A randomized trial of continuous glucose monitoring to improve post-transplant glycemic control.

INTRODUCTION: This study examines whether the use of inpatient Continuous Glucose Monitors provides improved glycemic control over finger-stick glucose monitoring post-transplant. METHODS: This is a single-site, prospective randomized controlled trial of 40 patients receiving conventional finger-stick glucose monitoring or continuous monitoring using the Medtronic Guardian Sensor 3 during the first 5 days post-transplant. Included patients were adult renal transplant recipients with a diagnosis of diabetes. Assessed endpoints included post-transplant daily median glucose level, hyperglycemic (≥180 mg/dL) and hypoglycemic (≤80 mg/dL) episodes, number of post-transplant bacterial infections and length of stay. RESULTS: Groups were well matched in demographic variables. Median daily glucose was significantly lower in the intervention group. There were also significantly less episodes of hyperglycemia on postoperative days 2, 3, 4, and 5. There were no differences in the incidences of hypoglycemia, postoperative bacterial infections, or length of stay. CONCLUSION: In this randomized study, the use of a continuous glucose monitor to guide post-transplant glucose management significantly lowered the incidence of hyperglycemic episodes and median glucose levels through the first 5 days post-transplant without increasing the number of hypoglycemic episodes. The use of these devices can be considered in the immediate post-renal transplant setting.

Use of preprocurement biopsy in donation after circulatory death liver transplantation.

We perform routine preprocurement image-guided percutaneous liver biopsies on potential donation after circulatory death (DCD) liver donors. The purpose of this study was to examine the impact of preprocurement liver biopsy on the use of livers from DCD donors. We retrospectively reviewed demographics, liver histology, and disposition of DCD liver donors within a single organ procurement organization (OPO) who underwent preprocurement liver biopsy from January 2000 through December 2019. A total of 212 potential donors underwent prerecovery biopsy. No donors were lost as a result of complications of biopsy. Of these, 183 (86.3%) had acceptable biopsies: 146 (79.8%) were successfully transplanted and 37 (20.2%) were deemed not suitable for transplant. In contrast, of 120 DCD livers recovered with the intent to transplant that were not biopsied prior to recovery, 59 (49.2%) were successfully transplanted, and 61 (50.8%) were deemed not suitable for transplant. A total of 14 donors were ruled out for transplant based on prerecovery histology. Successfully transplanted livers that underwent preprocurement biopsy were more likely to come from donors aged older than 50 years or with body mass index more than 30 kg/m2 compared with successfully transplanted livers without a prerecovery biopsy. Biopsy excluded 6.6% of DCD donor livers for transplant prior to recovery and facilitated the successful recovery and transplant of two-thirds of potential DCD donor livers. Livers intended for transplant at the time of recovery that did not undergo preprocurement biopsy were more likely to not be recovered or to be discarded. Preprocurement biopsy provides additional histologic information prior to deploying resources and helps to identify usable livers that might otherwise be declined for transplant. Consideration of liver biopsy in this group benefits OPOs and transplant centers by maximizing organ use and optimizing resource deployment.

Expanding access to pancreas transplantation for type 2 diabetes mellitus.

PURPOSE OF REVIEW: The vast majority of cases of diabetes mellitus (DM) in the United States are classified as type 2 DM (T2DM). Restrictive listing criteria and uncertainty regarding outcomes have historically limited access to pancreas transplantation for individuals with T2DM, although it has been used with success in patients with type 1 DM (T1DM). This review summarizes several recent studies that have sought to clarify the indications, appropriate patient selection, and outcomes of pancreas transplantation in the setting of T2DM. RECENT FINDINGS: Pancreas transplants have increased over the last few years, largely due to an increase in listings for simultaneous pancreas-kidney transplant (SPK) in patients with T2DM. Retrospective data demonstrate similar patient and allograft survival in patients with T1DM and T2DM undergoing SPK, and improved outcomes in patients with T2DM after SPK compared to those receiving a kidney transplant alone, although these studies are often confounded by selection biases. Patient selection for pancreas transplant has traditionally focused on body mass index, pretransplant insulin requirements, and fasting C-peptide, and the categorization of patients to T1DM or T2DM. Emerging data suggests this practice is inadvertently and unnecessarily restrictive. SUMMARY: There is a growing body of evidence to support increasing consideration of pancreas transplantation in patients with T2DM, with support for equivalent patient and graft survival and glycemic control. Future prospective studies are indicated to better evaluate the role of preoperative patient factors in selection for pancreas transplantation and to explore long-term outcomes in patients with T2DM.

