The validity of central venous to arterial carbon dioxide difference to predict adequate fluid management during living donor liver transplantation. A prospective observational study.

BACKGROUND: To assess the validity of central and pulmonary veno-arterial CO2 gradients to predict fluid responsiveness and to guide fluid management during liver transplantation. METHODS: In adult recipients (ASA III to IV) scheduled for liver transplantation, intraoperative fluid management was guided by pulse pressure variations (PPV). PPV of ≥15% (Fluid Responding Status-FRS) indicated fluid resuscitation with 250 ml albumin 5% boluses repeated as required to restore PPV to < 15% (Fluid non-Responding Status-FnRS). Simultaneous blood samples from central venous and pulmonary artery catheters (PAC) were sent to calculate central venous to arterial CO2 gap [C(v-a) CO2 gap] and pulmonary venous to arterial CO2 gap [Pulm(p-a) CO2 gap]. CO and lactate were also measured. RESULTS: Sixty seven data points were recorded (20 FRS and 47 FnRS). The discriminative ability of central and pulmonary CO2 gaps between the two states (FRS and FnRS) was poor with AUC of ROC of 0.698 and 0.570 respectively. Central CO2 gap was significantly higher in FRS than FnRS (P = 0.016), with no difference in the pulmonary CO2 gap between both states. The central and Pulmonary CO2 gaps are weakly correlated to PPV [r = 0.291, (P = 0.017) and r = 0.367, (P = 0.002) respectively]. There was no correlation between both CO2 gaps and both CO and lactate. CONCLUSION: Central and the Pulmonary CO2 gaps cannot be used as valid tools to predict fluid responsiveness or to guide fluid management during liver transplantation. CO2 gaps also do not correlate well with the changes in PPV or CO. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03123172 . Registered on 31-march-2017.

Efficacy of contrast-enhanced FDG PET/CT in patients awaiting liver transplantation with rising alpha-fetoprotein after bridge therapy of hepatocellular carcinoma.

OBJECTIVE: To assess the diagnostic accuracy and illustrate positive findings of contrast-enhanced fluorine-18 fluoro-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) image in patients awaiting liver transplantation (LT) with rising alpha-fetoprotein (AFP) after bridge therapy of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: This prospective study included 100 patients who were waiting for LT and who previously underwent locoregional therapy (LRT) of HCC. These patients had rising AFP levels on a routine follow-up examination awaiting LT. All patients underwent a contrast-enhanced 18F-FDG PET/CT examination. We calculated for each patient the maximum standardised uptake value (SUVmax) of the tumour and the ratio of the tumoral SUVmax to the normal-liver SUVmax. The diagnostic accuracy and positive contrast-enhanced findings of 18F-FDG PET/CT were established by histopathology and clinical and imaging follow-up as the reference standards. RESULTS: Contrast-enhanced 18F-FDG PET/CT detected tumour relapse in 78 patients (13 patients had intrahepatic lesions, 10 patients had extrahepatic metastases and 55 patients with combined lesions). The sensitivity, specificity and accuracy values of contrast-enhanced 18F-FDG PET/CT examination in the detection of HCC recurrence were 92.8%, 94.1% and 93%, respectively. A significant correlation was found between the AFP level and SUVmax ratio (r = 0.2283; p = 0.0224). The best threshold for 18F-FDG PET positivity was >1.21. CONCLUSION: Contrast-enhanced 18F-FDG PET/CT is a valuable tool for the detection of intrahepatic HCC recurrence or extrahepatic metastasis following rising AFP levels after LRT of HCC, and should be incorporated during routine workup awaiting LT. KEY POINTS: • 18F-FDG PET/CT is a valuable tool for the detection of HCC recurrence • 18 F-FDG PET/CT should be incorporated during routine workup awaiting liver transplantation • Significant correlation was found between AFP level and SUVmax ratio • The best threshold for 18 F-FDG PET positivity was >1.21 • The ideal cut-off value for AFP was >202.

Right ventricular function as a predictor of short-term mortality in patients with sepsis and septic shock: an observational study.

