Impact of the Model for End-stage Liver Disease (MELD) score on liver transplantation in Greece.

INTRODUCTION: The impact of preoperative Model for End-stage Liver Disease (MELD) score in postoperative mortality remains unclear. The assumption that patients with a higher MELD score will have a higher mortality rate is not confirmed and studies are contradictory. AIM: The study of the clinical course of patients with a higher MELD score and its impact in immediate and later mortality in comparison with patients with a lower MELD score in the only liver transplantation center in Greece. METHOD: We retrospectively studied 71 patients who underwent orthotopic liver transplantation (OLT) in the time period between 1-1-2011 and 31-12-2013. The patients were divided into 2 groups: Group A with a MELD score ≥23 and Group B with a MELD score <23. RESULTS: In the patients with a MELD score ≥23 the duration of mechanical ventilation and length of stay in the ICU were prolonged (P = .013 and .009, respectively), the transfusions were more (P = .005), and the rates of ICU readmissions (22.5% vs 7.31%, P = .001) and infections (42.5% vs 17.5%, P = .011) were higher. Thirty-day mortality did not differ between the 2 groups (P = .420), but there was a statistically significant difference in morbidity and in 180-day mortality. CONCLUSION: The patients with a higher MELD score have more complex pathophysiology. This score seems to affect morbidity and late, but not early, mortality.

Bloodstream infections caused by carbapenemase-producing Klebsiella pneumoniae among intensive care unit patients after orthotopic liver transplantation: risk factors for infection and impact of resistance on outcomes.

BACKGROUND: Carbapenem-resistant Klebsiella pneumoniae (CRKP) has emerged as an important cause of bloodstream infections in intensive care units (ICUs). The aim of this study was to determine risk factors for bloodstream infections caused by CRKP as well as risk factors for CRKP-associated mortality among ICU patients after orthotopic liver transplantation (LT). METHODS: The study cohort of this observational study comprised 17 ICU patients after LT with CRKP bloodstream infections. The data from these patients were matched with 34 ICU patients (1:2) after LT without CRKP infections. The 2 groups were compared to identify risk factors for development of CRKP infection and risk factors for mortality. RESULTS: Seventeen CRKP bloodstream infections occurred in ICU patients after LT from January 1, 2008, to December 31, 2011. In univariate analysis, primary liver disease and especially hepatitis C virus infection or hepatocellular cancer were significant factors for development of CRKP. Acute Physiology and Chronic Health Evaluation (APACHE II) score and Sequential Organ Failure Assessment (SOFA) score as well as CRKP bloodstream infection were predictors for ICU death (P < .05) in univariate analysis. CONCLUSIONS: CRKP bloodstream infections affect immunocompromised post-transplantation patients more. Bloodstream infections with CRKP along with APACHE and SOFA scores were predictors of death in ICU patients after LT.

Tigecycline for treatment of carbapenem-resistant Klebsiella pneumoniae infections after liver transplantation in the intensive care unit: a 3-year study.

BACKGROUND: This 3-year prospective, observational, single-center study was undertaken to describe prescription, microbiology findings, tolerance, and efficacy of tigecycline for carbapenem-resistant Klebsiella pneumoniae (CRKP) infections after liver transplantation in the intensive care unit (ICU). METHODS: All patients after liver transplantation treated with tigecycline for ≥3 days for CRKP infections in our ICU from January 1, 2010, to December 31, 2012, were studied. Patient characteristics, indication of treatment, bacteriology, and ICU mortality were collected. The main end points were clinical and microbiologic efficacy and tolerance of tigecycline. RESULTS: Over the study period, 8 men and 2 women (18 CRKP isolates), aged 54.3 ± 7.7 years, were included in the study. Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores on ICU admission were 13.7 ± 2.7 and 10 ± 2.2, respectively. In 7 isolates, tigecycline was prescribed for CRKP blood stream infection (BSI), in 6 for complicated intra-abdominal infection (IAI), in 2 for ventilator-associated pneumonia (VAP), in 2 for surgical site infection, and in 1 for urinary tract infection. In 4 cases, tigecycline was prescribed for secondary BSI followed by VAP and/or IAI. All isolates were susceptible to tigecycline, 83.4% to colistin, 44.5% to gentamicin, and 27.8% to amikacin. In 2 patients, tigecycline was prescribed as monotherapy. Three patients had clinical failure. The microbiologic response rate was 70%. Superinfection was detected in 5 patients, and Pseudomonas aeruginosa was the most frequently isolated pathogen. Tigecycline was generally well tolerated. The ICU mortality rate was 60% with attributable mortality rate 30%. CONCLUSIONS: Our pilot study suggests that tigecycline shows a good safety and tolerance profile in patients with CRKP infections in the ICU after orthotopic liver transplantation. Limited therapeutic options for such infections leave physicians no choice but to use tigecycline for off-label indications such as urinary tract and blood stream infections.

Causes and incidence of renal replacement therapy application in orthotopic liver transplantation patients: our experience.

BACKGROUND: Renal dysfunction is commonly found in patients with end-stage liver disease, as well as after liver transplantation, and it often needs renal replacement therapy (RRT) with the application of continuous or intermittent methods. The aim of this study was the recording of the patients who underwent continuous venovenous hemodiafiltration (CVVHDF) in the early postoperative period, as well as the recording of mortality and risk factors. METHODS: We retrospectively examined 71 patients who underwent orthotopic liver transplantation during a 2-year period (2011-2012). We recorded the incidence of acute kidney injury (AKI), according to the Acute Kidney Injury Network criteria, and we distinguished 2 groups of patients. Group A included those who needed RRT during the 1st 7 days after transplantation, and group B included the patients who did not require RRT. The RRT method of choice was CVVHDF. RESULTS: In group A, the population of patients who presented AKI reached 52.1%, and 22.5% of the them underwent RRT. The mean Model for End-Stage Liver Disease and Acute Physiology and Chronic Health Evaluation scores were higher in group A, who also presented greater hemodynamic instability and more frequent infections and required more transfusions. The transfusion of >10 units of red blood cells was recognized as a risk factor for RRT (P = .024; odds ratio, 1.15; 95% confidence interval, 1.8-7.53). CONCLUSIONS: Patients who required RRT immediately after surgery had a significantly higher rate of mortality and it seemed that the number of transfusions played an important role in this.