Validation of the Children's Sleep Habits Questionnaire in a sample of Greek children with allergic rhinitis.

BACKGROUND: Obstructive respiratory disorders, such as allergic rhinitis and asthma may impair sleep quality. The aim of this study is to validate the Children's Sleep Habits Questionnaire (CSHQ) for Greek children from 6 to 14 years of age. No validated tool has been developed so far to assess sleep disturbances in Greek school-aged children. METHODS: We examined the reliability and validity of the CSHQ in a sample of children with allergic rhinitis (AR) and a non-clinical population of parents of these children as a proxy measure of children's AR quality of life (QoL) as evaluated by the Pediatric Allergic Rhinitis Quality of Life (PedARQoL) questionnaire. RESULTS: The CSHQ questionnaire Child's Form (CF) had a moderate internal consistency with a Cronbach's alpha 0.671 and Guttman split-half coefficient of 0.563 when correlated with the PedARQoL (CF). There was also a moderate intraclass correlation of ICC=0.505 between the responses to both questionnaires in the two visits. The CSHQ Parent's Form (PF) had a very good internal consistency with a Cronbach's alpha of 0.928 and Guttman split-half coefficient of 0.798. There was a high intraclass correlation of 0.643 between the responses in the two visits. CONCLUSIONS: The Greek version of the CSHQ CF, but particularly the PF has proved to be a very reliable clinical instrument, which can be used in clinical trials for assessing sleep quality in school-aged children with sleep disturbances because of obstructive airway disorders, such as AR.

Assessment of IgE-mediated food allergies in children with atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is an inflammatory disease of the skin, which is characterised by a chronic relapsing course. AIM: The aim of the study was to assign the prevalence of clinically active food allergies among a group of children between 3 months and 7 years of age, with AD. METHODS: Eighty-eight children with AD were screened for specific IgE antibodies to food proteins. All patients with AD and specific IgE antibodies to food proteins were subjected to Oral Food Challenges (OFCs) with the relevant foods. RESULTS: Food-sensitised patients with moderate levels of sIgE had clinically active food allergy to milk (39.28%) and egg (42.34%) on the basis of positive OFCs. High IgE and eosinophilia had a prevalence of almost 80% and 25%, regardless of concomitant food sensitisation and disease severity. CONCLUSIONS: In this study, clinically active food allergies were recognised in 26.13% of children with AD. Nevertheless, no association was confirmed between food sensitisation and AD severity. High IgE and peripheral eosinophilia have not been found more prevalent among children with severe AD nor among children with food sensitisation. Infants and younger children with AD should be screened for an underlying food allergy, regardless of disease severity.

Nucleos(t)ide analog(s) prophylaxis after hepatitis B immunoglobulin withdrawal against hepatitis B and D recurrence after liver transplantation.

BACKGROUND/AIMS: Nucleos(t)ide analogs (NAs) have made a hepatitis B immunoglobulin (HBIG)-sparing protocol an attractive approach against hepatitis B virus (HBV) recurrence after liver transplantation (LT). However, this approach is considered controversial in patients transplanted for HBV and hepatitis D (HDV) co-infection. MATERIAL/METHODS: All patients transplanted for HBV/HDV cirrhosis were evaluated. After LT, each patient received HBIG + NAs and then continued with NAs prophylaxis. All patients were followed up with HBV serum markers and HBV DNA, while anti-HDV/HDV RNA was performed in those with HBV recurrence. RESULTS: A total of 34 recipients were included (22 men, age: 46.7 ± 16 years). After HBIG discontinuation, NAs were received as monoprophylaxis (lamivudine [LAM]: 2, adefovir [AFV]: 1, entecavir: 9, tenofovir [TDF]: 12) or dual prophylaxis (LAM + AFV [or TDF]: 10 patients). Two (5.8%) of the 34 patients had HBV/HDV recurrence after HBIG withdrawal (median follow-up: 28 [range, 12-58] months). These 2 patients had undetectable HBV DNA at LT. Statistical analysis revealed that those with recurrence had received HBIG for shorter period, compared to those without recurrence (median: 9 vs. 28 months, P = 0.008). CONCLUSIONS: We showed for the first time, to our knowledge, that maintenance therapy with NAs prophylaxis after HBIG discontinuation was effective against HBV/HDV recurrence, but it seems that a longer period of HBIG administration might be needed before it is withdrawn after LT.