The Impact of Pathological Criteria on Pediatric Negative Appendectomy Rate.

INTRODUCTION: Negative appendectomy rate (NAR) is a quality metric used in the surgical management of appendicitis. The rates of negative appendectomy (NA) in children range anywhere from 1% to 40% in the literature. Many reports do not provide clear pathological definitions for either appendicitis or NA on which they base their calculation of NAR. We reviewed our experience with pediatric appendectomy and the pathological spectrum encompassed within our definition of a NA and examined how the pathologic definition impacts our hospital's NAR. METHODS: A retrospective review from 2012 to 2016 in a single institution identified 1676 children that underwent appendectomy. Average age was 11.4 (2-18 years). Patient demographics, clinical outcomes and pathological findings were collected. At our institution, appendicitis is defined as the presence of transmural acute inflammation in the appendix and those patients without this finding have been considered to have had a negative appendectomy. RESULTS: 1435 patients underwent appendectomy for presumed appendicitis. The rate of pathologically diagnosed appendicitis was 91.1% (1307/1435) and as such, the NAR was 8.9% (128/1435). Review of the pathology of the NA cohort identified 67/128 (52.3%) patients with completely normal pathology. The remaining 61 patients displayed some sort of pathological abnormality including malignancy (n = 2), fecaliths (n = 9), pinworms (n = 3), granuloma (n = 2), fibrous obliteration (n = 4), isolated periappendiceal inflammation (n = 1), and acute inflammation confined to the mucosa (n = 40). Exclusion of these patients with abnormal pathology decreased the NAR to 4.6%. Patients with pathological abnormalities of the appendix other than transmural inflammation had a higher rate of 30-day readmission than patients with acute appendicitis (8.2% versus 4.5% p < 0.01). CONCLUSION: Pediatric NAR is dependent upon the pathological definition of appendicitis and negative appendectomy. Institutional variation in definition may explain discrepancies in the literature. By example, including only those that show "the absence of inflammation or other appendiceal pathology" would decrease our NAR by 50%. This study calls into question the interpretation of interhospital NAR and the use of NAR as a quality metric in the management of appendicitis. Retrospective comparative study: Level III evidence.

Activation of Invariant Natural Killer T Cells Redirects the Inflammatory Response in Neonatal Sepsis.

Sepsis is the third leading cause of death in the neonatal population, due to susceptibility to infection conferred by immaturity of both the innate and adaptive components of the immune system. Invariant natural killer T (iNKT) cells are specialized adaptive immune cells that possess important innate-like characteristics and have not yet been well-studied in septic neonates. We hypothesized that iNKT cells would play an important role in mediating the neonatal immune response to sepsis. To study this, we subjected 5- to 7-day-old neonatal C57BL/6 mice to sepsis by intraperitoneal (i.p.) cecal slurry (CS) injection. Thirty hours prior to or immediately following sepsis induction, pups received i.p. injection of the iNKT stimulator KRN7000 (KRN, 0.2 µg/g) or vehicle. Ten hours after CS injection, blood and tissues were collected for various analyses. Thirty-hour pretreatment with KRN resulted in better outcomes in inflammation, lung injury, and survival, while immediate treatment with KRN resulted in worse outcomes compared to vehicle treatment. We further analyzed the activation status of neonatal iNKT cells for 30 h after KRN administration, and showed a peak in frequency of CD69 expression on iNKT cells and serum IFN-γ levels at 5 and 10 h, respectively. We then used CD1d knockout neonatal mice to demonstrate that KRN acts through the major histocompatibility complex-like molecule CD1d to improve outcomes in neonatal sepsis. Finally, we identified that KRN pretreatment exerts its protective effect by increasing systemic levels of TGF-ß1. These findings support the importance of iNKT cells for prophylactic immunomodulation in neonates susceptible to sepsis.

