Transplantation ethics: are we approaching the crossroads?

Ethical issues of organ transplantation are of extreme importance to involved physicians and to society. The basic principle is that the donor cannot be considered as a commodity; financial incentives must not occur. Regarding deceased-donor organ transplantations, ethical issues are related to the consent for donation, determination of death, and principles of organ allocation. Living donors should be healthy, giving free consent after being fully informed about the risks of the procedure. Transplant professionals have a double responsibility because they must remember about the rights of the organ recipient as well as of the donor. Because of the organ shortage we commonly use organ recovery from donors after cardiac arrest and extend the living-donor pool, practices that may influence some important ethical principles. A proper detailed determination of donor death is of utmost importance. The dead donor rule must be preserved. However category III non-heart-beating donors (so-called controlled cardiac arrest) raise doubts as to the time of the decision to transfer the dying (not yet dead) patient to the operating room to withhold supportive treatment. In certain centers, not quite healthy living donors are being used; they are called extended-criteria or complex donors. Although organ trade is condemned, some workers agree to use as complete strangers donors, obviously believing in pure altruistic motivation of such donors without the additional incentives. Finally, is the trend to consider utility in organ allocation justified? It seems that quite soon we may need a new transplantation ethics code that is not totally directed by transplant professionals exclusively to the needs of potential recipients.

Survey on attitudes and knowledge on the organ recovery from deceased donors in Roman Catholic nuns and priests.

UNLABELLED: Deceased donors (DD) organ recovery rate in Poland has never been satisfactory but over the years kidney transplantation from deceased donors has reached the level of 26 transplants/pmp. In 2007 due to a number of reasons, a dramatic fall of organ recovery rate from deceased donors (DD) occurred. The survey on public attitude toward organ transplantation carried out in the same year showed a large reduction of the public trust toward medical profession. Since then, the number of kidney transplantations has never come back to its level from 2006, regardless of a positive attitude toward organ transplantation. The attitude and knowledge survey was recently carried out in 100 physicians and 100 nurses employed in one large district hospital. The results of the attitude survey among the hospital staff showed that the level of knowledge among nurses corresponded to their age and the time since graduation. Younger nurses showed much more appreciation and knowledge toward recovery of organs from the deceased donors. Survey among physicians indicated some hesitation toward recognition of the brain death. In the present paper results of the survey on attitude and knowledge toward organ transplantation among nuns (98 nuns), priests (100 priests) and students (98 students) of the Theological School living in the same area are presented. Despite quite high (>60%) acceptance of the deceased donation, one third of questioned population showed lack of knowledge not only on existing legal regulations, but also of important documents issued by the Catholic Church. CONCLUSIONS: Improvement of transplantation program in Poland requires extensive educational program among various parts of the society: most importantly among physicians, nurses and priests. The Partnership for Transplantation program has been directed to achieve these goals.

Partnership for transplantation: a new initiative to increase deceased organ donation in Poland.

Despite the long-standing history of transplantation, the shortage of organs has remained its most restrictive factor. In 2010, the number of actual deceased organ donors in Poland was 13.5/million population (pmp). However, a huge difference in organ recovery rates is evident between various regions, eg, 32 pmp, in western Pomerania compared with 1-3 pmp in southern districts. A substantial number of patients who die while awaiting organ transplantations could be saved were effective programs able to overcome barriers in deceased organ donation. Such programs, eg, the European Donor Hospital Education Program, Donor Action, European Training Program on Organ Donation, United States Collaborative in Donation were introduced several years ago, but after transient improvements there has not been real progress. A new comprehensive program-Regional Partnership for Transplantation-was initiated a year ago in 4 districts of southern Poland by the Polish Union for Transplantation Medicine. The letter of intent to activate the donation program was signed by the local administration, the president of the local medical school, president of the Physician's Chamber, transplant centers, the Polish Union for Transplantation, and the Polish Transplant Coordinating Center. The plan of action included training of in-hospital coordinators, visits to all regional hospitals in company of a representative of the hospital founding body, examination of the real donation pool and the need for participation in a donation program training and education of the hospital staff in legal and organizational aspects of donation, brain death recognition, and various aspects of donor care. In addition, the program included communication skills workshops for intensive care unit physicians (with participation of 2 actors, an experienced anesthesiologist, and a psychologist), lectures for high school and university students and for hospital chaplains as well as alumni of higher seminaries. The preliminary results (after the first year) showed 40%-70% increases in activity of the local hospitals in the organ donation process.