Heterozygous liver transplantation for maple syrup urine disease: First European reported case.

MSUD is an autosomal recessive metabolic disorder that results from a defect in the BCKDH enzyme. This enzyme is essential for the second step in the metabolism of the branched-chain amino acids, leucine, isoleucine, and valine. Patients with MSUD are subject to severe, irreversible neurologic injury unless closely managed with a specialized metabolic formula and a diet restricted in leucine throughout their lifetime. During times of illness, patients with MSUD can suffer from severe metabolic derangement, acute cerebral edema, and untimely death. Deceased donor liver transplant restores the ability to metabolize branched-chain amino acids, even on an unrestricted diet, and prevents metabolic derangements during times of illness. We report a successful case of living donor (parental) transplant for a child with MSUD. The donor was the child's father. This approach has been controversial as parents of children with MSUD are obligate heterozygotes for the condition and have diminished levels of BCKDH activity. If effective, living-related donor transplant provides a promising alternative for deceased donor liver transplant, which often requires a prolonged waiting period and may not be feasible in areas with limited medical resources.

Association of Double-J Stenting in Renal Transplant Patients With Urinary Tract Colonization and Infections in a Multidrug-resistant Microbe Endemic Nosocomial Environment.

PURPOSE: We investigated the association of ureteral stenting after kidney transplantation with the development of urinary tract infections (UTIs) and/or urinary tract colonization, in a hospital environment considered endemic for multidrug resistant (MDR) Gram-negative Enterobacteriaceae. METHODS: Seventy-five recipients of deceased donor grafts were divided in groups A and B. Group A (with subgroups A1 and A2) included 45 transplanted patients without urinary stenting, and group B 30 patients with stenting. Subgroup A1 consisted of 30 patients transplanted before 2006, and A2 of 15 patients transplanted after 2006, when MDR, mainly carbapenem-resistant, Enterobacteriaceae, frequency has risen in our hospital. RESULTS: The incidence and the number of UTIs per patient were significantly higher in patients without stenting compared to those with stenting. (Group A: 32/45 vs group B: 9/30, P < .001, and group A: 2.86 ± 0.43 vs group B: 0.6 ± 0.19, P < .01 respectively). Patients without stenting tended to have a higher frequency of recurrent UTIs compared to those with stenting (group A: 16/45 vs group B: 4/30, P < .05). Asymptomatic bacteriuria was more frequent in the patients with stent (group A: 8/45 vs group B: 14/30, P < .05). Further sub-comparison of the A1 and A2 subgroups with group B did not change the statistical results. CONCLUSIONS: There is no clinically significant association of ureteral stenting after kidney transplantation with the high frequency of MDR Gram-negative bacteria in our hospital.

Hepatic Artery Anatomic Variations and Reconstruction in Liver Grafts Procured in Greece: The Effect on Hepatic Artery Thrombosis.

AIMS: Variations of the anatomy of donor hepatic arteries increase the number of arterial anastomoses during liver transplantation and, possibly, the incidence of hepatic artery thrombosis (HAT). In this study, we describe the arterial anatomic variations in liver grafts procured and transplanted by a single center in Greece, the techniques of arterial anastomosis, and their effect on the incidence of early HAT. MATERIALS AND METHODS: From January 2013 to December 2017, the arterial anatomy of 116 grafts procured for liver transplantation were recorded, as well as the technique of arterial anastomosis and the incidence of early hepatic artery thrombosis (HAT <30 days). RESULTS: A single hepatic artery was recorded in 72.41% of the procured grafts, an aberrant left hepatic artery (accessory or replaced) in 18 grafts (15.52%), and an aberrant right hepatic artery (accessory or replaced) in 17 grafts (14.66%), while other variations were observed in less than 1% of the procured livers. Of the 116 primary liver transplantations, 6 patients (5.17%) developed early HAT <30 days. Two of these patients (1.72%) had 1 anastomosis of the hepatic artery and 4 (3.45%) had 2 anastomoses due to anatomic variations. CONCLUSIONS: Anatomic variations of the hepatic artery in liver grafts is a common finding and increase the incidence of early HAT but not to a degree to make these grafts unusable.