BACKGROUND: In recent years, attention has shifted to the role of right ventricular (RV) dysfunction in prediction of clinical outcome among patients with septic shock. However, very few studies have correlated RV dysfunction with survival early in the course of sepsis. In the period from September 2021 to July 2022, we included a total number of 248 patients within 24 h of their presentation with sepsis. All patients were subjected to a comprehensive echocardiographic study to evaluate different parameters of RV function and LV systolic and diastolic functions. We aimed primarily to study the predictive value of RV dysfunction on 30-day all-cause mortality rates and ventilator-free days. RESULTS: Almost half of study population (48.4%) showed evidence of RV dysfunction (in isolation or with LV dysfunction), with 25.4% showing evidence of isolated RV dysfunction. Patients with RV dysfunction had a significantly higher APACHE 2 (P < 0.001) score and 30-day all-cause mortality rates (P = 0.003) compared to those without RV dysfunction. A significant association was reported between 30-d mortality and dysfunction status (P = 0.025). Those with no dysfunction had lower mortality (14.1%) than in those with RV dysfunction only (33.3%), LV dysfunction only (20%), and RV + LV dysfunction (31.6%). No significant difference was observed in ventilator free days according to dysfunction status (P = 0.081). A multivariate logistic regression analysis showed that RV dysfunction was among the significant independent predictors for 30-day mortality (OR 2.01, 95% CI 1.07-3.81, P = 0.031), controlling for the effect of age and gender. CONCLUSIONS: In a cohort of ICU patients with early sepsis, RV dysfunction is found to be common and predictive of 30-day mortality irrespective to the LV function.

Bacterial infections post-living-donor liver transplantation in Egyptian hepatitis C virus-cirrhotic patients: A single-center study.

AIM: To determine risk factors, causative organisms and antimicrobial resistance of bacterial infections following living-donor liver transplantation (LDLT) in cirrhotic patients. METHODS: This prospective study included 45 patients with hepatitis C virus-related end-stage liver disease who underwent LDLT at Ain Shams Center for Organ Transplant, Cairo, Egypt from January 2014 to November 2015. Patients were followed-up for the first 3 mo after LDLT for detection of bacterial infections. All patients were examined for the possible risk factors suggestive of acquiring infection pre-, intra- and post-operatively. Positive cultures based on clinical suspicion and patterns of antimicrobial resistance were identified. RESULTS: Thirty-three patients (73.3%) suffered from bacterial infections; 21 of them had a single infection episode, and 12 had repeated infection episodes. Bile was the most common site for both single and repeated episodes of infection (28.6% and 27.8%, respectively). The most common isolated organisms were gram-negative bacteria. Acinetobacter baumannii was the most common organism isolated from both single and repeated infection episodes (19% and 33.3%, respectively), followed by Escherichia coli for repeated infections (11.1%), and Pseudomonas aeruginosa for single infections (19%). Levofloxacin showed high sensitivity against repeated infection episodes (P = 0.03). Klebsiella, Acinetobacter and Pseudomonas were multi-drug resistant (MDR). Pre-transplant hepatocellular carcinoma (HCC) and duration of drain insertion (in days) were independent risk factors for the occurrence of repeated infection episodes (P = 0.024). CONCLUSION: MDR gram-negative bacterial infections are common post-LDLT. Pre-transplant HCC and duration of drain insertion were independent risk factors for the occurrence of repeated infection episodes.

Living donor liver transplantation for high model for end-stage liver disease score: What have we learned?

AIM: To assess the impact of model for end-stage liver disease (MELD) score on patient survival and morbidity post living donor liver transplantation (LDLT). METHODS: A retrospective study was performed on 80 adult patients who had LDLT from 2011-2013. Nine patients were excluded and 71 patients were divided into two groups; Group 1 included 38 patients with a MELD score < 20, and Group 2 included 33 patients with a MELD score > 20. Comparison between both groups was done regarding operative time, intra-operative blood requirement, intensive care unit (ICU) and hospital stay, infection, and patient survival. RESULTS: Eleven patients died (15.5%); 3/38 (7.9%) patients in Group 1 and 8/33 (24.2%) in Group 2 with significant difference (P = 0.02). Mean operative time, duration of hospital stay, and ICU stay were similar in both groups. Mean volume of blood transfusion and cell saver re-transfusion were 8 ± 4 units and 1668 ± 202 mL, respectively, in Group 1 in comparison to 10 ± 6 units and 1910 ± 679 mL, respectively, in Group 2 with no significant difference (P = 0.09 and 0.167, respectively). The rates of infection and systemic complications (renal, respiratory, cardiovascular and neurological complications) were similar in both groups. CONCLUSION: A MELD score > 20 may predict mortality after LDLT.

Donor rejection before living donor liver transplantation: causes and cost effective analysis in an egyptian transplant center.

BACKGROUND: In the living donor liver transplant setting, the preoperative assessment of potential donors is important to ensure the donor safety. OBJECTIVES: The aim of this study was to identify causes and costs of living liver-donors rejection in the donation process. MATERIALS AND METHODS: From June 2010 to June 2012, all potential living liver donors for 66 liver transplant candidates were screened at the Ain Shams Center for Organ Transplantation. Potential donors were evaluated in 3 phases, and their data were reviewed to determine the causes and at which phase the donors were rejected. RESULTS: One hundred and ninety two potential living liver donors, including 157 (81.7%) males, were screened for 66 potential recipients. Of these, 126 (65.6%) were disqualified for the donation. The causes of rejection were classified as surgical (9.5 %) or medical (90.5 %). Five donors (3.9 %) were rejected due to multiple causes. Factor V Leiden mutation was detected in 29 (23 %) rejected donors (P = 0.001), 25 (19.8 %) donors had positive results for hepatitis serology (P = 0.005), and 16 (12.7 %) tested positive for drug abuse. Portal vein trifurcation (n = 9, 7.1%) and small size liver graft estimated by CT volumetric analysis (n = 6, 4.8 %) were the main surgical causes which precluded the donation. CONCLUSIONS: Among potential Egyptian living liver donors, Factor V Leiden mutation was a significant cause for live donor rejection. A stepwise approach to donor assessment was found to be cost-effective.