Inhibition of necroptosis attenuates lung injury and improves survival in neonatal sepsis.

BACKGROUND: Neonatal sepsis represents a unique therapeutic challenge owing to an immature immune system. Necroptosis is a form of programmed cell death that has been identified as an important mechanism of inflammation-induced cell death. Receptor-interacting protein kinase 1 plays a key role in mediating this process. We hypothesized that pharmacologic blockade of receptor-interacting protein kinase 1 activity would be protective in neonatal sepsis. METHODS: Sepsis was induced in C57BL/6 mouse pups (5-7 days old) by intraperitoneal injection of adult cecal slurry. At 1 hour after cecal slurry injection, the receptor-interacting protein kinase 1 inhibitor necrostatin-1 (10 µg/g body weight) or vehicle (5% dimethyl sulfoxide in phosphate buffered saline) was administered via retro-orbital injection. At 20 hours after cecal slurry injection, blood and lung tissues were collected for various analyses. RESULTS: At 20 hours after sepsis induction, vehicle-treated pups showed a marked increase in serum levels of interleukin 6, interleukin 1-beta, and interleukin 18 compared to sham. With necrostatin-1 treatment, serum levels of interleukin 6, interleukin 1-beta, and interleukin 18 were decreased by 77%, 81%, and 63%, respectively, compared to vehicle. In the lungs, sepsis induction resulted in a 232-, 10-, and 2.8-fold increase in interleukin 6, interleukin 1-beta, and interleukin 18 mRNA levels compared to sham, while necrostatin-1 treatment decreased these levels to 40-, 4-, and 0.8-fold, respectively. Expressions of the neutrophil chemokines keratinocyte chemoattractant and macrophage-inflammatory-protein-2 were also increased in the lungs in sepsis, while necrostatin-1 treatment decreased these levels by 81% and 61%, respectively, compared to vehicle. In addition, necrostatin-1 treatment significantly improved the lung histologic injury score and decreased lung apoptosis in septic pups. Finally, treatment with necrostatin-1 increased the 7-day survival rate from 0% in the vehicle-treated septic pups to 29% (P = .11). CONCLUSION: Inhibition of receptor-interacting protein kinase 1 by necrostatin-1 decreases systemic and pulmonary inflammation, decreases lung injury, and increases survival in neonatal mice with sepsis. Targeting the necroptosis pathway might represent a new therapeutic strategy for neonatal sepsis.

Deficiency of receptor-interacting protein kinase 3 (RIPK3) attenuates inflammation and organ injury in neonatal sepsis.

INTRODUCTION: Sepsis is the third leading cause of morbidity and mortality in neonates. Sepsis in neonates is characterized as the systemic inflammation owing to infection within the first 28days after birth. The molecular mechanism causing the exaggerated inflammation phenotype in neonates has not been completely elucidated. Receptor interacting protein kinase 3 (RIPK3) is a protein identified as a mediator in programmed necrosis or necroptosis. We hypothesize that RIPK3 could be responsible for the inflammatory response in neonates and that deficiency in the RIPK3 protein attenuates inflammation and organ injury in neonatal sepsis. METHODS: Male and female C57BL6 wild-type (WT) and RIPK3 knock-out (KO) newborn mice aged 5-7days (3-4g body weight) were injected intraperitoneally with 0.9mg/g cecal slurry (CS). At 10h after injection, the newborns were euthanized and blood, the lungs and gut tissues were collected. RESULTS: At 10h after CS injection, serum cytokines IL-6 and IL-1ß in the WT mice were increased by 511- and 43-fold whereas in KO mice, these levels were increased by 166-fold and 22-fold, respectively. Lung IL-1ß in the WT mice increased by 7-fold after CS injection whereas only a 4-fold increase was seen in the KO mice. In the lungs of CS injected KO mice, the injury score, MIP-2 mRNA, myeloperoxidase (MPO) activity and TUNEL staining were significantly reduced by 76%, 70%, 26% and 74%, respectively compared to the CS WT mice. Gut TUNEL staining was also reduced by 80%. CONCLUSION: The deficiency in RIPK3 attenuated serum and lung cytokines, lung injury and neutrophil infiltration and lung and gut apoptosis. These data suggest that RIPK3, in part, is responsible for the systemic inflammatory response in neonatal sepsis.

