Abdominal Transplant Recipients Research Articles

Novel Pharmacy Model: Pharmacy Diabetes Clinic in Abdominal Transplant Recipients.

Novel Pharmacy Model: Pharmacy Diabetes Clinic in Abdominal Transplant Recipients.

PB0495 Apixaban Use in Abdominal Transplant Recipients at a Large Academic Medical Center

PB0495 Apixaban Use in Abdominal Transplant Recipients at a Large Academic Medical Center

Reduced dosing versus full dosing valganciclovir for prophylaxis of cytomegalovirus in high-risk abdominal transplant recipients.

Cytomegalovirus (CMV) is a common infection in abdominal transplant recipients (ATR). Prevention of CMV in the highest risk population (CMV IgG donor+/recipient-) is critical as CMV is associated with negative outcomes. Guideline recommended prophylactic valganciclovir dosing is 900mg daily for 6 months in this population. However, reduced dosing strategies are utilized in practice. This single center, retrospective study in adult ATR compared full valganciclovir prophylactic dosing (900mg daily for 6 months) to reduced dosing (900mg daily for 3 months, then 450mg daily for 3 months). The primary endpoint was incidence of CMV infection with viral load >1000 IU/mL. Secondary endpoints included incidence of CMV infection with viral load 200-1000 IU/mL, neutropenia, and leukopenia. Incidence of CMV infection with viral load >1000 IU/mL (29%vs. 27%, p=1) or CMV infection with viral load 200-1000 IU/mL (6%vs. 12%, p=.421) did not differ significantly between 68 ATR in reduced and full dosing groups, as well as incidence of leukopenia (94%vs. 97%, p=1) and neutropenia (77%vs. 70%, p=.586). There was no difference in the incidence of CMV infection, neutropenia, or leukopenia of the two dosing regimens, although time to CMV diagnosis was different.

Treating acute diverticulitis in pre- and post-solid-organ transplant patients: a single-institution cohort study.

Immunosuppressed patients are more likely to fail nonoperative management of acute diverticulitis and have more postoperative complications than the immunocompetent. Transplant recipients form a subcategory among the immunosuppressed with unique challenges. The aim of this work is to report 30-day postoperative complications after colectomy for acute diverticulitis and success rates of nonoperative management in pre- and post-transplant patients. This is a retrospective cohort study at a single-institution tertiary referral centre. Patients with a history of acute diverticulitis were extracted from a database of 6152 recipients of solid-organ abdominal transplant between 2000 and 2015 and stratified by the index episode of diverticulitis: before or after solid-organ transplant surgery. Outcomes included 30-day postoperative complications and failure of nonoperative management. Acute diverticulitis occurred in 93 patients, 69 (74%) posttransplant. Postcolectomy complications were higher posttransplant than pretransplant (43% vs. 13%, p= 0.04). Posttransplant status was not an independent risk factor for complications (odds ratio 3.59, 95% CI 0.79-16.31) when adjusting for sex and surgical acuity. Immediate urgent colectomy (29% vs. 31%, p= 0.84) and failure of nonoperative management (7% vs. 9%, p= 0.82) were similar. Complications occurred equally in those requiring urgent colectomy after nonoperative management and those undergoing immediate urgent colectomy. Urgent colectomy rates are similar in solid-organ abdominal transplant recipients pre- and posttransplant. Posttransplant complication rates appear to be increased but transplant status as an independent factor is not significantly associated with an increased risk in this study cohort. These findings should be considered when counselling patients on the relative risks and benefits of surgical intervention for diverticulitis before versus after solid-organ transplantation.

The Effect of Language on Access to Timely COVID-19 Vaccination of Solid Abdominal Organ Transplant Recipients.

In dynamic healthcare environments including the COVID-19 pandemic, it is paramount to communicate health recommendations expediently and clearly. Research has shown social determinants of health affect the impact of COVID-19 on abdominal transplant recipients, but there has been less research on the effect of language proficiency. This is a cohort study of time to first COVID-19 vaccination among abdominal organ transplant recipients in an academic medical center in Boston, MA between 18 December 2020, and 15 February 2021. Cox proportional hazards analysis of time to vaccination by preferred language were adjusted for race, age group, insurance, and transplanted organ. Among 3001 patients, 53% were vaccinated during the study period. Language preference other than English was independently associated with delay to vaccination (0.64, p = 0.001), on adjusted analysis. In addition, Black, Hispanic and other race patients were less likely to be vaccinated than white patients (0.58, 0.67, 0.68 vs. reference, all p < 0.03). Language preference other than English is an independent barrier to solid abdominal organ transplant recipients' access to timely COVID-19 vaccination. Equity in care should be improved by providing targeted services to minority language speakers.