Cellular interferon-gamma based assay for diagnosis of pulmonary tuberculosis.

A major breakthrough in recent years has been the development of an in vitro assays that measure T-cell release of interferon gamma (IFN-gamma) in response to stimulation with antigens specific to Mycobacterium tuberculosis (MTB) such as early secreted antigenic target 6 (ESAT6) and culture filtrate protein 10 (CFP10). This study aimed at evaluating the diagnostic potential of IFN-gamma in vitro production assay for diagnosis of pulmonary tuberculosis. The study included 40 patients from Abbasia Chest Hospital, Cairo, Egypt. Thirty patients had the provisional clinical and radiological diagnosis of pulmonary tuberculosis (TB), twenty of them had positive acid fast (AF) sputum smears (group I), and ten had negative smears (group II). Bacteriological confirmation of TB was based on cultivation on L.J solid media (group I & II), and by BACTEC radiometric assay (group II). Ten patients with non tuberculous chest diseases were also included as a control group (group III). Effector T cells, within the peripheral blood mononuclear cells, which secrete IFN-gamma in response to stimulation by antigens specific for MTB (ESAT-6 and CFP-10) were analyzed in all subjects using a commercially available assay based on the enzyme linked immunospot technique. We demonstrated that 24 out of 30 (80%) suspected tuberculous patients were bacteriologically confirmed based on positive AF smears and/or culture. In vitro IFN-gamma release assay was positive in 22 of them giving a sensitivity of 91.7%. In the remaining 6 who were not confirmed bacteriologically, the assay showed positive results in 4 (66.7%) of them. Based on bacteriological diagnosis as the gold standard for diagnosis of pulmonary TB, the specificity of the assay was found to be 75%. However the assay results were negative in all non tuberculous patients (group III). It is concluded that the used in vitro IFN-gamma release assay has the potential to become a useful diagnostic tool for active tuberculosis.

Effect of schistosoma mansoni egg deposition on multiple low doses streptozotocin induced insulin dependent diabetes.

To explore the role of Schistosoma mansoni infection in the prevention of autoimmune mediated insulin dependant diabetes mellitus, we examined the effects of multiple low doses of the pancreatic islets beta cell toxin, streptozotocin (STZ) 40mg/kg body weight i.p., given 8 weeks post infection, period of S. mansoni egg deposition, on S. mansoni infected C57BL/6J mice, in comparison to non-infected STZ given group. Mice treated with STZ (G III) became gradually hyperglycemic reaching highest level on days 17 post STZ with mean blood glucose level of 334.9 +/- 14.9 vs 130.3 +/- 9.2 mg/dl in control group (G IV). S. mansoni infection (G II) significantly reduced the elevation in blood glucose levels from days 7 post STZ onwards reaching 224mg/dl +/- 12.7 on days 17 (P < .0.001). Morphologic examination of pancreas on day 21 post STZ, revealed that the non-infected STZ (G III) given mice had significantly smaller mean islets area (5,060.51 mu2 +/- 1,567.28) and significantly fewer mean number of beta cells/islets (76.23 +/- 19.18) than the infected STZ given group (G II) which had mean islets area (9,305. 3l mu2 +/- 3,277.59) and 116.75 +/- 27.27 beta-cells/islets. Pancreatic tissue revealed also focal degeneration in the cells of islets of Langrhans in the non-infected STZ given mice (G III), in comparison, to the infected STZ given group (G II). which had much less evident cells degeneration. These findings revealed that S. mansoni egg deposition which leads to a shift from Th1 (IFN-gamma mainly) to Th2 (IL4, IL5, IL10 and TGF-beta cytokine profiles causes down-regulation of the Th1 cell mediated autoimmune insulin dependant diabetes mellitus (IDDM). On the other hand, S. mansoni eggs excretions were significantly lower in the infected STZ given group (G II) than the infected group (G I). This finding may be the result of impaired maturation of egg in diabetic mice. It is concluded that the modulation of immune response in S. mansoni infected mice with S. mansoni egg deposition, can suppress the autoimmune type 1 insulin dependant diabetes mellitus induced by multiple low doses streptozotocin.