Perioperative Chemoprophylaxis οr Treatment for Extensively Drug Resistant Gram-Negative Bacteria in Patients Undergoing Liver Transplantation Based on Preoperative Donor/Recipient Surveillance Cultures: A Prospective Study.

INTRODUCTION: The importance of preoperative donor/recipient colonization or donor infection by extensively drug-resistant Gram-negative bacteria (XDR-GNB) and its relation to serious post-transplantation infection pathogenicity in liver transplantation (LT) patients has not been clarified. AIM: Prevention of postoperative infection due to XDR-GNB with the appropriate perioperative chemoprophylaxis or treatment based on preoperative donor/recipient surveillance cultures in LT patients, as well as their outcome. MATERIALS AND METHOD: Twenty-six patients (20 male, 6 female) were studied (average preoperative Model for End-Stage Liver Disease score ≈15, range: 8-29) from January 2017 to January 2018. In all patients, blood, urine, and bronchial secretions culture samples as well as a rectal colonization culture were taken pre- and postoperatively, once weekly after LT, and after intensive care unit discharge. Recipients with positive XDR-GNB colonization and patients receiving a transplant from a donor with an XDR-GNB positive culture or colonization received the appropriate chemoprophylaxis one half hour preoperatively according to culture results. De-escalation of the antibiotic regimen was done in 2 to 5 days based on the colonization/culture results of the donor and recipient and their clinical condition. Evaluation for serious infection was done at 1 week and at 28 days for outcome results. RESULTS: Fourteen out of 26 recipients (53.8%) were positive for XDR-GNB colonization preoperative, with 2/14 (14.28%) presenting serious infection due to the same pathogen. Intensive care unit length of stay was significantly longer in colonized with XDR-GNB patients (P < .0001). The outcome of colonized patients was 6/14 (42.8%) expired, but only in 2/14 (14.2%) was mortality attributable to infection. CONCLUSION: Administering appropriate perioperative chemoprophylaxis and treatment may limit the frequency of XDR-GNB infections and intensive care unit length of stay and may improve the outcome in LT recipients.

Colonization and Infection With Extensively Drug Resistant Gram-Negative Bacteria in Liver Transplant Recipients.

BACKGROUND: Infections due to extensively drug resistant Gram-negative bacteria (GNB) after solid organ transplantation are increasing in prevalence and are associated with high morbidity and mortality. Surveillance culture (SC) seems to be an important tool for extensively drug resistant GNB control. The aim of this study was to evaluate colonization rates and subsequent infections by XDR-GNB in liver transplant recipients. MATERIAL AND METHODS: This was a prospective cohort study in patients who underwent liver transplantation (LT) between January 2016 and January 2018. Data on demographics, extensively drug resistant colonization, and 3-month clinical outcomes were obtained. Colonization was defined as a positive surveillance culture (SC-perirectal) immediately before transplantation, once weekly after LT, and after intensive care unit discharge, with emphasis to carbapenem-resistant Gram-negative bacteria (CR-GNB). RESULTS: Forty-four patients who underwent LT were included in the study. Ten patients (22.72%) were colonized with CR-GNB prior to transplantation, and 7/10 (70%) developed infection due to the same pathogen (5 patients bloodstream infections, 2 patients pneumonia) during the study period. Intensive care unit length of stay was significantly longer in colonized with CR-GNB patients (P < .05). Mortality rate was higher in colonized patients (30%) than in noncolonized (11.76%) (P = .2). CONCLUSION: Our study results suggest an overall 70% risk of CR-GNB infection among colonized patients. Given the high mortality rate and the difficulty in treating these infections, further research to investigate and develop strategies to eliminate the colonization is needed.

Cyclosporine enhances liver regeneration: the role of hepatocyte MHC expression and PGE2--a study relevant to graft immunogenicity.

