No abstract

Background: There is a lack of high-level evidence identifying meaningful outcomes and the place in therapy for systemic perioperative antifungal prophylaxis (ppx) in pancreas transplant recipients. As our program does not routinely utilize systemic perioperative antifungal ppx in pancreas transplant recipients, we assessed the incidence of post-transplant infectious complications. Methods: This was a single-center, retrospective cohort study of consecutive adult pancreas transplant recipients between 01/2016 and 04/2018 to describe the incidence of fungal infections. Patients with a history of previous simultaneous pancreas-kidney (SPK) transplant, HIV, or unexplained use of antifungal ppx after transplantation were excluded. The primary outcome was the incidence of fungal infections within 3 months after transplantation. Results: After screening 60 patients, 56 met inclusion criteria. Within 3 months posttransplantation, two (3.6%) patients had a positive fungal culture requiring systemic antifungal treatment. The sources for infection in both cases were intra-abdominal fluid cultures, positive for Candida albicans. Both patients were treated with fluconazole. Allograft-related outcomes included a 6-month pancreas graft survival of 91.1% and pancreas transplant rejection incidence of 10.7%. Conclusion: In this single-center experience, pancreas transplant recipients not receiving systemic antifungal ppx had similar infectious and graft-related outcomes to what is reported in literature. K E Y W O R D S fungal infection, pancreas transplantation, perioperative, prophylaxis

Less than two-thirds of centers utilize the FDA-approved daily dosing regimen with various methods of CrCl calculation and serum creatinine assay measurements used. More retrospective and prospective studies with clinical outcomes associated with VCGV dosing strategies are warranted to determine the most appropriate prophylaxis and treatment strategies for CMV.

Purpose There is a lack of high-level evidence identifying meaningful outcomes and the optimal place in therapy of rasburicase in patients with, or at high risk for tumor lysis syndrome. The primary objective of this study was to evaluate and characterize outcomes resulting from an institution-specific guideline emphasizing supportive care, xanthine oxidase inhibitors, and lower doses of rasburicase. Methods In this retrospective chart review, we compared conservative rasburicase dosing, in accordance with newly developed UMHS tumor lysis syndrome guidelines, with aggressive rasburicase in adult patients (≥ 18 years of age) with hematological or solid tumor malignancies, and a uric acid level between 8 and 15 mg/dL. The primary efficacy outcome assessed the difference in the proportion of patients achieving a uric acid level <8 mg/dL within 48 h using a one-sided noninferiority test. The principle safety outcomes analyzed included incidence of acute kidney injury and hemodialysis requirement. Results One hundred sixty-one patients met inclusion criteria and were included in the study. Within 48 h of an elevated uric acid level, treatment was successful in 97.03% of patients in the conservative group, as compared with 98.33% in the aggressive group (difference, 1.3 percentage points; 95% confidence interval [CI], -3.33 to 5.93). Furthermore, there was no difference in the proportion of patients requiring hemodialysis (2.97% vs. 10.0%, p-value 0.079), or incidence of acute kidney injury (4.0% vs. 12.5%, p-value 1.00) between the treatment group and control group, respectively. Conclusions Conservative rasburicase use was noninferior to aggressive rasburicase use in patients with or at high risk for tumor lysis syndrome.

This is the first description of liver injury secondary to garlic supplementation. Therefore, this garlic supplement should be listed as a potential cause of acute drug-induced liver injury.

Primary sclerosing cholangitis (PSC) frequently progresses to end-stage liver disease and cirrhosis, requiring liver transplantation. Approximately 70% of patients with PSC have concomitant inflammatory bowel disease (IBD) during their clinical course. After liver transplantation for PSC, corticosteroids and other high-intensity immunosuppressants are initiated to keep IBD in remission. Patients with IBD that is refractory to these agents may need to be managed with biologic therapies. Biologic agents, however, may further increase the risks for malignancy and infection due to their immunosuppressive effects. Thus, to gain a better understanding of the risks and benefits of these agents in this high-risk patient population, we performed a literature search of the PubMed database (2002-2017) to identify studies assessing the efficacy and safety of various biologic agents for the management of IBD in liver transplant recipients. No randomized controlled studies or retrospective comparative studies were identified; however, 15 case reports and case series were identified that met our inclusion criteria. From these case reports, we identified 67 patients who developed de novo or recurrent IBD after liver transplantation and received anti-tumor necrosis factor-α or anti-integrin therapy. Of the 13 published cases reporting clinical response or remission of IBD activity in liver transplant recipients (59 patients), clinical response or remission of IBD was reported in 38 (64.4%) of those patients. Adverse complications reported included cholangitis, oral candidiasis, Clostridium difficile colitis, bacterial pneumonia, cryptosporidiosis, Epstein-Barr virus-positive posttransplantation lymphoproliferative disease, and hepatotoxicity. Given the limited literature (case reports and case series) highlighted in this review, biologic agents such as tumor necrosis factor-α inhibitors and integrin inhibitors commonly used for moderate to severe IBD may be appropriate after liver transplantation; however, consideration of risk versus benefit should always occur in a patient-specific manner.

Social Media: Do kidney transplant patients require antiviral prophylaxis to prevent hepatitis B virus reactivation? Check out the results of our multicenter study here < link to visual

Introduction: Recent evidence remains inconclusive about the impact of atrial fibrillation (AF) on prognosis after intravenous thrombolysis and/or intra-arterial (IA) acute stroke treatment (AIS). Hypothesis: AF (either first episode or chronic) adversely affects stroke outcomes in patients undergoing IA treatment for AIS. Methods: We analyzed data from the 434 subjects in the IA treatment arm of Interventional Management of Stroke (IMS) III trial. The trial included AIS patients who were eligible for IV rtPA infusion within three hours after stroke onset. The subjects that were randomized to the IA treatment arm later received a protocol approved endovascular treatment. Demographics, vascular risk factors, and outcome measures were compared between patients with and without atrial fibrillation. The main outcomes considered were early neurological deterioration and hemorrhagic complications, excellent (mRS: scores of 0-2) functional outcome at 3 months, and good quality of life (EQ-5D index 0.5-1.0) at one year from randomization. Adjusted logistic regression analysis was performed to compare these outcomes. Results: Of the 434 patients who were studied (mean ± SD age, 66.3 ± 12.3 years, with 50.2% of patients being men), 153 had AF either chronic or diagnosed at baseline EKG and 281 had no AF. The patients with AF were significantly older (age 71.2±8.2 vs. 63.6±13.3 years), had more severe strokes (NIHSS>=20) at baseline assessment (40.5% vs. 24.9%). The subjects with AF had higher adjusted odds of early neurological deterioration (OR 1.3, 95%CI 0.6-1.9, p=0.81), symptomatic intracranial hemorrhage (OR 1.7; 95% CI 0.7-3.8; p=0.27), and subarachnoid hemorrhage (OR 1.4; 95% CI 0.7-2.7; p=0.31). The subjects with AF had lower odds of having good functional outcome 3 months after randomization (OR 0.8; 95% CI 0.4-1.1; p=0.06). The two groups did not differ in their adjusted odds of symptomatic ICH, parenchymal hematomas, 90 days mortality, and quality of life after one year. Conclusions: In the patients undergoing IA treatment for AIS, AF may adversely impact early recovery in neurological function and long-term functional outcomes but not the rates of hemorrhagic complications, mortality, or good quality of life.