Causes of Hemoptysis in Renal Transplant Patients.

OBJECTIVES: Hemoptysis is a symptom that can be caused by airway disease, pulmonary parenchymal disease, or pulmonary vascular disease, or it can be idiopathic. Infection is the most common cause of hemoptysis, accounting for 60% to 70% of cases. Hemoptysis is also an initial symptom of diffuse alveolar hemorrhage syndrome, although it may be absent at presentation in one-third of patients. Diffuse alveolar hemorrhage is characterized by disruption of the alveolar-capillary basement membranes because of either injury or inflammation of the arterioles, venules, or capillaries, resulting in bleeding in alveolar spaces. To date, no study in the literature has investigated the cause of hemoptysis in renal transplant patients. In this retrospective study, we aimed to investigate the causes of hemoptysis in renal recipients. MATERIALS AND METHODS: The data included in this study were obtained from 352 renal transplant patients who were consulted by the pulmonology department regarding hemoptysis between 2011 and 2017 at Baskent University. Patient medical records were reviewed for demographic, clinical, radiographic, bronchoscopic features, and microbiology data. Immunosuppressive drugs and clinical outcome data were also noted. RESULTS: This study included 352 renal transplant patients (139 male patients with mean age of 34.9 ± 7 years and 113 female patients with mean age of 31.1 ± 5 years). Hemoptysis was detected in 17 patients (4.8%),with 3 (0.85%) having massive hemoptysis as a result of diffuse alveolar hemorrhage syndrome. Fourteen of our patient group (4%) had pneumonia, and Aspergillus species was detected in 5 patients (1.4%). The only reason for diffuse alveolar hemorrhage was immunosuppressive agents, including sirolimus and mycophenolate mofetil. CONCLUSIONS: Hemoptysis is an important respiratory symptom in renal transplant patients. Although community- or hospital-acquired pneumonia may result in hemoptysis, drug-induced diffuse alveolar hemorrhage and Aspergillus infection should be considered for causes in renal transplant patients.

Clinical Characteristics of Acinetobacter baumannii Infection in Solid-Organ Transplant Recipients.

OBJECTIVES: Acinetobacter baumannii, depending on the immune status of the host, may result in one of the most serious hospital infections. Infections involving A. baumannii infection have been recently rising. However, little is known about the clinical features of A. baumannii infection in solid-organ transplant recipients. We aimed to share our clinical experiences with A. baumannii infection in our transplant recipients. MATERIALS AND METHODS: Between 2011 and 2017, 41 solid-organ transplant patients developed A. baumannii infection at Baskent University Hospital. Medical records were reviewed, and patient demographics, microbiology results, and overall outcome data were noted. RESULTS: Of 41 solid-organ transplant patients with A. baumannii infection, 29 were male and 12 were female patients with mean age of 47.15 ± 13.24 years. Our infection rate with A. baumannii infection was 6.1%. The most common sites of infection were deep tracheal aspirate (48.8%)and bloodstream (36.6%). Onset of infection 1 year posttransplant was identified in 58.5% of recipients. Risk factors included presence of invasive procedures (56.1%) and administration of high-dose corticosteroids for rejection 1 year before infection (68.3%). Thirty-day mortality rate was 41.5% (17/41 patients) and was not associated with the infection site, microbiological cure, clinical cure, and drug resistance in our study group. CONCLUSIONS: Acinetobacter baumannii is an important cause of hospital-acquired infection and mortality worldwide. A major problem with A. baumannii infection is delayed initiation of appropriate antibiotic treatment and the rising numbers of extensively drug-resistant organisms. Predicting the potential risk factors, especially in the already at-risk solid-organ transplant population, has an important role in patient outcomes.

American Society of Anesthesiologists Classification Versus ARISCAT Risk Index: Predicting Pulmonary Complications Following Renal Transplant.