Urinary tract infections in the early posttransplant period after kidney transplantation: etiologic agents and their susceptibility.

OBJECTIVE: Urinary tract infection (UTI) is among the most common infections in solid organ transplantation, especially in kidney transplantation. PATIENTS AND METHODS: This study included 295 adult patients undergoing KTx between September 2001 and December 2007. All patients were followed prospectively for UTI during the first 4 weeks after surgery. Samples of urine were investigated by bacteriological cultures to identify microorganisms in accord with standard procedures. Susceptibility testing was performed using Clinical and Laboratory Standards Institute procedures. RESULTS: Urine specimens (n=582) were obtained from 84.5% of 245 recipients during the first month after transplantation. Among the isolated bacterial strains (n=291), the most common were Gram-negative bacteria (56.4%) predominantly Serratia marcescens (32.3%) and Enterobacter cloacae (14.6%). Extended- spectrum beta-lactamase (ESBL+) strains were isolated in 52.5% of cases. Gram-positive bacteria comprised 35.7%; most commonly, high-level aminoglycoside resistant (HLAR; 87.8%) and vancomycin-resistant (VRE; 11%) Enterococci. There were fungal strains in 23 cases (7.9%). CONCLUSION: Our study showed predominantly Gram-negative rods from the Enterobacteriaceae family comprising (84.8%) of Gram-negative isolates: 52.5% ESBL and resistant enterococci (87.5%) in Gram-positive isolates. The increased proportion of isolates of multi-drug-resistant bacterial agents which can cause severe UTIs may be due to our frequent use of ceftriaxone for perioperative bacterial prophylaxis.

Urinary tract infections in the early posttransplant period after liver transplantation: etiologic agents and their susceptibility.

BACKGROUND: We performed an analysis of etiologic agents for urinary tract infections in the early posttransplant period after orthotopic liver transplantation (OLT) in adult recipients. PATIENTS AND METHODS: The study covered the first 4 weeks after OLT of 190 patients from September 2001 to the end of 2007. Immunosuppression consisted of steroids and tacrolimus. Antimicrobial prophylaxis was piperacillin/tazobactam, fluconazole, and SBD. Urine samples were cultured to identify microorganisms in accord with standard microbiological procedures and to test susceptibility using Clinical Laboratory and Standards Institute guidelines. RESULTS: Urine specimens (n=539) examined from 185 recipients (97.4%) showed 210 microbial strains. The most common were Gram-negative (n=131; 62.4%) with predominance of Escherichia coli (28.2%), Enterobacter cloacae (19.1%), and Acinetobacter baumannii (11.4%). Extended-spectrum ß- lactamases (ESBL(+)) strains were isolated in 38.5% of cases. Gram-positive bacteria comprised 28.6% (n=60): The most common strains were enterococci (85% including HLAR 80.4% and VRE 17.6%] and staphylococci 11.8% [MRSA/MRCNS; 100%]. There were 19 (9%) fungal strains. CONCLUSIONS: In general, the identification in urine samples of multi-drug-resistant bacterial and fungal strains in patients after OLT such as ESBL(+) 38.5%; HLAR 80.4%; VRE 17.6%; and MRSA/MRCNS 100% requires better infection control.

At what price kidneys from complex donors while patients die on the waiting list: a word of caution.

More and more often living donors worldwide are used for kidney transplantation. The results are excellent, much better than from the deceased donors, disregarding the genetic disparity. Not surprisingly, living donation has not influenced the existing gap, and waiting lists are increasing. Live kidney donation technically has become a standardized, safe procedure. Many papers, including that from the Minneapolis Center quote follow-up results documenting that unilateral nephrectomy is safe. The Amsterdam Forum established criteria for living kidney donors. Most unfortunately, however, the continuous need for kidneys has led in the recent three years to the use of the so-called "complex" or "marginal" living donors, that is donors with metabolic syndrome. The argument for a continuous increase in living kidney donation, often used by transplant physicians, is quoted in the title of the abstract. This argument should never be used, especially by transplant physicians, who must consider the interests of both the recipient and the donor. Our own data presented at the last Congress of the Transplantation Society showed that moderate hypertension occurs in some patients. The risk of cardiovascular complications is definitely higher among donors with the metabolic syndrome, those with prediabetes, obesity, or mild hypertension. Most unfortunately there are no long-term follow-up data concerning such donors. They may require preemptive prophylaxis with step-wise interventional reno-protection and cardio-protection programs, which so far have not been implemented. For this reason, a Living Donor Registry is needed. It would allow objective assessment of the long-term risks of uninephrectomy among donors with metabolic syndrome. Such a registry is in operation in our country. Considering the use of kidney donors with the metabolic syndrome, one should remember a popular saying: "Be good, and if you cannot be good--be careful."

