Browsing UA Faculty Publications by Publisher "ELMER PRESS INC"
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Differential Simultaneous Liver and Kidney Transplant Benefit Based on Severity of Liver Damage at the Time of TransplantationBackground: We evaluated the concept of whether liver failure patients with a superimposed kidney injury receiving a simultaneous liver and kidney transplant (SLKT) have similar outcomes compared to patients with liver failure without a kidney injury receiving a liver transplantation (LT) alone. Methods: Using data from the United Network of Organ Sharing (UNOS) database, patients were divided into five groups based on pre-transplant model for end-stage liver disease (MELD) scores and categorized as not having (serum creatinine (sCr) <= 1.5 mg/dL) or having (sCr > 1.5 mg/dL) renal dysfunction. Of 30,958 patients undergoing LT, 14,679 (47.5%) had renal dysfunction, and of those, 5,084 (16.4%) had dialysis. Results: Survival in those (liver failure with renal dysfunction) receiving SLKT was significantly worse (P < 0.001) as compared to those with sCr < 1.5 mg/dL (liver failure only). The highest mortality rate observed was 21% in the 36+ MELD group with renal dysfunction with or without SLKT. In high MELD recipients (MELD > 30) with renal dysfunction, presence of renal dysfunction affects the outcome and SLKT does not improve survival. In low MELD recipients (16 - 20), presence of renal dysfunction at the time of transplantation does affect post-transplant survival, but survival is improved with SLKT. Conclusions: SLKT improved 1-year survival only in low MELD (16 - 20) recipients but not in other groups. Performance of SLKT should be limited to patients where a benefit in survival and post-transplant outcomes can be demonstrated.
Efficacy of Low Dose Chemoprophylaxis for Coccidioidomycosis Infection in Liver Transplant RecipientsBackground: Coccidioidomycosis (CM) infections among transplant recipients result in significant morbidity and mortality. The goal of our study was to establish the efficacy of low dose (LD) versus standard dose (LD, 50 mg daily) fluconazole in preventing CM infection. Methods: This was a retrospective study utilizing electronic medical records of liver transplant recipients at the University of Arizona. The primary end point was post-transplant CM status, such as infection, complications and survival. Results: We detected a statistically significant correlation between positive pre-transplant status and positive post-transplant status (hazards ratio: 8.25 (95% confidence interval: 1.028 - 66.192)). There was a trend towards improved survival in patients who had a positive post-transplant CM status in the SD group versus LD group (90.9% versus 81.3%), although not statistically significant. Conclusion: The risk of CM infection among transplant recipients in the absence of prophylaxis is associated with high morbidity and mortality. We currently use SD fluconazole as universal prophylaxis in all transplant recipients despite not establishing statistical significance between LD and SD. We believe that the survival trend detected may have not reached statistical significance due to low power impact. Since the standardization of SD prophylaxis at our institution, we have not diagnosed further new post-transplant CM infections.
Fungal Infection in Acutely Decompensated Cirrhosis Patients: Value of Model for End-Stage Liver Disease ScoreBackground: Infection in acute-on-chronic liver failure (ACLF) patients is known to cause higher mortality. The current approach is to culture all patient samples. There are no published data evaluating fungal infections in acutely decompensated patients. In this study, we aim to identify clinical factors predictive of infections within ACLF patients and assess workup compliance within 24 h of hospital admission. Methods: We retrospectively analyzed the charts of 457 ACLF patients seen at the University of Arizona between January 1, 2014 and December 31, 2014. We used logistic regression to identify potential risk indicators for bacterial, fungal, and any infections. In order to proceed to a systemic infection workup, the following parameters were assessed: complete blood count, urinalysis, urine culture, bacterial blood culture, chest X-ray, and ascitic fluid analysis in patients with ascites. Additionally, serological markers were also assessed in patient samples. Systemic inflammatory response syndrome (SIRS) was defined as the presence of two or more of the following criteria: temperature > 38 degrees C or < 36 degrees C, heart rate > 90 beats/min, respiratory rate > 20 breaths/min, white blood cell count > 12,000 or < 4,000 cells/mm or > 10% bands. Results: An established infection was observed in 60.61% of ACLF patients. SIRS criteria predicted infections with concordance statistic (C-statistic) of 0.71 (odds ratio (OR) 6.85, 95% confidence interval (CI): 4.33, 10.85) for any infection, 0.63 (OR 2.88, 95% CI: 1.96, 4.23) for bacterial infection, and 0.53 (OR 1.32, 95% CI: 0.59, 2.96) for fungal infection. After including other significant variables (over 10 additional variables), predictive ability improved, C-statistic 0.83 (95% CI: 0.77, 0.90) for any infection and 0.71 (95% CI: 0.65, 0.77) for bacterial infections. The combination of model for end-stage liver disease (MELD) and hemoglobin (Hb) predicted fungal infections with C-statistic 0.74 (95% CI: 0.63, 0.84). Workup within 24 h of admission was obtained in 12% of patients. Conclusions: Fungal infections in ACLF patients results in an increased mortality rate. Elevated MELD and low Hb in combination predict fungal infections. Compliance is very poor to obtain diagnostic workup efficiently, better tools are needed to predict infection upon admission.