OBJECTIVES: Patients with chronic renal failure are prone to pulmonary complications. Renal transplant recipients should undergo complete preoperative evaluation to determine risk of postoperative pulmonary complications. The American Society of Anesthesiologists classification and the Assess Respiratory Risk in Surgical Patients in Catalonia risk index correlate well with incidence of postoperative pulmonary complications. Here, we compared their accuracy in predicting pulmonary complications following renal transplant. MATERIALS AND METHODS: We retrospectively reviewed medical records of renal transplant recipients between years 2004 and 2015. We collected patient data on Assess Respiratory Risk in Surgical Patients in Catalonia risk index, including demographics, smoking history, comorbidities, preoperative pulmonary risk score, laboratory results, surgery information, history of lower respiratory tract infection 1 month pretransplant, urgency of surgery, American Society of Anesthesiologists classification, and pulmonary complications within 1 month posttransplant. RESULTS: Of 172 patients (123 males; mean age 38.82 y), 22 (12.8%) developed pulmonary complication during the first month posttransplant, including effusion (9 patients), pneumonia (10 patients), respiratory inefficiency (2 patients), and pulmonary embolism (1 patient). Atelectasis was observed in 95.4% of patients with complications. A positive correlation was observed between age and development of complications (r = 0.171; P = .025). Regarding risk score, 75% of patients at high risk and 19.5% at intermediate risk developed pulmonary complications. Patients with low-risk scores had significantly lower complications than intermediate- and high-risk groups (P < .001). A positive correlation was observed between preoperative risk score and complications (r = 0.34; P < .001). There was no association between the American Society of Anesthesiologists scores and postoperative complications (P = .7). CONCLUSIONS: The American Society of Anesthesiologists classification was found to be a weaker modality to predict pulmonary complications after renal transplant; as it relates to the general health status, than the Assess Respiratory Risk in Surgical Patients in Catalonia risk index.

Culture-Positive Pulmonary Aspergillosis Infection: Clinical and Laboratory Features of Solid-Organ Transplant Recipients.

OBJECTIVES: Aspergillosis is a common fungal infection among solid-organ transplant recipients. Even after awareness of this infection occurs, there are still gaps in nonculture diagnostic tests, which can delay treatment initiation. Here, we aimed to define the common traits of pulmonary aspergillosis infection among solid-organ transplant recipients, thus shedding light on prevention and early diagnosis. MATERIALS AND METHODS: We conducted a database search of patients at Baskent University who had a positive aspergillosis culture between January 2010 and March 2016. Among 20 patients identified, 15 (mean age of 50.93 ± 11.17 y, 2 female and 13 male patients) with solid-organ transplant were included in the study. RESULTS: Of the 15 study patients, 7 were heart transplant, 6 were kidney transplant, and 2 were liver transplant recipients. Three patients had positive aspergillosis cultures from extrapulmonary specimens (1 brain biopsy and 2 wound swap cultures). Other patients with positive cultures were from bronchoalveolar lavage (6 patients), sputum (4 patients), both bronchoalveolar lavage and sputum (1 patient), and deep tracheal aspiration specimen (1 patient). Aspergillus fumigatus was the most common species. Mean hospitalization duration was 31.53 days (range, 2-135 d). Although all patients had positive culture results, 7 patients (46.7%) had negative galactomannan test results at the time of culture specimen collection. Positive galactomannan test results were statistically higher in 6 heart transplant patients (P = .045). All patients had fever at presentation, and 13 patients had been referred to the pulmonary disease department before positive culture results were obtained. CONCLUSIONS: Risk factors for pulmonary aspergillosis and its clinical presentation in solid-organ transplant recipients are still unclear. Although the expected time for aspergillosis infection in solid-organ transplant recipients is 6 months after transplant, clinicians must remember the nonspecific presentation of infections in these patients and be aware of the reliability of diagnostic tools.

Peripheral Muscle Strength Indicates Respiratory Function Testing in Renal Recipients.