Surgical site infections in the early posttransplant period after simultaneous pancreas-kidney transplantation.

OBJECTIVE: This study evaluated the frequency of microbial isolates and their susceptibility profiles among cultures from the "surgical site" of 26 simultaneous pancreas-kidney (SPKT) recipients in the early posttransplant period. PATIENTS AND METHODS: Data on microbiologic cultures of 26 adult patients undergoing SPKT were collected prospectively from 2001 to the end of 2006. The isolation and identification of cultured micro-organisms was performed according to standard microbiological procedures and commercially available tests. Susceptibility of the strains to antibacterial agents was made by the Clinical and Laboratory Standards Institute (CLSI) guidelines. RESULTS: All patients were followed prospectively for the first 4 weeks after surgery yielding 168 microbial isolates from the surgical site. The most commonly isolated organisms were Gram-positive bacteria (65.5%) with domination of staphylococci (52.7%) as methicillin-resistant S aureus and methicillin-resistant coagulase-negative staphylococci. The second most common were enterococci (33.6%) with the presence of an high level aminoglycoside-resistant strains (64.9%) and vancomycin-resistant strains (2.7%). Gram-negative bacteria comprised 19% of positive cultures; among them were isolated extended spectrum beta-lactamase producers and carbapenem-resistant strains. Yeast-like fungi comprised 15.5% of positive cultures. In conclusion, we observed predominantly Gram-positive bacteria, comprising 65.5% of isolates. The increased proportion of multi-drug-resistant bacterial isolates may be due to the frequent prophylaxis of bacterial infections in patients.

Urinary tract infections in the early posttransplant period after simultaneous pancreas-kidney transplantation.

OBJECTIVE: Urinary tract infection (UTI) is among the common infection in simultaneous pancreas-kidney transplantation (SPKT). PATIENTS AND METHODS: The study included 26 adult patients undergoing SPKT between September 2001 and December 2006. All the patients were followed prospectively for UTI during the first 4 weeks after surgery. Urine samples were investigated for bacteriologic cultures. The micro-organisms were identified in accordance with standard bacteriologic procedures. Susceptibility testing was carried out using Clinical and Laboratory Standards Institute (CLSI) procedures. RESULTS: Among 77 urine specimens obtained from all recipients during the first month, there were 30 isolated bacterial strains. The most common were Gram-positive bacteria (53.3%) with predominance of enterococci (75%) associated with high levels of aminoglycoside resistant strains (HLAR; 58.3%) and vancomycin-resistant strains (VRE; 25%). Gram-negative bacteria were detected in 46.7% of positive cultures. CONCLUSIONS: In our study, enterococci predominated as 75% of Gram-positive isolates. The increased proportion of multi-drug-resistant bacteria, which can caused severe UTI in patients after SPKT, may be due to the frequent use of prophylaxis of bacterial infections in patients.

Etiologic agents of bacteremia in the early period after simultaneous pancreas-kidney transplantation.

BACKGROUND: Bacteremia is among the known complications in simultaneous pancreas-kidney transplantation (SPKT). This study evaluated the frequency of microbial isolates and their susceptibility profiles among cultures of clinical samples obtained from blood and from the tips of blood vessel catheters of 26 SPKT recipients suspected of bacteremia in the early posttransplant period. PATIENTS AND METHODS: Data on microbiologic blood cultures of 26 adult patients undergoing SPKT were collected prospectively from 2001 to the end of 2006. The isolation and identification of cultured microorganisms were performed according to standard microbiological procedures and commercially available tests. The susceptibility of the strains to antibacterial agents was established by the Clinical and Laboratory Standards Institute guidelines. RESULTS: All patients were followed prospectively for the first 4 weeks after surgery. Among 66 clinical samples, there were 23 microbial isolates from blood samples of 17 recipients and catheter tips of 12 recipients. The most common isolates were Gram-positive bacteria (73.9%) with domination of staphylococci (64.7%) and MRCNS strains (81.8%). Gram-negative bacteria comprised 17.4% of positive cultures, whereas yeast-like fungi, 8.7% with a predominance of Candida glabrata. CONCLUSION: Our study showed predominately Gram-positive bacteria in 73.9% of isolates. The increased proportion of multi-drug-resistant bacteria and fungi to antimicrobial agents may be due to the frequent use of these agents for prophylaxis of bacterial infections in patients.

