Plasma receptor for advanced glycation end-products predicts duration of ICU stay and mechanical ventilation in patients after lung transplantation.

BACKGROUND: Primary graft dysfunction, formerly termed reperfusion pulmonary edema, is the leading cause of short-term complications after lung transplantation. New evidence shows that alveolar type I epithelial cells play an active role in alveolar fluid transport and are therefore presumed to be critical in the absorption of pulmonary edema. We tested the potential relevance of a novel marker of alveolar type I cell injury, the receptor for advanced glycation end-products (RAGE), to short-term outcomes of lung transplantation. METHODS: The study was a prospective, observational cohort study of 20 patients undergoing single lung, bilateral lung or combined heart-lung transplantation. Plasma biomarkers were measured 4 hours after allograft reperfusion. RESULTS: Higher plasma RAGE levels were associated with a longer duration of mechanical ventilation and longer intensive care unit length of stay, in contrast to markers of alveolar type II cell injury, endothelial injury and acute inflammation. Specifically, for every doubling in plasma RAGE levels, the duration of mechanical ventilation increased on average by 26 hours, adjusting for ischemia time (95% confidence interval [CI] 7.4 to 44.7 hours, p = 0.01). Likewise, for every doubling of plasma RAGE levels, intensive care unit length of stay increased on average by 1.8 days, again adjusting for ischemia time (95% CI 0.13 to 3.45 days p = 0.04). In contrast, the clinical diagnosis of primary graft dysfunction was not as predictive of these short-term outcomes. CONCLUSIONS: Higher levels of plasma RAGE measured shortly after reperfusion predicted poor short-term outcomes from lung transplantation. Elevated plasma RAGE levels may have both pathogenetic and prognostic value in patients after lung transplantation.

Predictors of long-term mortality in patients with ventilator-associated pneumonia.

PURPOSE: To determine the long-term outcome of ventilator-associated pneumonia (VAP) and identify factors associated with increased mortality. METHODS: We retrospectively studied 671 patients with VAP admitted to an intensive care unit between 1994 and 2000. We determined long-term and out-of-hospital mortality for these patients. RESULTS: The in-hospital mortality was 42.3%; 19.8% of patients had concomitant bacteremia, the mortality was 59.7% versus 38.0% for those without bacteremia (P <.001). The factors associated with increased hospital mortality by univariable analysis were: diagnosis on admission, the need of vasopressors during the stay in the intensive care unit, not undergoing a tracheostomy, the absence of fever, the presence of concomitant bacteremia, and renal failure or the need for dialysis. Patients transferred from an outside hospital and patients with normal serum bicarbonate, serum total bilirubin <2 mg/dL, and platelets >120x4> 10(3)/microL had a lower in-hospital mortality. All of these factors except bilirubin level, platelet count, transfer from outside hospital, and serum bicarbonate remained significant on multivariable analysis. The estimated mortality at 1, 3 and 5 years is 25.9% (95% confidence interval [CI], 20.2-30.1%), 33.6% (95% CI, 27.4-39.2%) and 44.7% (95% CI, 38.1-50.6%), respectively. CONCLUSIONS: VAP is associated with a high rate of hospital and long-term mortality. The presence of bacteremia is associated with a high mortality. The 5-year estimated mortality of the survivors is less than 50%.