OBJECTIVES: Muscle wasting occurs in renal recipients due to decreased physical performance, and decreased respiratory muscle strength may occur due to changes in structure and function. Data are scarce regarding the roles of sarcopenia and nutritional status on respiratory muscle function in these patients. Here, we evaluated interactions among peripheral muscle strength, sarcopenia, nutritional parameters, and respiratory muscle function in renal transplant recipients. MATERIALS AND METHODS: Ninety-nine patients were prospectively enrolled between September and April 2016 at Baskent University. Forced vital capacity values (via pulmonary function tests), respiratory muscle strength (via maximal static inspiratory and expiratory pressures), and peripheral muscle strength (via hand grip strength test) were recorded. Nutritional parameters, fat weight, arm circumference, waist circumference, and C-reactive protein levels were also recorded. RESULTS: Of 99 patients, 68 were renal transplant recipients (43 men, mean age: 39.09 ± 10.70 y) and 31 were healthy participants (14 men, mean age: 34.94 ± 10.95 y). Forced vital capacity (P < .001, r = 0.65), maximal inspiratory (P = .002, r = 0.39) and expiratory (P < .001, r = 0.4) pressure, and hand grip strength showed significant relations in transplant recipients. Positive correlations were found between serum albumin levels and both hand grip strength (P = .16, r = 0.347) and forced vital capacity (P = .03, r = 0.436). Forced vital capacity was statistically different between renal recipients and healthy participants (P = .013), whereas maximal inspiratory and expiratory pressures were not (P > .05). No statistically significant relation was observed between biochemical parameters and maximal inspiratory and expiratory pressures (P ? .05). CONCLUSIONS: Respiratory function and peripheral muscle strength were significantly related in renal transplant recipients, with significantly lower peripheral muscle strength suggesting the presence of inadequate respiratory function. Peripheral and respiratory muscle training and nutritional replacement strategies could help to improve postoperative respiratory function.

Association Between Preoperative Pulmonary Risk Scores and Postoperative Complications in Renal Transplant Recipients.

OBJECTIVES: Patients who are being considered for renal transplant must undergo thorough preoperative pulmonary evaluation to determine risk of postoperative pulmonary complications. The aim of this study was to determine the relation between the preoperative pulmonary risk factor score and pulmonary complications in patients undergoing renal transplant. MATERIALS AND METHODS: Medical records of patients who underwent renal transplant at our institution between 2004 and 2015 were retrospectively reviewed. Patient demographics, smoking history, comorbidities, and preoperative pulmonary risk factors (age, oxygen saturation, hemoglobin level, type of incision, duration of surgery, history of lower respiratory tract infection 1 month before surgery, urgency of surgery), and type of pulmonary complications within 1 month after transplant were recorded. RESULTS: Our study included 131 patients (94 male patients; mean age of 38.25 ± 12.96 y). Of total patients, 21(16%) developed complications during the first month after transplant, with 10 of the 21 (7.6% overall) developing pulmonary complications. These complications were pleural effusion (2 patients), pneumonia (3 patients), respiratory failure (2 patients), and pulmonary embolism (1 patient). There were no deaths directly attributed to the pulmonary complications. A significant correlation was observed between the preoperative pulmonary risk factor score and postoperative pulmonary complications in renal transplant recipients (P = .003). A positive correlation between the preoperative pulmonary scores and postoperative pulmonary complications existed among life-long nonsmokers (r = 0.371; P = .003). CONCLUSIONS: Renal transplant is an established modality in treatment of chronic renal failure. Prevention of pulmonary complications is essential for successful outcomes following transplant. Health care professionals involved with renal transplant and transplant centers should be aware of preoperative pulmonary risk factors. Patients should be observed so that these risk factors can be reduced before planned transplant. Moreover, we also suggest that smoking history should be considered as a preoperative pulmonary risk factor as it was found to be a factor leading to postoperative pulmonary complications in our study.