Letermovir conversion after valganciclovir treatment in cytomegalovirus high‐risk abdominal solid organ transplant recipients may promote development of cytomegalovirus‐specific cell mediated immunity

To evaluate the association of conversion from valganciclovir to letermovir on cytomegalovirus-specific cellular immunity. Adult patients were included if they received a kidney or liver transplant between 8/1/2018-12/31/20, developed symptomatic, high-level CMV viremia and were converted to letermovir 480mg daily as monotherapy after treatment with ganciclovir-derivatives for a minimum of 4weeks and had subsequent CMV cell-mediated immunity (CMI) testing via ICS assay by flow cytometry (Viracor Eurofins T Cell Immunity Panel). Seven patients met inclusion criteria; 87.5% were male and recipients of a kidney transplant. All patients were CMV high risk (D+/R-). Mean time from transplant to CMV disease was 200±91 days. Peak viral load (VL) during CMV treatment was 540,341±391,211 IU/mL. Patients received a mean of 30±24weeks (range: 4-78weeks) of therapy with ganciclovir-derivatives at induction doses prior to letermovir introduction. The median absolute lymphocyte count (ALC) at letermovir initiation was 400/μL (IQR 575) and the median VL was 51.6 (range: ND-490) IU/mL. Most patients (n=5/7, 71.4%) experienced an increase in VL 1 and/or 2weeks after conversion to letermovir. All patients had positive CMI per ICS assay after conversion. Patients received a mean of 10.3±6.9weeks of letermovir prior to having a positive result. Median ALC at positivity was 900/μL. Immunosuppression was not further reduced from initiation of letermovir to demonstration of CMV CMI. No patient had progressive replication or breakthrough disease while maintained on letermovir and three patients (42.9%) underwent antiviral withdrawal without recurrence at the last follow-up. In this case series of abdominal transplant recipients with severe or persistent CMV infection, patients developed CMV-specific CMI after conversion to letermovir monotherapy. These data suggest that using letermovir in place of valganciclovir for secondary prophylaxis may address the lack of efficacy previously seen with this approach, as well as the issues that plague antiviral withdrawal with systematic monitoring. Future prospective studies are needed to evaluate this effect in a more controlled research environment with serial CMI testing to elucidate the optimal duration of letermovir when used in this way.

A Programmatic Response, Including Bamlanivimab or Casirivimab-imdevimab Administration, Reduces Hospitalization and Death in COVID-19 Positive Abdominal Transplant Recipients.

(COVID-19) has resulted in significant morbidity and mortality in solid organ transplant recipients. In December 2020, at the peak of the Los Angeles outbreak, our center rapidly implemented a protocol to improve outpatient management and provide bamlanivimab or casirivimab-imdevimab [COVID monoclonal antibody (mAb) therapies] to all eligible COVID-19 positive liver and kidney transplant recipients. A retrospective review of all abdominal organ transplant recipients who were COVID-19 polymerase chain reaction positive between February 2020 and February 2021 from our center was performed. Patient demographics, COVID-19 treatments, hospitalizations, and survival were reviewed. Patients were considered eligible for COVID mAb therapy if they met outpatient criteria at the time of diagnosis. In the study period, 121 patients in the kidney transplant recipients group (KG) and 105 patients in the liver or combined liver/kidney transplant recipients group (LG) were COVID-19 polymerase chain reaction positive. Hospitalization rates were similar for the KG (45%) versus LG (35%) (P = 0.20), but mortality was higher for the KG (22%) when compared to LG (10%) (P = 0.02). Our programmatic response, including outpatient COVID mAb therapies, reduced hospitalizations (P = 0.01) and deaths (P = 0.01). Ninety-four KG and 87 LG patients were identified as potentially eligible for COVID mAb therapy, and 17 KG and 17 LG patients were treated. COVID mAb therapies reduced hospitalization from 32% to 15% (P = 0.045) and eliminated mortality (13% versus 0%, P = 0.04). An aggressive approach including outpatient COVID mAb therapy in the COVID positive abdominal organ transplant recipients significantly decreased hospitalization and death. Early outpatient intervention for COVID-19 disease in transplant patients should be considered where possible.