AIM: We have investigated CsA induced liver hyperplasia to explore the potential effects on the immunogenicity of the regenerating liver within the clinical context of rejection after transplantation. MATERIALS AND METHODS: Flow cytometry analysis of hepatocytes, isolated 48 hours after 2/3 partial hepatectomy (PH2/3) or sham operation in rats, was performed to determine the effect of CsA on DNA synthesis and MHC molecule expression. The possible role of PGE2 was evaluated by the administration of SC-19220, an EP1-PGE2 receptor antagonist. RESULTS: CsA augmented liver regeneration and this was partially attenuated by SC-19220. The moderate expression of class I MHC expression, as well as the very low class II MHC expression detected in normal hepatocytes by flow cytometry was augmented after PH2/3 and reduced by CsA. The CsA-mediated decrease of hepatocyte immunogenicity was not SC-19220 dependent. CONCLUSIONS: It is proposed that the enhancing effect of CsA on hepatocyte proliferation is by means of an indirect mechanism that can be attributed to a) reduced immunogenicity of the regenerating liver as a result of inhibition of class I and II MHC hepatocyte expression and b) increased PGE2 synthesis in the liver mediated by its action on EP1 receptor.

Tc-99m sestamibi accuracy in detecting parathyroid tissue is increased when combined with preoperative laboratory values: a retrospective study in 453 Greek patients with chronic renal failure who underwent parathyroidectomy.

PURPOSE: Technetium(99m) sestamibi (MIBI) has poor sensitivity and specificity when applied to patients with secondary hyperparathyroidism. We investigated whether the combination of MIBI with preoperative parameters increased its accuracy. PATIENTS AND METHODS: This prospective study of 453 consecutive patients with secondary hyperparathyroidism who underwent parathyroidectomy (bilateral neck exploration) included preoperative MIBI scintigraphy compared with intraoperative and histopathology findings. Four patient groups were comprised according to the results: true positivity (TP), true negativity (TN), false positivity (FP), and false negativity (FN). RESULTS: MIBI scintigraphy sensitivity, specificity, positive predictive value, and negative predictive value were 66.4%, 50%, 76.3%, and 37.9%, respectively. For the TP group, mean age and mean parathormone (PTH) value were 56 years and 754, respectively. The binary logistic regression for the prediction (1) or not (2) of TP was as follows: 0.138 + (-.011) * age + 0.001 * PTH (P = .012). For the TN group, the mean age and mean phosphate value were 49 years and 5.24, respectively. The binary logistic regression for the prediction (1) versus not (2) of the TN was as follows: -1.463 + age * (-.029) + phosphate * 0.233 (P = .012). CONCLUSION: MIBI accuracy in patients with secondary hyperparathyroidism was increased when combined with other preoperative parameters. The sensitivity was increased as patients were older and the PTH levels were lower. The specificity was increased as patients were younger and the phosphate levels were lower.

Use of everolimus in de novo renal recipients: initial experience in the Greek population.

Although everolimus has proven to be as clinically efficacious as mycophenolate mofetil (MMF), there are reports that proliferation signal inhibitors are associated with poor tolerability. This study reported the experience of a Greek transplant center using either everolimus or MMF in de novo renal transplant recipients. In this retrospective study, a cohort of 40 patients who received everolimus after renal transplant was matched for 10 descriptive parameters with a cohort of another 40 patients who received MMF. The primary endpoint was renal function measured by creatinine and its clearance as well as wound dehiscence and opportunistic infections. The mean creatinine clearance at month 3 was 61.03 +/- 16.99 mL/min versus 60.99 +/- 8.03 for living related recipients on everolimus versus MMF, respectively. The mean creatinine clearance at month 3 was 71.24 +/- 12.61 and 62.61 +/- 20.24 mL/min for cadaveric recipients on everolimus versus MMF, respectively. In addition, the incidence of wound dehiscence was 33.34% versus 3.92% and the incidence of cytomegalovirus infection, 8.33% versus 17.64% for the same two groups, respectively.

Impact of double-j ureteric stent in kidney transplantation: single-center experience.