Cold-inducible RNA-binding protein activates splenic T cells during sepsis in a TLR4-dependent manner.

Cold-inducible RNA-binding protein (CIRP) is a novel inflammatory mediator that stimulates the release of proinflammatory cytokines from macrophages in sepsis. Given the immune dysregulation that characterizes sepsis, the effect of CIRP on other immune cells is an area of increasing interest that has not yet been studied. In the present study, we hypothesized that extracellular CIRP promotes activation of T lymphocytes in the spleen during sepsis. We observed that mice subjected to sepsis by cecal ligation and puncture showed significantly higher expression of the early activation markers CD69 and CD25 at 20 h on CD4+ splenic T cells, and significantly higher CD69 expression on CD8+ splenic T cells compared with sham-operated controls. Furthermore, at 20 h after receiving intravenous injection of recombinant murine CIRP (rmCIRP, 5 mg/kg body weight (BW)) or PBS (vehicle), those mice receiving rmCIRP showed significantly increased expression of CD69 and CD25 on both CD4+ and CD8+ splenic T cells. This effect, however, was not seen in TLR4-deficient mice after rmCIRP injection. In addition, treatment with CIRP predisposed CD4+ T cells to a Th1 hyperinflammatory response profile, and influenced CD8+ T cells toward a cytotoxic profile. Taken together, our findings indicate that CIRP is a proinflammatory mediator that plays an important role in T-cell dysregulation during sepsis in a TLR4-dependent manner.

Treatment with milk fat globule epidermal growth factor-factor 8 (MFG-E8) reduces inflammation and lung injury in neonatal sepsis.

BACKGROUND: Sepsis remains one of the leading causes of infant death worldwide. It is characterized by uncontrolled inflammatory responses due to proven bacterial infection. Despite improvement in supportive care and the availability of effective antibiotics, no specific therapy targeting the dysregulated inflammatory response is available for neonatal sepsis. Milk fat globule epidermal growth factor-factor 8 (MFG-E8) is a secretory glycoprotein abundantly present in human milk. MFG-E8 suppresses the systemic inflammatory responses in adult murine injury models by improving the clearance of dying cells. We hypothesized that exogenous administration of recombinant mouse MFG-E8 could inhibit the exaggerated inflammatory response and lung injury in a murine model of neonatal sepsis. METHODS: Neonatal sepsis was induced in 5- to 7-day-old male and female C57BL6 mice using an intraperitoneal injection of cecal slurry. At 1 hour after sepsis induction, a single dose of 40 µg/kg recombinant mouse MFG-E8 or vehicle was administered via retro-orbital injection. All neonates were returned to their mothers as a group. At 10 hours after cecal slurry injection, pups were killed and blood and lung tissues were collected. Control mice underwent a similar procedure with the exception of cecal slurry intraperitoneal injection. RESULTS: Serum lactate dehydrogenase, IL-1ß, and IL-6 were significantly increased 10 hours after cecal slurry injection. Treatment with recombinant mouse MFG-E8 decreased these levels by 30%, 56%, and 37%, respectively. Lung morphology was significantly compromised in the vehicle group after cecal slurry injection, whereas the recombinant mouse MFG-E8-treated groups demonstrated a 48% improvement in the lung injury score. Lung IL-6 and MIP-2 protein levels were significantly reduced with recombinant mouse MFG-E8 treatment. Lung neutrophil infiltration as observed by Gr-1 staining and, TUNEL-positive cells were also significantly reduced with recombinant mouse MFG-E8 treatment. CONCLUSION: Treatment with recombinant mouse MFG-E8 attenuated inflammation and lung injury in murine neonatal sepsis. Thus, MFG-E8 could be developed as a possible therapy for neonatal sepsis.