Nonopioid Modalities for Acute Postoperative Pain in Abdominal Transplant Recipients.

The field of abdominal organ transplantation is multifaceted, with the clinician balancing recipient comorbidities, risks of the surgical procedure, and the pathophysiology of immunosuppression to ensure optimal outcomes. An underappreciated element throughout this process is acute pain management related to the surgical procedure. As the opioid epidemic continues to grow with increasing numbers of transplant candidates on opioids as well the increase in the development of enhanced recovery after surgery protocols, there is a need for greater focus on optimal postoperative pain control to minimize opioid use and improve outcomes. This review will summarize the physiology of acute pain in transplant recipients, assess the impact of opioid use on post-transplant outcomes, present evidence supporting nonopioid analgesia in transplant surgery, and briefly address the perioperative approach to the pretransplant recipient on opioids.

Effects of Sofosbuvir-Based Hepatitis C Treatment Regimens on Calcineurin Inhibitor Dosing in Liver and Kidney Transplant Recipients.

Available data have suggested that directacting antivirals for hepatitis C virus may decrease calcineurin inhibitor concentrations. In this study, our aim was to determine the effects of hepatitis C directacting antivirals on calcineurin inhibitor doses and trough levels. This retrospective, singlecenter study included 52 abdominal transplant recipients treated with sofosbuvir-based regimens between 2014 and 2017. The primary outcome was percent change in calcineurin inhibitor troughs and total daily doses between the week before treatment with direct-acting antivirals, days 21 to 35 oftreatment, and days 21 to 35 aftertreatment. Secondary outcomes included sustained virologic response and biopsyproven acute rejection rates. The median percent difference in calcineurin inhibitor troughs from pretreatment to during treatment was -20.5% (interquartile range, -36.2% to 13.1%) and from pretreatment to posttreatment was -13.5% (interquartile range, -33.7% to 10.7%). Corresponding percent changes in calcineurin inhibitor doses were 0% (interquartile range, 0%-0%) and 0% (interquartile range, -10.5% to 33.3%), respectively. Patients on tacrolimus experienced statistically significant changes in troughs but not doses. During treatment, 65% of patients required no dose change, 23% underwent a dose increase, and 12% had a dose decrease. The sustained virologic response rate was 98%, and the biopsy-proven acute rejection rate was 0%. Hepatitis C direct-acting antiviraltherapy may decrease calcineurin inhibitor levels, but this was not associated with clinically different dosing requirements or rejection rates.

Intra-abdominal infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice.

This new guideline from the AST IDCOP reviews intra-abdominal infections (IAIs), which cause substantial morbidity and mortality among abdominal SOT recipients. Each transplant type carries unique risks for IAI, though peritonitis occurs in all abdominal transplant recipients. Biliary infections, bilomas, and intra-abdominal and intrahepatic abscesses are common after liver transplantation and are associated with the type of biliary anastomosis, the presence of vascular thrombosis or ischemia, and biliary leaks or strictures. IAIs after kidney transplantation include renal and perinephric abscesses and graft-site candidiasis, which is uncommon but may require allograft nephrectomy. Among pancreas transplant recipients, duodenal anastomotic leaks can have catastrophic consequences, and polymicrobial abscesses can lead to graft loss and death. Intestinal transplant recipients are at the highest risk for sepsis, infection due to multidrug-resistant organisms, and death from IAI, as the transplanted intestine is a contaminated, highly immunological, pathogen-rich organ. Source control and antibiotics are the cornerstone of the management of IAIs. Empiric antimicrobial regimens should be tailored to local susceptibility patterns and pathogens with which the patient is known to be colonized, with subsequent optimization once the results of cultures are reported.

Non-tuberculous Mycobacterial Infections in Thoracic Transplant Candidates and Recipients.