Are we taking proper care of living donors? A follow-up study of living kidney donors in Poland and further management proposal.

OBJECTIVE: The first kidney transplantation was performed in Poland in 1966. Since that time approximately 11,000 patients have undergone the procedure, but most of them have received the kidney from deceased donors; only 342 procedures utilized living donors (LD; 2.7%). The aim of this study was to review the results of a LD follow-up in Poland. PATIENTS AND METHODS: A questionnaire was sent to 11 centers that had performed 197 LD kidney transplantations during the last 10 years. The donors, who were all genetically or emotionally related, were 23 to 61 years old. No donor showed an abnormality regarding cardiovascular function or metabolic abnormalities. RESULTS: The 6 centers that responded reported data on 118 donors. In 2 centers no donor follow-up was available. Eleven of 118 donors did not attend the control visits. Follow-up of the remaining donors ranged from 2 to 8 years. Four donors died at 4 to 5 years after nephrectomy due to cerebral hemorrhage, brain tumor, stomach cancer, or car accident. The overall mean serum creatinine had increased from 0.8 to 1.25 mg/dL, but 2 patients displayed a value >2 mg/dL. The calculated creatinine clearance (MDRD formula) had decreased from 95 to 65 mL/min (P < .05). In 3 donors proteinuria (>0.6 g/24 h) was observed at 3 to 5 years after donation. Of 3 patients who experienced mild hypertension, 2 required treatment. The remaining donors showed normal blood pressures. CONCLUSIONS: Since 2007, when the Living Donor Registry was introduced by law, transplant centers have been obliged to report data on each LD procedure together with follow-up data. All donors are life-insured (by Alianz SA) for 3 months from the time of transplantation. Stepwise interventional reno- and cardioprotection programs have been introduced after nephrectomy for LD, especially those with metabolic abnormalities at the time of donation.

The assessment of residual kidney function after living donor nephrectomy.

BACKGROUND: The number of patients on the waiting list for kidney transplantation is increasing as a result of the cadaveric donor shortage. One way to expand the pool is living donor transplantation. However, only 2% of kidney transplants in Poland come from living-related donors. AIM: We sought to assess residual renal function, incidence of hypertension, and proteinuria among living kidney donors. PATIENTS AND METHODS: Between 2004 and 2007, we performed 46 living donor open nephrectomies. The mean age of the kidney donor was 39 years (range, 25-57). The donors were predominantly females (61%). Mean hospitalization time was 8 days (range, 4-22). Nine donors did not report for follow-up visits. The observation periods ranged from 1 to 24 months. Physical examination, blood and urine tests, as well as ultrasound scans were performed before nephrectomy and at every follow-up visit (1, 3, 12, and 24 months post operatively). RESULTS: Mean creatinine concentration was higher at 3 months after nephrectomy than preoperatively (P < .05). Mean creatinine clearance according to Cockroft-Gault formula and mean creatinine clearance according to abbreviated modification of diet in renal disease equation (aMDRD) decreased after donation by 30% (P < .05). No cases of proteinuria were observed. Hypertension occurred in 1 donor (2.7%). CONCLUSION: Living kidney donation resulted in a reduced creatinine clearance in the donor. Follow-up of living kidney donors is essential to determine risk factors for deterioration of residual kidney function.

Chlamydia pneumoniae infection in patients after kidney transplantation treated with spiramycin.

