Transplantation
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Timely access to transplantation for eligible patients with end-stage renal disease (ESRD) is critical. However, pressures exist to improve efficiencies in transplantation and to achieve high center performance ratings, including the recently submitted "Final Rule" by Center for Medicare and Medicaid Services. This policy may affect the availability of public funding for as many as 10% of kidney transplant centers in the United States. ⋯ The health status of centers' transplant candidate pool is a significant determinant of outcomes and performance ratings. Centers with a higher risk candidate pool are significantly more likely to be identified for poor performance and could potentially lose public funding. Pressures to enhance outcomes may lead centers to exclude high-risk but otherwise viable transplant candidates.
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Randomized Controlled Trial
Randomized trial of steroid-free induction versus corticosteroid maintenance among orthotopic liver transplant recipients with hepatitis C virus: impact on hepatic fibrosis progression at one year.
Due to the known high recurrence rate of hepatitis C virus (HCV) among orthotopic liver transplant (OLT) recipients who receive tacrolimus+corticosteroid maintenance, use of steroid-free induction was considered. ⋯ OLT recipients with HCV tolerated the steroid-free protocol with fewer side effects; however, its use had no apparent impact on hepatic fibrosis progression. Occurrence of acute rejection was strongly associated with increased hepatic fibrosis at 1 year, and MMF use appears to have significantly reduced the rejection rate.
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Recipients of allogeneic hematopoietic stem cell transplantation (HSCT) frequently require support with parenteral nutrition and immunosuppressive drugs, which introduce the risk of hyperglycemia. Van den Berghe et al. showed that the strict glucose control improved the outcome of patients treated in the intensive care unit, and this point was evaluated in this study in a HSCT setting. ⋯ While the results suggested an association between the degree of hyperglycemia during neutropenia and an increased risk of posttransplant complications and NRM, the possibility that intensive glucose control improves the outcome after HSCT can only be confirmed in a prospective randomized trial.
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Pneumocystis jiroveci pneumonia may be a life-threatening opportunistic infection in immunosuppressed solid organ transplant recipients. Despite effective treatment with high-dose trimethoprim-sulfamethoxazole and steroids, morbidity is often severe and lethality remains high. New therapeutic approaches are therefore warranted. Caspofungin, a beta-1,3-glucan synthesis inhibitor, has shown activity against the cyst forms of P. jiroveci in experimental animal models. We here report our preliminary clinical experience with caspofungin as an additional drug to the standard trimethoprim-sulfamethoxazole regimen. ⋯ This preliminary clinical experience suggests that the addition of caspofungin to trimethoprim-sulfamethoxazole, which is active against trophic forms, may provide a synergistic activity against P. jiroveci by fully inhibiting the organism life cycle.
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Ischemia reperfusion injury (IRI) results in damage to local and remote organs. Remote ischemic preconditioning (RIPC) is a strategy to protect against IRI by inducing a prior brief period(s) of IRI to an organ remote from that undergoing sustained injury. ⋯ For this review, a Medline/Pubmed search (January 1985 to January 2007) was conducted and all relevant articles were included. RIPC protocols are organ and species specific and both humoral and neurogenic pathways are involved in triggering intracellular signal pathways for protection.