To review and discuss the epidemiology, risk factors, clinical presentation, diagnosis, and treatment of non-tuberculous mycobacteria (NTM) in thoracic transplantation. Non-tuberculous mycobacteria are ubiquitous but are an uncommon cause of disease after solid organ transplantation. The incidence of infection is higher in thoracic transplant recipients than in abdominal transplant recipients, with most cases seen after lung transplantation. It is associated with increased morbidity and, occasionally, mortality. Infection in the pre-transplant setting can occur in lung transplant candidates, often posing a dilemma regarding transplant listing. Disease manifestations are diverse, and pulmonary disease is the most common. Diagnosis requires a high index of suspicion. Treatment requires a multiple-drug combination and is limited by drug-drug interactions and tolerability. Mycobacterium abscessus is a challenge in lung transplant recipients, due to its intrinsic resistance and propensity to relapse even after prolonged therapy. Mycobacterium chimaera is an emerging pathogen associated with contamination of heater-cooler units and is described to cause disease months after cardiothoracic surgery. NTM infections in thoracic organ transplant recipients are uncommon but are associated with substantial morbidity and mortality. Data from larger multicenter studies is needed to better define the epidemiology of NTM in thoracic transplantation, best treatment options, and the management of infected transplant candidates.

Collaborative practice agreement in solid organ transplantation.

Background Given the complexity of solid organ transplant recipients, a multidisciplinary approach is required. To promote medication safety and enable providers to focus on the medical and surgical needs of these patients, our department of pharmacy created a collaborative practice agreement between physicians and pharmacists. Through this agreement, credentialed pharmacists are empowered to provide inpatient services including initiation and adjustment of medications through independent review of laboratory results after multidisciplinary rounds. Objective Toevaluate the effect of our collaborative practice agreement on clinical care and institutional finances. Setting Aninpatient setting at a large academic medical center. Methods Three transplant pharmacists entered all clinical interventions made on abdominal transplant recipients between September and October 2013 into Quantifi®, a software application that categorizes and assigns a cost savings value based on impact and type of intervention. Main outcome measure The main outcome measures in this study were number and categorization of interventions, as well as estimated cost savings to the institution. Results There were 1060 interventions recorded, an average of 20 interventions per pharmacist per day. The most common interventions were pharmacokinetic evaluations (36%) and dose adjustments (19%). Over the time period, these interventions translated into an estimated savings of $107,634.00, or an annual cost savings of $373,131.20 per pharmacist, or a cost-benefit ratio of 2.65 to the institution. Conclusions Based on our study, implementation of a collaborative practice agreement enables credentialed pharmacists to make clinically and financially meaningful interventions in a complex patient population.

Cardiac Surgery Outcomes in Abdominal Solid Organ Transplant Recipients

Cardiovascular disease is a cause of morbidity and mortality in organ transplant recipients. Cardiac surgery after organ transplantation is not uncommon in this population. We evaluated 30-day outcomes and long-term survival of abdominal transplant recipients undergoing cardiac surgery at our institution. In all, 138 patients with previous kidney, kidney-pancreas, and liver transplants underwent cardiac surgery from 2000 to 2016. Propensity score (ratio 1:3) matched 115 abdominal transplant with 345 patients undergoing cardiac surgery without a history of abdominal transplant. They were matched for type and year of cardiac surgery, age, sex, body mass index, history of diabetes mellitus, and creatinine level before cardiac surgery. Median time from abdominal transplant to cardiac surgery was 7 years (interquartile range, 3 to 12 years). Perioperative variables, including surgery and cardiopulmonary bypass time, aortic cross-clamp and intubation time, and intensive care unit stay did not differ between the groups. Hospital length of stay and rate of 30-day hospital readmissions did not differ between the groups. Patients with abdominal transplants had more strokes (4% versus 0.6%; p= 0.005) within 30 days after surgery. There were no differences in renal failure, bleeding, site infections, atrial fibrillation, and pneumonia between the groups. Five patients (4%) died within 30 days after surgery in the abdominal transplant group (4 kidneys, 1 liver, 0 kidney-pancreas), and 7 patients (2%) died in the nontransplanted group (p= 0.24). Previous history of abdominal transplant is associated with an increased 30-day incidence of stroke after cardiac surgery. Abdominal transplant does not affect 30-day mortality after cardiac surgery, whereas long-term survival is significantly reduced. Regular patient follow-up and prevention and early treatment of postoperative complications are key to patient survival.