Smoking Is Related to Postoperative Pulmonary Complications and Graft Outcomes in Renal Transplant Patients.

OBJECTIVES: Renal transplant is an important treatment option for end-stage renal disease. A successful kidney transplant improves the quality of life and reduces the mortality risk compared with maintenance dialysis in patients with end-stage renal disease. Several immunologic and nonimmunologic factors are responsible for graft outcomes in renal transplant patients. Our study was performed to evaluate the role of smoking on postoperative pulmonary complications and graft outcomes in renal transplant patients. MATERIALS AND METHODS: Our study retrospectively analyzed 1740 patients who had renal transplants between 1987 and 2014 at Baskent University. Patients with smoking data were included in the study. Patient demographic, smoking status, comorbid diseases, postoperative pulmonary complications, graft outcomes, and clinical features were recorded. The relation between postoperative pulmonary complications and risk factors was investigated. RESULTS: Our study included 131 adult renal transplant recipients who had smoking data. The incidence of postoperative pulmonary complications was 16% (21 patients) in the first month after surgery. Smoking history was found in 52 patients (39.7%). There was a statistically significant relationship between the presence of atelectasis and smoking history (P = .004). A positive and statistically significant correlation was detected between atelectasis and pack-years smoking (r = 0.424; P = .001). We evaluated graft rejection within 1 month after transplant regardless of being acute cellular or humoral rejection. The relation between smoking history and graft rejection within 1 month after transplant was significant (P = .011). CONCLUSIONS: Renal transplant patients who are smokers have an increased risk for early postoperative pulmonary complications. Furthermore, cigarette smoking contributes to allograft loss in renal transplant patients. Smoking cessation before surgery can reduce the risk of early postoperative complications.

Role of Serum Procalcitonin Levels in Solid-Organ Transplant Patients.

OBJECTIVES: Systemic infection is among the common complications after solid-organ transplant and is associated with increased mortality and morbidity. Because it has prognostic significance, timely diagnosis and treatment are crucial. Procalcitonin is a propeptide of calcitonin and has been increasingly used as a biomarker of bacterial infection. Here, we investigated procalcitonin's role in identifying infectious complications in solid-organ transplant recipients. MATERIALS AND METHODS: We retrospectively evaluated the records of 86 adult patients who underwent solid-organ transplant (between 2011 and 2015) with procalcitonin levels determined at our center. Clinical and demographic variables and laboratory data were noted. Relation between C-reactive protein and procalcitonin serum levels were compared in patients who were diagnosed as having pneumonia on clinical, microbiologic, and radiologic findings. RESULTS: Mean age of our patients was 45.5 ± 13.4 years (range, 18-70 y), with 61 male patients (70.9%). We included 26 liver, 44 kidney, 14 heart, and 2 heart and renal transplant recipients. Procalcitonin was positive in 43 patients (50%). Of the 39 patients who were diagnosed with pneumonia, procalcitonin was positive in 18 patients (46.2%). There was a significant correlation between serum levels of procalcitonin and C-reactive protein (r = 0.45; P < .001) and neutrophil count (r = 0.24; P = .025). There was no correlation between mortality and procalcitonin level, CRP level, or leukocyte count (P > .05). CONCLUSIONS: Our findings indicate that procalcitonin is a promising biomarker to detect infectious complications in transplant recipients. Physical examination and radiologic findings of bacterial pneumonia may be nonspecific, and in a considerable number of immunocompromised patients the site of infection could not be identified. Serum levels of procalcitonin should not be used as sole criteria for clinical decision making; however, it can guide us in therapy of such conditions in addition to currently used serum markers of infection.

Postoperative Pleural Effusions After Orthotopic Heart Transplant: Cause, Clinical Manifestations, and Course.