We retrospectively evaluated the use of double-j stent and the incidence of urological complications in 2 groups of patients who received a kidney transplant. From January 2005 to September 2007 we studied 172 patients receiving kidney transplants, 65 and 107 from living and cadaver donors, respectively. From the 172 patients, a total of 34 were excluded due to ureterostomy or Politano-Leadbetter ureterovesical anastomosis. Another 21 patients were excluded from the study due to graft loss due to acute or hyperacute rejection, cytomegalovirus (CMV) infection, or vascular complication. The remaining patients were divided into 2 groups: group A (44 patients) and B (73 patients) with versus without the use of a double-j-stent, respectively. The 2 groups were comparable in terms of donor and recipient gender, ischemia time, and delayed graft function. We failed to observes significant differences between the 2 groups in mean hospital stay (23 +/- 9 and 19 +/- 9), urinary leak (2.3% and 4.1%), and urinary tract infection (20.4% and 19.2%), among groups A and B, respectively. The only difference observed concerned the gravity of the urinary leak; no surgical intervention was needed among the double-j stent group versus 2 patients demanding ureterovesical reconstruction in the nonstent group. In conclusion, our data suggested that the routine use of a double-j stent for ureterovesical anastomosis neither significantly increased urinary tract infection rates, nor decreased the incidence of urinary leaks, but may decrease the gravity of the latter as evidenced by the need for surgical intervention.

The evolution of the role of liver transplantation in treating alcoholic cirrhosis in Greece.

BACKGROUND: Liver transplantation represents the main treatment for alcoholic cirrhosis. The goal of this article is to review the results of liver transplantation for alcoholic cirrhosis in Greece over the last 2 decades. METHODS: Among 247 patients who underwent liver transplantation between 1991 and 2007, 34 (13.7%) experienced alcoholic cirrhosis as the primary diagnosis. We reviewed their demographic data, stage of liver disease, and outcomes regarding survival via a Kaplan-Meier curve. Also we analyzed the causes of death and the postoperative complications. RESULTS: Mean Model for End-Stage Liver Disease (MELD) score was 18.4. Other diagnoses included hepatitis C virus (HCV; 23.5%), hepatitis B virus (HBV; 14.7%), and hepatocellular carcinoma (8.8%). Eleven patients died the most frequent causes being primary graft nonfunction (n = 3), hepatic artery thrombosis (n = 2), sepsis (n = 2), and portal vein thrombosis (n = 2). Complications included rejection (32.4%), infection (26.5%), hepatic graft dysfunction (11.8%), and recurrent HCV, recurrent HBV, and renal failure (8.8% each). Recurrence of alcoholism was observed in 3 patients (8.8%) with mild effects on liver function tests. There has been a significant increase in the number of liver transplantations for alcoholic cirrhosis in the last 6 years, namely 25 patients versus 9 in the previous 10 years. CONCLUSIONS: We observed a significant increase in the frequency of alcoholic cirrhosis leading to liver transplantation in the last several years in Greece.

New-Onset Diabetes After Transplantation: Comparison Between a Cyclosporine-Based and a Tacrolimus-Based Immunosuppressive Regimen.

INTRODUCTION: New-onset diabetes after transplantation (NODAT) is a complication of renal transplantation (RT) with an adverse effect on graft survival. OBJECTIVES: The purpose of the present study was to compare modifiable or non-modifiable clinical and laboratory parameters as well as the course of patients and transplants between 2 groups of RT recipients with NODAT in relation to the use of either a cyclosporine-based (group A) or a tacrolimus-based immunosuppressive regimen (group B). MATERIALS AND METHODS: Retrospectively comparing 66 renal transplant recipients with NODAT, multiple clinical, and laboratory parameters were investigated. For statistical analysis, the χ2 test, the Student t test, and the patient and graft survival or the Kaplan-Meier analysis from the statistical software SPSS 22.0 for Windows were used. RESULTS: There was no statistically significant difference in association with the majority of the investigated parameters. In group B (tacrolimus [Tac]), more patients had HbA1c >7.2% at 3 years after RT. The mean value of systolic blood pressure was higher in group A (cyclosporine [CsA]) at 6 months and at 1 year after RT. More patients in group A (CsA) experienced at least one acute rejection episode. Finally, greater levels of cold ischemia time were recorded in group B (Tac) and statistically significant difference was found in connection with the patient and graft survival in the fourth year after RT. CONCLUSIONS: NODAT in patients on tacrolimus requires the adjustment of modifiable clinical and metabolic parameters and possible change of the immunosuppressive regimen to a cyclosporine-based one.