High-Dose Acyclovir for Cytomegalovirus Prophylaxis in Seropositive Abdominal Transplant Recipients.

Following abdominal solid organ transplant (aSOT), valganciclovir (VGC) is recommended for cytomegalovirus (CMV) prophylaxis. This agent is associated with efficacy concerns, toxicity, and emergence of ganciclovir resistance. To evaluate the incidence of high-dose acyclovir (HD-A) prophylaxis failure in seropositive aSOT recipients (R+). This was a retrospective, single-center study of R+ transplanted without lymphocyte-depleting induction between January 1, 2000, and June 30, 2013, discharged with 3 months of HD-A prophylaxis (800 mg 4 times daily). The primary outcome was incidence of prophylaxis failure. Secondary outcomes were incidence of biopsy-proven tissue-invasive disease and prophylaxis failure for each allograft subgroup. A total of 1525 patients met inclusion criteria: 944 renal (RTX), 108 simultaneous pancreas-kidneys (SPK), 462 liver (LTX), and 11 pancreas (PTX) transplant recipients. The composite rate of HD-A prophylaxis failure was 7%; incidence of tissue-invasive disease was 0.4%. Failure rates were 4.5%, 6.1%, 11%, and 20% in the RTX, SPK, LTX, and PTX populations, respectively; tissue-invasive disease rates were 0.2%, 0%, 0.7%, and 10%. Failure occurred more frequently in the LTX and PTX populations ( P < 0.0001, HR = 2.6; P = 0.04 HR = 4.4). Incidence of tissue-invasive disease was minimal and not different in the RTX, LTX and SPK populations ( P = 0.34). When evaluating recipients of seronegative allografts (D-), the composite failure rate was 3.4% with no significant difference between allograft subgroups ( P = 0.45). HD-A may be a reasonable prophylaxis alternative for D-/R+ recipients, in the absence of lymphocyte-depleting induction, if low incidence viremia is tolerable. Future studies are needed to determine the long-term impact of CMV viremia in the setting of this prophylaxis approach.

Ganciclovir-resistant cytomegalovirus infection in solid organ transplant recipients: a single-center retrospective cohort study.

Ganciclovir-resistant cytomegalovirus (GCV-R CMV) is an emerging challenge among solid organ transplant (SOT) recipients. The literature suggests that about 1% of abdominal transplant recipients develop GCV-R CMV infection. The epidemiology and outcome of GCV-R CMV in SOT recipients who have received alemtuzumab induction is not well described. After Institutional Review Board approval, a single-center, retrospective review of 2148 abdominal SOT recipients between January 2006 and July 2011 at our institution (n = 2148) was conducted to identify patients with proven or empirically treated GCV-R CMV. Descriptive statistics on collected demographics, clinical course, and therapeutic outcomes were performed. Of 116 SOT recipient treated for CMV, 14 patients (12.1% of cases; 0.65% of all SOT patients) had proven or suspected GCV-R CMV. Eight (50%) developed GCV-R CMV while receiving valganciclovir (valGCV) prophylaxis. The remainder developed late-onset disease, after having completed an average 212 days (range 83-353) of prophylaxis. Resistance was clinically suspected an average of 103 days (range 10-455) after CMV infection was initially identified; 10 patients had confirmed genotypic resistance. Foscarnet therapy was associated with resolution of CMV in 13. Suboptimal dosing of valGCV is associated with development of GCV-R CMV. Our observed rate of GCV-R CMV in alemtuzumab-induced patients is similar to rates seen to historical data for other induction agents.

Contraceptive Use and Counseling Needs in Heart and Lung Versus Abdominal Transplant Recipients [12O