OBJECTIVES: Postoperative pleural effusions are common in patients who undergo cardiac surgery and orthotopic heart transplant. Postoperative pleural effusions may also occur as postcardiac injury syndrome. Most of these effusions are nonspecific and develop as a harmless complication of the surgical procedure itself and generally have a benign course. Here, we investigated the cause and clinical and laboratory features of postoperative early and late pleural effusions in orthotopic heart transplant patients. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 50 patients who underwent orthotopic heart transplant between 2004 and 2015 at Baskent University. Patient demographics and clinical and laboratory data, including cause of heart failure, presence of pleural effusions at chest radiography in the first year after transplant, timing of onset, microbiologic and biochemical analyses of pleural effusions, and treatment strategies were noted. RESULTS: Mean age of patients was 39.22 ± 13.83 years (39 men, 11 women). Reason for heart failure was dilated cardiomyopathy in most patients (76%). Nineteen patients (38%) had postoperative pleural effusions, with 15 patients (78.9%) with pleural effusion during the first week after transplant. Of these, 4 patients had recurrent pleural effusion. A diagnostic thoracentesis was performed in 10 patients, with 4 showing transudative effusion and 6 showing exudative effusion secondary to infection (2 patients), postcardiac injury syndrome (1 patient), and hemothorax (3 patients). Aspergillus fumigatus was detected by quantitative culture from pleural effusion in 1 patient. Tube thoracoscopy drainage was performed in 10 patients (25%), and 2 patients received antibiotic therapy. CONCLUSIONS: Pleural effusions are frequent after cardiac transplant. Complications may occur in a small portion of patients, with most effusions being nonspecific and having a benign course with spontaneous resolution. Early diagnostic thoracentesis could improve postoperative outcomes in these patients.

Awareness of Respiratory Failure Can Predict Early Postoperative Pulmonary Complications in Liver Transplant Recipients.

OBJECTIVES: Cardiovascular and respiratory system complications are the most common causes of early mortality after liver transplant. We evaluated the causes of respiratory failure as an early postoperative pulmonary complication in liver transplant recipients. MATERIALS AND METHODS: Patients who underwent orthotropic liver transplant between 2001 and 2014 were retrospectively evaluated. Clinical and demographic variables and pulmonary complications at the first and second visit after transplant were noted. The first visit was within the first week and the second was between 1 and 4 weeks after transplant. An arterial oxygen saturation value below 90% in room air for at least 1 day was considered a medically significant respiratory failure. RESULTS: Our study included 204 (148 men and 56 women; mean age 43.0.4 ± 13.06 y) adult liver transplant recipients (46 from deceased and 158 from living donors). At the first visit after transplant, 161 patients (79%) had postoperative pulmonary complications, including pleural effusion accompanied by atelectasis (47.1%), only atelectasis (17.2%), and only pleural effusion (10.3%). At the second visit, complications included atelectasis associated with pleural effusion (12.3%) and pneumonia (12.3%). All patients had documented respiratory failure at the first visit, and 92 patients (45.1%) had respiratory failure at the second visit. Causes of respiratory failure at the first visit included atelectasis in 35 patients (17.2%) and atelectasis accompanied by pleural effusion in 96 patients (47.1%). At the second visit, 25 of 161 patients (25.3%) had respiratory failure due to pneumonia. Other causes included atelectasis accompanied by pleural effusion (24.2%) and pleural effusion (23.2%). Ninety-seven patients had no pulmonary complications. The mortality rate was 6.4% within the first visit and 8.7% within the second visit. CONCLUSIONS: Pneumonia, atelectasis, and pleural effusion can cause respiratory failure within the first month after liver transplant. Early pulmonary examination, diagnosis, and treatment can improve patient survival.

Postoperative pulmonary complications in living-liver donors: a retrospective analysis of 188 patients.