INTRODUCTION: Previous research has pointed to a role of Chlamydia pneumoniae infection in the development of chronic renal allograft dysfunction, chronic liver rejection, and vasculopathy in the transplanted heart. The aim of this study was to evaluate the presence of C. pneumoniae prior to and after kidney transplantation as well as to determine the role of spiramycin therapy among kidney transplant recipients. MATERIALS AND METHODS: The study group consisted of 50 patients (25 pairs) who received kidney transplants from cadaveric donors. One of the 2 kidneys from a donor was transplanted to a patient randomized to spiramycin (2 x 3 million U/d orally for 3 months; group S) and the other to a patient assigned as control (group C). Markers of infection were assessed on day 1 posttransplantation and 3 months later (average, 94 days). All 50 patients were examined for the presence of bacterial DNA in peripheral blood leukocytes using real-time polymerase chain reaction (PCR) and for titers of serum anti C. pneumoniae immunoglobulin (IgG) and IgA antibodies using microimmunofluorescence (MIF). C. pneumoniae infection was diagnosed by the presence of C. pneumoniae DNA in peripheral blood leukocytes or positive antibodies of both classes. RESULTS: C. pneumoniae infection was initially diagnosed in 14 patients among group S and 8 patients among group C (P = not significant [ns]) and after 3 months in 12 and 9 patients, respectively (P = ns). Conversion from positive to negative C. pneumoniae status occured in 7 patients among group S and 1 patient among group C (P = .04). Conversion from negative to positive C. pneumoniae status occured in 5 patients from group S and 2 patients from group C (P = ns). CONCLUSIONS: These results suggest a possible role for spiramycin treatment of C pneumoniae infection in kidney allograft recipients. C. pneumoniae infection diagnosis and treatment should be considered to be routine for every patient awaiting transplantation.

Ischemia/reperfusion injury in kidney transplantation: mechanisms and prevention.

Ischemia has been an inevitable event accompanying kidney transplantation. Ischemic changes start with brain death, which is associated with severe hemodynamic disturbances: increasing intracranial pressure results in bradycardia and decreased cardiac output; the Cushing reflex causes tachycardia and increased blood pressure; and after a short period of stabilization, systemic vascular resistance declines with hypotension leading to cardiac arrest. Free radical-mediated injury releases proinflammatory cytokines and activates innate immunity. It has been suggested that all of these changes-the early innate response and the ischemic tissue damage-play roles in the development of adaptive responses, which in turn may lead to an acute font of kidney rejection. Hypothermic kidney storage of various durations before transplantation add to ischemic tissue damage. The final stage of ischemic injury occurs during reperfusion. Reperfusion injury, the effector phase of ischemic injury, develops hours or days after the initial insult. Repair and regeneration processes occur together with cellular apoptosis, autophagy, and necrosis; the fate of the organ depends on whether cell death or regeneration prevails. The whole process has been described as the ischemia-reperfusion (I-R) injury. It has a profound influence on not only the early but also the late function of a transplanted kidney. Prevention of I-R injury should be started before organ recovery by donor pretreatment. The organ shortage has become one of the most important factors limiting extension of deceased donor kidney transplantation worldwide. It has caused increasing use of suboptimal deceased donors (high risk, extended criteria [ECD], marginal donors) and uncontrolled non-heart-beating (NHBD) donors. Kidneys from such donors are exposed to much greater ischemic damage before recovery and show reduced chances for proper early as well as long-term function. Storage of kidneys, especially those recovered from ECD (or NHBD) donors, should use machine perfusion.

Long-term results of kidney transplantation from HCV-positive donors.

BACKGROUND: Due to the shortage of organs for transplantation, procurement of kidneys from marginal donors is inevitable. Not infrequently, these donors are infected with hepatitis C virus (HCV). AIM: We sought to determine the effect of transplanting kidneys from anti-HCV-positive donors to anti-HCV-positive recipients. PATIENTS AND METHODS: Among 765 procedures between 1994 and 2006, 259 kidney recipients were anti-HCV-positive, including 60 who received kidneys from anti-HCV-positive donors (HCV(+)/HCV(+) group) and the others, from seronegative donors (HCV(-)/HCV(+) group). The control group of 506 seronegative recipients received kidneys from seronegative donors (HCV(-)/HCV(-) group). All kidneys from anti-HCV-positive donors were preserved with machine perfusion. We investigated recipient liver function tests (LFTs; alanine aminotrasferase, aspartate aminotransferase; alkaline phosphatase, and bilirubin), graft survival, and patient survival. RESULTS: No significant difference was observed between the groups among the biochemistry results (LFTs, creatinine at 5 years). No significant differences, were observed in patient survival, graft survival, or number of patients returning to dialysis. CONCLUSION: Transplantation of kidneys from HCV-positive donors to HCV-positive recipients did not influence long-term liver function, or long-term renal allograft function. This strategy enhances the availability of transplantation as means of end-stage renal disease treatment.