Liver transplantation outcomes in patients with cirrhosis and hepatocellular carcinoma: experience of a single center in a viral hepatitis endemic area.

Our center has performed 205 orthotopic liver transplantations (OLT) in 201 patients. Hepatocellular carcinoma (HCC) was discovered in 32 (15%) patients, 5 of whom were diagnosed incidentally in recipient explants. The main underlying diagnosis was viral hepatitis (n = 28; 87.5%). Most patients (17; 53.1%) were diagnosed as having Child class B cirrhosis. Single tumors measuring <3 cm were diagnosed in 29 (90.6%) patients. Downstaging chemoembolization was performed in 7 (21.8%) patients. Preoperative aFP levels were normal in 20 (62.5%) patients. In the rest (n = 12; 37.5%), aFP levels normalized immediately after the OLT. In the latter group, 2 patients had a delayed (2 years) postoperative increase in aFP levels; both patients had tumor recurrence in the graft. All patients with hepatitis B received antiviral treatment with HBIG and lamivudine. There were 9 deaths (28.1%) in the immediate postoperative period (<30 days). One-year survival rate was 62.5% (n = 20). Actuarial 5-year survival rate was 55%, and actuarial 10-year survival rate was 40%. In conclusion, OLT has become the standard treatment for patients diagnosed with HCC in a population that shows cirrhosis most of the time to be secondary to viral hepatitis, provided that recipients are selected according to the size of the neoplasm and that they receive adequate antiviral prophylaxis.

Orthotopic liver transplantation for hepatic GVHD following allogeneic BMT for chronic myeloid leukaemia.

A 21-year-old man who had an HLA-identical sibling donor BMT for chronic myeloid leukaemia developed grade IV acute GVHD of the liver that was unresponsive to corticosteroids and anti-IL2 receptor monoclonal antibody. He was treated with an orthotopic liver transplant and is currently well 6 months later with normal liver function and no evidence of GVHD in the transplanted liver.

Prosthetic mesh repair of multiple recurrent and large abdominal hernias in continuous ambulatory peritoneal dialysis patients.

OBJECTIVE: The aim of this study was to find out whether prosthetic mesh repair of recurrent and large abdominal hernias in continuous ambulatory peritoneal dialysis (CAPD) patients is effective in maintaining them on CAPD. DESIGN: Retrospective analysis of case notes over a period of 5 years. SETTING: Single renal unit of a university hospital. PATIENTS: Forty-six of 217 CAPD patients (16%) had their hernias repaired. Among them, 5 women in whom hemodialysis was not possible had multiple or large hernias repaired with polypropylene (PP) mesh. RESULTS: Radical repair was achieved by a modified operation consisting of a conventional hernioplasty complemented by a supporting prostetic overlay mesh, without discontinuation of CAPD. The patients continued CAPD for a mean period of 17.6 months without hernia recurrence. Two patients died in the twelfth and fifteenth post-operative month due to cardiac arrest and hepatic failure, respectively, and the remaining 3 are alive and have been doing well on CAPD for 13, 14, and 21 months. CONCLUSIONS: Prosthetic mesh repair of large recurrent hernias in CAPD patients with vascular access problems seems to be a valuable method to maintain them on this renal replacement therapy.

Impact of the Model for End-stage Liver Disease (MELD) score on liver transplantation in Greece.

INTRODUCTION: The impact of preoperative Model for End-stage Liver Disease (MELD) score in postoperative mortality remains unclear. The assumption that patients with a higher MELD score will have a higher mortality rate is not confirmed and studies are contradictory. AIM: The study of the clinical course of patients with a higher MELD score and its impact in immediate and later mortality in comparison with patients with a lower MELD score in the only liver transplantation center in Greece. METHOD: We retrospectively studied 71 patients who underwent orthotopic liver transplantation (OLT) in the time period between 1-1-2011 and 31-12-2013. The patients were divided into 2 groups: Group A with a MELD score ≥23 and Group B with a MELD score <23. RESULTS: In the patients with a MELD score ≥23 the duration of mechanical ventilation and length of stay in the ICU were prolonged (P = .013 and .009, respectively), the transfusions were more (P = .005), and the rates of ICU readmissions (22.5% vs 7.31%, P = .001) and infections (42.5% vs 17.5%, P = .011) were higher. Thirty-day mortality did not differ between the 2 groups (P = .420), but there was a statistically significant difference in morbidity and in 180-day mortality. CONCLUSION: The patients with a higher MELD score have more complex pathophysiology. This score seems to affect morbidity and late, but not early, mortality.

