in controls in the absence of their relative ligands. The incidence of CxTx subset was increased in lung cancer patients (OR 1.83), and disease risk strikingly increased by more than fivefold among genotype ID19 carriers (a CxTx genotype that carries 2DL2 in the absence of 2DS2, OR 5.92). We found that genotypes with iKIRs > aKIRs (OR 1.67) were more frequently presented in lung cancer patients. Additionally, patients with lung cancer were more likely to carry the combination of CxTx/2DS2 compared to controls (OR 2.04), and iKIRs > aKIRs genotypes in the presence of 2DL2 (OR 2.05) increased the likelihood of lung cancer development. Here we report new susceptibility factors and the contribution of KIR and HLA-I encoding genes to lung cancer risk, highlighting an array of genetic effects and disease setting which regulates NK cell responsiveness. Our results suggest that inherited KIR genes and HLA-I ligands specifying the educational state of NK cells can modify lung cancer risk.

Asthma and its related socioeconomic factors: The Shiraz Adult Respiratory Disease Study 2015.

OBJECTIVE: This study aimed to explore the association between the prevalence of asthma and the socioeconomic factors using data from the Shiraz Adult Respiratory Disease Study, 2015(SARDS). METHODS: The SARDS was conducted from June to October 2015 among adult subjects of the general population of Shiraz, Iran. Current asthma was defined as the presence of at least 1 of the following factors in the preceding 12 months: (1) being awakened by an attack of shortness of breath, coughing, or chest tightness without any identifiable cause; (2) having an asthma attack; (3) currently using medication for asthma; or (4) having wheezing or whistling in the chest not associated with a cold or the flu. Information on individual socioeconomic status was derived from self-reported education level, occupation, income, and residence location. A value of P < .05 was considered statistically significant. RESULTS: A total of 4582 respondents aged 20-60 years were included in the analysis. The overall prevalence of adult asthma was 7.8%. The prevalence of asthma was higher significantly among female and subjects with higher body mass index, allergic rhinitis, smokers, jobless, and individuals who live in suburban areas. In the adjusted logistic regression model, being jobless (odds ratio [OR], 2.256; 95% confidence interval [CI], 1.123-4.535) and living in a suburban area (OR, 1.735; 95% CI, 1.058-2.845) were the most significant socioeconomic predictive factors for adult current asthma. CONCLUSIONS: It can be concluded that lower socioeconomic status is associated with higher adult current asthma prevalence. Target interventions are necessary to reduce disparities in healthcare systems.

Epstein-Barr virus hepatitis can cause transient hepatopulmonary syndrome.

INTRODUCTION: Hepatopulmonary syndrome is commonly seen in the patients with chronic liver disease. Acute liver diseases are rarely associated with HPS. We have reported here a case of Transient HPS caused by Epstein-Barr virus hepatitis. CASE REPORT: The patient was a 31 years old man that came to hospital due to RUQ pain and yellowish skin. In examination the patient was tachypnic and O2 saturation was 71% with prominent JVP. ver enzyme and bilirubin were high. All viral hepatitis was negative except anti viral capsid antigen-antibody of EBV. In Blood gas PaO2 was 54 mmHg, O2 saturation 73% and alveolar-arterial gradient was 18 mmHg. Stress Echocardiography with saline injection reported pulmonary arterial pressure 32 cmHg with delayed opacification of left atrium. CONCLUSION: transient HPS can be manifestation in the acute hepatitis caused by EBV infection.

Hypokalemia associated with a solitary pulmonary nodule: A case report.