Significance of urodynamic assessment of lower urinary tract in dialysis patients before renal transplantation.

INTRODUCTION: Some dialyzed patients suffer from lower urinary tract (LUT) anatomic and functional disturbances. Complete LUT assessment should be performed to decide whether they can be included on the waiting list, because such disorders, if not diagnosed and properly treated before transplant, may lead to graft loss. PATIENTS AND METHODS: Based on data in the medical records of 4170 dialysis patients, 535 were selected for further investigation: 265 patients after undergoing urethrocystography or urethrocystoscopy, were included on the waiting list for transplantation and 145 patients underwent nephroureterectomy owing to reflux, nephrolithiasis, polycystic renal disease, or hydronephrosis. Five patients with urethral or bladder neck stricture underwent urethral dilation or bladder neck incision. These patients were also ultimately listed for transplantation. Twenty-two patients, with serious LUT disease were qualified for kidney transplantation after extra-anatomic urine outflow. Ninety-eight patients underwent a urodynamic study (URD) to assess LUT disturbances. RESULTS: Of 535 studied patients, 460 (86%), including those who underwent surgical or pharmacologic treatment, were ultimately listed for kidney transplantation. Out of 98 patients who underwent a URD, 45 (46%) were included for kidney transplantation, and 47 for transplantation with atypical urinary outflow. Six patients were excluded from transplantation owing to refusal of investigations or serious contraindications. CONCLUSIONS: All potential kidney recipients should undergo proper evaluation of the LUT before being qualified for kidney transplantation. This study allows selection of patients who should undergo surgical and/or pharmacologic treatment before transplantation.

Surgical site infections in liver recipients in the early posttransplantation period: etiological agents and susceptibility profiles.

OBJECTIVE: This study evaluated the frequency of microbial isolates and their susceptibility profiles from cultures at the surgical site of 83 liver recipients in the early posttransplantation period. PATIENTS AND METHODS: We prospectively collected microbiologic culture data on 83 adult patients undergoing orthotopic liver transplantation (OLT) using standard procedures and commercially available tests. Susceptibility of the strains to antibacterial agents was performed by the Clinical and Laboratory Standards Institute (CLSI) guidelines. RESULTS: All patients were followed prospectively for the first 4 weeks after surgery. Among 284 microbial isolates from clinical surgical site samples in 80 liver recipients, cultures were positive in 110 samples. The most commonly isolated species were: Gram-positive cocci (n = 222 isolates, 78%) with dominance of methicillin-resistant coagulase-negative staphylococci (MRCNS; 42%) and high-level aminoglycoside-resistant enterococci (HLAR strains; 24.3%). Gram-negative bacteria were identified in 21.5% of positive cultures, including 30 strains (24%) from the Enterobacteriaceae family, with 13.3% of extended spectrum beta-lactamase producers [ESBL(+)]. Significant differences (P = .0012) were observed during the analysis of changes in the occurrence of Gram-positive bacteria isolated from the surgical site in the first week versus the second to the end of the fourth week. CONCLUSION: Gram-positive bacteria predominated as 78% of isolates.

Bacteria isolated from bile samples of liver recipients in the early period after transplantation: epidemiology and susceptibility of the bacterial strains.

OBJECTIVE: We estimated the frequency and susceptibility to antibacterial agents of bacterial isolates from bile samples obtained from 83 liver recipients in the early period after transplantation. PATIENTS AND METHODS: We prospectively collected data on 83 adult patients undergoing orthotopic liver transplantation (OLT), including bile samples taken during the first 30 days after OLT from adult liver recipients suspected to have bile infections. The isolation/identification of cultured bacteria was performed according to standard microbiological procedures and commercially available tests. Susceptibility of the strains to antibacterial agents was determined according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. RESULTS: Among 210 bile samples obtained from 79 liver recipients, bacterial cultures were positive in 110 samples from 59 (75%) recipients yielding 156 bacterial strains. The most commonly isolated species were as follows: gram-positive cocci (109 isolates) with dominance of coagulase-negative staphylococci (52%) and enterococci (36%); and gram-negative bacteria, 21 strains from the Enterobacteriaceae family and 14 of non-fermenting rods. We identified some multidrug-resistant (MDR) bacterial strains. In the first week after OLT, we investigated samples from 59 patients, yielding 36 bacterial strains. From the second to the end of the fourth week after OLT, 120 bacterial strains were isolated from 65 recipients. CONCLUSION: Gram-positive bacteria comprised 68.5%. The dominance of MDR gram-positive bacteria may be related to selection by perioperative antibiotic prophylaxis.