INTRODUCTION: Women who have undergone solid-organ transplantation have unique reproductive health needs, including avoiding pregnancy, especially short term, after transplant. This study aims to compare contraceptive use among reproductive-age women after heart or lung transplantation and after kidney or liver transplantation to identify opportunities to improve patient care. METHODS: This was a cross-sectional survey at two academic health systems of reproductive-age women between 1 and 48 months post solid organ transplant. Participants completed a questionnaire regarding reproductive history and contraceptive counseling and use before and after transplant surgery. RESULTS: Twenty-three women completed the survey. Six were heart, three were lung, and 18 were kidney or kidney/liver transplant recipients. Pregnancy counseling was usually provided before transplantation (35%) or after transplantation in the hospital or clinic (39%), with the remaining receiving no counseling on when it would be safe to consider pregnancy. While most were using a contraceptive method before and after transplant, 56% were using condoms only and 13% were using no method at all. Condoms followed by intrauterine devices (IUDs) and injectable contraceptives were the most commonly discussed/offered methods. While condom use still accounted for 55% of the heart and lung transplant recipients, all were using some method with implant/injectable/ocp accounting for the rest. The kidney group, on the other hand, had two women using IUD but the others using condoms (57%), fertility awareness, or no method (21%). CONCLUSION: Despite increased morbidity of unintended pregnancy, heart and lung transplant patients' contraceptive counseling and utilization is similar to kidney and liver transplant patients.

Early Postoperative Emergency Department Care of Abdominal Transplant Recipients.

Research on posttransplant care has predominantly focused on predictors of readmission with little attention to emergency department (ED) visits. The goal of this study was to describe early postoperative ED care of transplant recipients. A secondary database analysis of adult patients who underwent abdominal organ transplantation between January 1, 2008, and December 31, 2013, and sought ED care within 1 year after transplantation was conducted. Survival was compared using the Kaplan-Meier method with log-rank test. Cox proportional hazards regression analysis was performed to adjust for pertinent covariates A total of 1900 abdominal organ transplants were performed during the study period. Of these, 37% (N = 711) transplant recipients sought care in the ED (1343 total visits) with 1.89 mean ED visits per recipient. Of recipients seen in the ED, 58% received a kidney transplant and 28% received a liver transplant, with 45% of recipients presenting within the first 60 postoperative days. The most common chief complaints were gastroenterological (17%) and abnormal laboratory values or vital signs (17%). In total, 74% of recipients were readmitted and 50% of admitted patients were discharged in less than 24 hours. Transplant recipients with ED visits had lower 3-year graft (81% vs 87%; P < 0.001) and patient (89% vs 93%; P = 0.002) survival. Transplant recipients have a high frequency of ED visits in the first posttransplantation year and high rates of subsequent hospital admission. Further investigation is needed to understand what drives recipient presentation to the ED and create care models that achieve the best outcomes.

Human Metapneumovirus, a Neglected Respiratory Viral Infection in Abdominal Transplant Recipients.

Background: Human Metapneumovirus (hMPV) has been well recognized as a cause of respiratory illness in lung and bone marrow transplant recipients. However, little has been reported in the abdominal transplant population. The purpose of this study was to report the presentation, clinical course, and outcomes of hMPV infection in a series of kidney and pancreas transplant recipients. Methods: This was a retrospective study of hospitalized pts who were diagnosed with respiratory hMPV infection by polymerase chain reaction between January 2011 and June 2013. Results: During this period 11 pts with a positive BAL or nasopharyngeal aspirate were identified.Table: No Caption available.All pts presented with symptoms of respiratory infection. The most common symptoms were coughing, wheezing, dyspnea, and fever. Severity of symptoms ranged from shortness of breath with mild wheezing and no 02 requirement to hypoxemia requiring intubation. 6 pts required ICU level of care, 3 with co-infection at the time of hMPV detection, including 2 with CMV, and 1 with MRSA. Diagnosis of pneumonia (PNA) was confirmed radiographically in 9 pts. 3 pts received treatment for hMPV PNA, consisting of ribavirin and/or IVIg, as well as IS reduction in 2 pts. 3 untreated pts had IS reduced. 5 pts received supportive care only. A subset of 4 pts were diagnosed within 6 months of TX. 3 received basiliximab induction and 1 received alemtuzumab. 2 of these were co-infected at the time of hMPV detection. One pt was diagnosed with combined cellular and antibody-mediated rejection (AMR) and received rATG and PP/IVIg 5 months prior to hMPV detection. Another pt with chronic AMR had IS increased before hMPV detection. Of the 11 pts, 10 fully recovered with a median hospitalization of 7 days (range 2-56 days). One pt died of cardiogenic shock during hospitalization. 9 months after hMPV infection, one pt who had IS reduced developed AMR. Conclusions: Our experience demonstrates that in abdominal transplant recipients hMPV can result in significant morbidity and may contribute to pt death. We recommend screening for hMPV in such pts with acute respiratory illness requiring hospitalization. Optimal treatment of hMPV warrants further study.