BACKGROUND: Differential diagnosis of hypokalemia and adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome often presents challenging in endocrinology and requires careful clinical, biochemical, radiological, and pathological investigations. Hypokalemia is a common abnormality and systematic approach is required to avoid delays in diagnosis of important underlying causes. CASE SUMMARY & CONCLUSION: A 49-year-old woman presented with moderate hypokalemia. Further evaluation showed hypercortisolism due to ectopic ACTH secretion.Chest computed tomography (CT) revealed a peripheral solitary pulmonary nodule. Excision biopsy of the nodule showed carcinoid tumor. After excision biopsy, all of the patient's symptoms improved and electrolytes and ACTH levels also became normal.Carciniod tumors should be considered as a differential diagnosis in patients presenting with hypokalemia and ectopic ACTH syndrome. Carcinoid tumor often present as solitary pulmonary nodule and excision biopsy can be curative.

Pulse oximeter oxygen saturation in prediction of arterial oxygen saturation in liver transplant candidates.

BACKGROUND: Liver transplant is the only definitive treatment for many patients with end stage liver disease. Presence and severity of preoperative pulmonary disease directly affect the rate of postoperative complications of the liver transplantation. Arterial blood gas (ABG) measurement, performed in many transplant centers, is considered as a traditional method to diagnose hypoxemia. Because ABG measurement is invasive and painful, pulse oximetry, a bedside, noninvasive and inexpensive technique, has been recommended as an alternative source for the ABG measurement. OBJECTIVES: The aim of this study was to evaluate the efficacy of pulse oximetry as a screening tool in hypoxemia detection in liver transplant candidates and to compare the results with ABGs. PATIENTS AND METHODS: Three hundred and ninety transplant candidates (237 males and 153 females) participated in this study. Arterial blood gas oxyhemoglobin saturation (SaO2) was recorded and compared with pulse oximetry oxyhemoglobin saturation (SpO2) results for each participants. The area under the curve (AUC) of receiver operating characteristic (ROC) curves was calculated by means of nonparametric methods to evaluate the efficacy of pulse oximetry to detect hypoxemia. RESULTS: Roc-derived SpO2 threshold of ≤ 94% can predict hypoxemia (PaO2 < 60 mmHg) with a sensitivity of 100% and a specificity of 95%. Furthermore, there are associations between the ROC-derived SpO2 threshold of ≤ 97% and detection of hypoxemia (PaO2 < 70 mmHg) with a sensitivity of 100% and a specificity of 46%. The accuracy of pulse oximetry was not affected by the severity of liver disease in detection of hypoxemia. CONCLUSIONS: Provided that SpO2 is equal to or greater than 94%, attained from pulse oximetry can be used as a reliable and accurate substitute for the ABG measurements to evaluate hypoxemia in patients with end stage liver disease.

Pulmonary complications in cirrhotic candidates for liver transplantation.

BACKGROUND AND AIMS: The determination of the prevalence of cardiopulmonary complications at a liver transplant center in Iran. METHODS: Ninety-nine patients (61 male and 38 female) with a mean age of 36.5 (15-66) years with proven cirrhosis were enrolled in this study. Patients with primary cardiac disease, current smokers, those with sepsis, hepatocellular carcinoma, recently ruptured esophageal varices and chronic pulmonary or renal diseases were excluded from the study. Sixty-nine patients had ascites. Forty-four patients had grade C Child-Pugh classification. All patients were evaluated for respiratory function by chest X-ray (CXR), room air arterial blood gas, simultaneous pulse oximetry, cardiac echocardiography and spirometry. RESULTS: Sixty-one patients (66.1%) had a widened alveolar-arterial O2 difference ( > 20 mmHg); 14 (14.1%) had hypoxemia; 6 (6.1%) had mean pulmonary arterial pressure (MPAP) = 25-40 mmHg; 12 (12.1%) had tricuspid regurgitation; pleural effusion and lung restriction were detected in 4 (4%) and 50 (50.5%), respectively. P(A-a)O2 was negatively associated with pulmonary hypertension (P < 0.03) and tricuspid regurgitation (P < 0.005). Portal hypertension and portal vein thrombosis were detected in 91 and 8 patients, respectively. CONCLUSIONS: A widened alveolar-arterial oxygen difference was common in our patients, but hypoxemia occurred in 14% of patients. Portopulmonary hypertension was preponderant in those patients of male gender.