Detection of Clostridium difficile in stool samples from patients in the early period after liver transplantation.

OBJECTIVE: We examined the frequency of detection of Clostridium difficile (CD) toxins compared with the recovery of C. difficile in stool specimen cultures among orthotopic liver transplant (OLT) patients with nosocomial diarrhea in the early period. MATERIALS AND METHODS: The study included stool samples obtained during the first 30 days after OLT in adults who were suspected of CD-associated diseases. The identification of cultured CD strains was performed by standard microbiological methods. The presence of CD toxins was assayed using a commercial immunoassay. RESULTS: All patients were followed prospectively for CD infections from the date of OLT for the first 4 weeks after surgery. Among 54 samples, 16.7% were culture-positive for CD. CD toxins were tested on 54 samples, yielding 63% toxin-positive samples and 30% toxin- and culture-negative results. In the first week after OLT, samples from 19 patients were subjected to CD investigation. Among 19 samples positive for toxin, 52.6% of all samples were culture-negative. We analyzed 35 samples from the second to the fourth week after OLT in 31 recipients. Among 35 samples, 68.6% and 25.7% were positive for CD toxin and for culture, while 20% of samples were negative for toxin and culture. CONCLUSION: In our study, 63% of samples were toxin-positive with 16.7% yielding growth of CD and 30% being negative for toxins and cultures.

Etiological agents of bacteremia in the early period after liver transplantation.

Bacteremia is one of the major infections in orthotopic liver transplantation (OLT). The study of 83 adults who underwent OLT from 2001 to 2004, included patients followed prospectively from the day of transplantation to 4 weeks after the procedure by bacteriological cultures. The microorganisms were investigated according to standard National Committee for Clinical Laboratory Standards (NCCLS) procedures. Blood samples were examined in 59 recipients (71.1%) before and in 76 patients (91.6%) during the month after transplantation. Among 249 investigated samples, 96 were positive, as cultured from 19 recipients before OLT and 48 patients afterward. The most common were Gram-positive cocci (n = 71) and coagulase-negative staphylococci (n = 52), including methicillin-resistant coagulase-negative staphylococci (MRCNS). Enterococcus spp. occurred in 9 isolates (high-level aminoglycoside-resistant enterococci [HLAR] strains were cultured). We cultured the Enterobacteriaceae family (n = 16 isolates) and (n = 15 isolates), Gram-negative nonfermenting rods some of which were extended spectrum beta-lactamase producing [ESBL(+)] strains. The predominance of Gram-positive cocci was caused by CNS, and the use of prophylaxis to reduce Gram-negative bacteria. The increased rate of isolation of bacteria with multidrug resistance (MDR) to antimicrobial agents may be due to their frequent use for prophylaxis of bacterial infections in OLT. These MDR bacterial strains caused severe BSI after OLT.

Occurrence of glycopeptide-resistant enterococci in transplant medicine internal wards in 2001-2005.

The appearance of vancomycin-resistant enterococci (VRE) has caused serious therapeutic problems. In Poland, the frequency of VRE isolation is lower than in the United States or some other European countries. The aim of our work was to analyze the occurrence and characterization of VRE isolated from patients of 2 transplant medicine wards. These wards contained liver or kidney transplant patients. This study examined 5 years, including 235 to 313 enterococcal isolates per year. In 2001-2002, none of the isolated enterococci was confirmed as VRE, which appeared in 2003 (11 strains) and continued on a similar level (from 4% to 6%) in the next 2 years. Among all isolated enterococci, Enterococcus faecalis predominated. In 2003 and 2004, the numbers of E. faecium and E. faecalis among isolated VRE strains were similar, but in 2005, we observed significant predominance of E. faecium. Among VRE strains examined by polymerase chain reaction for the presence of vanA, vanB, vanD, vanE, and vanG ligases, only vanA was found in all cases. The examined strains represented several patterns of resistance to other antibiotics.