Aneurysms in abdominal organ transplant recipients

The purpose of this study was to characterize the prevalence and natural history of aneurysms among abdominal transplant recipients. This article is a retrospective review of adult patients who underwent a kidney or liver transplant at a single center between February 23, 2000, and October 6, 2011. Data were obtained by searching electronic medical records for documentation of arterial aneurysm. Abdominal aortic aneurysms (AAAs) were included if they were ≥3.0 cm in diameter, and thoracic aortic aneurysms were included if they had a diameter ≥3.75 cm. Additional data collected included recipient demographics, transplant-specific data, and characteristics of the aneurysms. There were 927 liver transplant recipients, 2133 kidney transplant recipients, 23 liver-kidney transplant recipients, and 133 kidney-pancreas transplant recipients included in our study; 127 of these patients were identified to have aneurysms (40 liver, 83 kidney, 3 liver-kidney, 1 kidney-pancreas). The overall prevalence of any aneurysm was similar for liver and kidney recipients, but the distribution of aneurysm types was different for the two groups. AAAs made up 29.6% of aneurysms in kidney transplant recipients and 11.4% of aneurysms in liver transplant recipients (P = .02). Visceral aneurysms were 10-fold as common in liver transplant recipients compared with kidney transplant recipients (47.7% of aneurysms vs 5.1% of aneurysms; P < .01). The majority of visceral artery aneurysms involved the hepatic and splenic artery. For both liver and kidney transplant recipients, most aneurysms occurred post-transplantation. All known aortic aneurysm ruptures occurred post-transplantation (25% of AAAs in liver transplant patients and 22.2% of thoracic aortic aneurysms in kidney transplant patients). There was a trend toward higher AAA expansion rates after transplantation (0.58 ± 0.48 cm/y compared with 0.41 ± 0.16 cm/y). Compared with the general population, aneurysms may be more common and may have an aggressive natural history in abdominal transplant recipients. Furthermore, the types of aneurysms that affect liver and kidney transplant recipients differ. Care teams should be aware of these risks and surveillance programs should be tailored appropriately.

Epidemiology, Clinical Characteristics and Outcomes of Extensively Drug-Resistant Acinetobacter baumannii Infections among Solid Organ Transplant Recipients

BackgroundExtensively drug-resistant Acinetobacter baumannii (XDR-Ab) has emerged as a major nosocomial pathogen, but optimal treatment regimens are unknown. Although solid organ transplant (SOT) recipients are particularly susceptible to XDR-Ab infections, studies in this population are limited. Our objectives were to determine the epidemiology, clinical characteristics and outcomes of XDR-Ab infections among SOT patients.MethodsA retrospective study of SOT recipients at our center who were colonized or infected with XDR-Ab between November 2006 and December 2011 was conducted. Among infected patients, the primary outcome was survival at 28 days. Secondary outcomes included survival at 90 days and clinical success at 28 days, and XDR-Ab infection recurrence.ResultsXDR-Ab was isolated from 69 SOT patients, of whom 41% (28) and 59% (41) were colonized and infected, respectively. Infections were significantly more common among cardiothoracic than abdominal transplant recipients (p = 0.0004). Ninety-eight percent (40/41) of patients had respiratory tract infections, most commonly ventilator-associated pneumonia (VAP; 88% [36/41]). Survival rates at 28 and 90 days were 54% (22/41) and 46% (19/41), respectively. Treatment with a colistin-carbapenem regimen was an independent predictor of 28-day survival (p = 0.01; odds ratio = 7.88 [95% CI: 1.60–38.76]). Clinical success at 28 days was achieved in 49% (18/37) of patients who received antimicrobial therapy, but 44% (8/18) of successes were associated with infection recurrence within 3 months. Colistin resistance emerged in 18% (2/11) and 100% (3/3) of patients treated with colistin-carbapenem and colistin-tigecycline, respectively (p = 0.03).ConclusionsXDR-Ab causes VAP and other respiratory infections following SOT that are associated with significant recurrence and mortality rates. Cardiothoracic transplant recipients are at greatest risk. Results from this retrospective study suggest that colistin-carbapenem combinations may result in improved clinical responses and survival compared to other regimens and may also limit the emergence of colistin resistance.