OBJECTIVES: Living-donor liver transplant has become a viable option and an important source of hepatic grafts. The goal of this study is to establish postoperative pulmonary complications of liver donation surgery in our center. MATERIALS AND METHODS: Data from 188 subjects (median age, 33.7 ± 8.4 y; male/female, 51.1%/48.9%) who had liver donation surgery from 1988 to 2013 were analyzed retrospectively. Patient demographic and clinical features were recorded. Postoperative complications and the correlation of risk factors for postoperative pulmonary complications were investigated. RESULTS: The incidence of early postoperative complications was 17% (n = 32), and 16 of these patients had postoperative pulmonary complications (8.5%); 2 of the postoperative pulmonary complications were detected on the day of surgery and the other 14 complications were observed between the second and seventh day after surgery. Most postoperative pulmonary complications were minor complications including atelectasis, pleural effusion, and pneumonia. There was 1 major postoperative pulmonary complication: pulmonary embolism that occurred on the fourth day after surgery in 1 patient. Late pulmonary complications also were reviewed and no late postoperative pulmonary complications were observed. There was no significant difference in early and late postoperative pulmonary complications between ex-smokers and smokers. Postoperative atelectasis was significantly higher in patients with body mass index ≤ 20 kg/m ² than patients with body mass index > 21 kg/m ² (P = .027). In our study population, no postoperative mortality was recorded. CONCLUSIONS: We believe that preoperative weight reduction strategies and early mobilization with postoperative respiratory physiotherapy could be important factors to reduce postoperative pulmonary complications in liver donors.

Pleural effusion in patients with end-stage liver disease who are candidates for transplant.

OBJECTIVES: The purpose of this retrospective study was to determine the rate of occurrence and features of pleural effusion in patients referred to our institution for liver transplant. MATERIALS AND METHODS: This study included 135 patients (43 women, 92 men) with a mean age of 40 years (range, 16-66 y). Patient characteristics such as history of pulmonary disease and types of respiratory symptoms were recorded. The chest radiographs of every study patient were examined. RESULTS: Of the 135 study patients, 16 (11.9%) had respiratory symptoms upon admission to the hospital, and 49 (36.3%) had abnormalities on their chest radiographs. The most common radiographic abnormality was elevated right hemidiaphragm in 32 patients (23.7%), followed by pleural effusion in 22 (16.2%), atelectasis in 21 (15.5%), hilar enlargement in 18 (13.3%), and elevated left hemidiaphragm in 9 (6.6%). Seventeen of 22 patients (77.3%) had right pleural effusion, 4 (18.2%) had bilateral, and 1 (4.5%) had left pleural effusion. Of the 10 patients undergoing thoracentesis, 9 had transudates and 1 had an exudate. CONCLUSIONS: Preoperative pleural effusion is a common problem in patients who are candidates for a liver transplant. Most of these patients have right transudative pleural effusion.

Early pulmonary complications of liver transplant.

OBJECTIVES: Pulmonary complications are a leading problem after a liver transplant. This study sought to predict postoperative early complications by a chest radiograph performed after a transplant among adult orthotopic liver transplant recipients. MATERIALS AND METHODS: One hundred thirty-five patients (43 women, 92 men; mean age, 40 y; range, 16-66 y) were included and their medical data reviewed retrospectively. A postoperative chest radiograph of each patient was evaluated to check for pulmonary complications. RESULTS: Smoking history was noted in 61 patients (45.2%). Postoperative first chest radiograph evaluation showed normal findings in 56 patients (41.5%). Right pleural effusion was found in 25 patients (18.5%), and atelectasis was found in 25 (18.5%). Bilateral pleural effusion was the second most-frequent finding on postoperative radiograph (14.8%). Effusion accompanied by atelectasis was found in 3 patients (2.2%). Other postoperative chest radiograph findings were consolidation (n=2, 1.5%), left pleural effusion (n=2, 1.5%), and bronchiectasis (n=2, 1.5%). CONCLUSIONS: We investigated the reflection of the first chest radiograph after liver transplant on postoperative early complications. Postoperative first chest radiograph can be an inexpensive and accessible diagnostic tool for predicting postoperative problems.