Tigecycline for treatment of carbapenem-resistant Klebsiella pneumoniae infections after liver transplantation in the intensive care unit: a 3-year study.

BACKGROUND: This 3-year prospective, observational, single-center study was undertaken to describe prescription, microbiology findings, tolerance, and efficacy of tigecycline for carbapenem-resistant Klebsiella pneumoniae (CRKP) infections after liver transplantation in the intensive care unit (ICU). METHODS: All patients after liver transplantation treated with tigecycline for ≥3 days for CRKP infections in our ICU from January 1, 2010, to December 31, 2012, were studied. Patient characteristics, indication of treatment, bacteriology, and ICU mortality were collected. The main end points were clinical and microbiologic efficacy and tolerance of tigecycline. RESULTS: Over the study period, 8 men and 2 women (18 CRKP isolates), aged 54.3 ± 7.7 years, were included in the study. Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores on ICU admission were 13.7 ± 2.7 and 10 ± 2.2, respectively. In 7 isolates, tigecycline was prescribed for CRKP blood stream infection (BSI), in 6 for complicated intra-abdominal infection (IAI), in 2 for ventilator-associated pneumonia (VAP), in 2 for surgical site infection, and in 1 for urinary tract infection. In 4 cases, tigecycline was prescribed for secondary BSI followed by VAP and/or IAI. All isolates were susceptible to tigecycline, 83.4% to colistin, 44.5% to gentamicin, and 27.8% to amikacin. In 2 patients, tigecycline was prescribed as monotherapy. Three patients had clinical failure. The microbiologic response rate was 70%. Superinfection was detected in 5 patients, and Pseudomonas aeruginosa was the most frequently isolated pathogen. Tigecycline was generally well tolerated. The ICU mortality rate was 60% with attributable mortality rate 30%. CONCLUSIONS: Our pilot study suggests that tigecycline shows a good safety and tolerance profile in patients with CRKP infections in the ICU after orthotopic liver transplantation. Limited therapeutic options for such infections leave physicians no choice but to use tigecycline for off-label indications such as urinary tract and blood stream infections.

Causes and incidence of renal replacement therapy application in orthotopic liver transplantation patients: our experience.

BACKGROUND: Renal dysfunction is commonly found in patients with end-stage liver disease, as well as after liver transplantation, and it often needs renal replacement therapy (RRT) with the application of continuous or intermittent methods. The aim of this study was the recording of the patients who underwent continuous venovenous hemodiafiltration (CVVHDF) in the early postoperative period, as well as the recording of mortality and risk factors. METHODS: We retrospectively examined 71 patients who underwent orthotopic liver transplantation during a 2-year period (2011-2012). We recorded the incidence of acute kidney injury (AKI), according to the Acute Kidney Injury Network criteria, and we distinguished 2 groups of patients. Group A included those who needed RRT during the 1st 7 days after transplantation, and group B included the patients who did not require RRT. The RRT method of choice was CVVHDF. RESULTS: In group A, the population of patients who presented AKI reached 52.1%, and 22.5% of the them underwent RRT. The mean Model for End-Stage Liver Disease and Acute Physiology and Chronic Health Evaluation scores were higher in group A, who also presented greater hemodynamic instability and more frequent infections and required more transfusions. The transfusion of >10 units of red blood cells was recognized as a risk factor for RRT (P = .024; odds ratio, 1.15; 95% confidence interval, 1.8-7.53). CONCLUSIONS: Patients who required RRT immediately after surgery had a significantly higher rate of mortality and it seemed that the number of transfusions played an important role in this.