Qiquan Wan

This study aimed to analyze the epidemiology, predictors, and clinical outcomes of postoperative delirium (POD) in liver transplant (LT) recipients. Clinical data from 427 LT recipients from the Third Xiangya Hospital were retrospectively reviewed. The epidemiology (incidence, onset, and duration), predictors, and associated clinical outcomes of POD were analyzed using standardized delirium assessment tools and multivariate regression. POD occurred in 19.0% of recipients, with a median onset at 26.0 hours posttransplant. Multivariate analysis identified 4 independent pre and postoperative predictors, including a higher model for end-stage liver disease score and hepatic encephalopathy within 24 hours before LT, infection within 2 months prior to LT, and abnormal sodium within 1 hour after LT (all P < .05). In a sensitivity analysis treating early death or persistent coma as a composite outcome with POD (n = 436), the same 4 independent predictors were identified, with consistent effect estimates. Regarding clinical outcomes, POD was significantly associated with prolonged intensive care unit stays, extended mechanical ventilation requirements, and increased use of renal replacement therapy (all P < .01). Although recipients with POD showed higher 1- and 6-month all-cause mortality in unadjusted analyses, POD was not an independent predictor of mortality after adjustment for confounding factors. POD occurs frequently and early after LT, with identifiable pre and postoperative risk factors. While POD markedly increases perioperative morbidity and resource utilization, it does not independently predict short-term all-cause mortality in this cohort.

Low-flow extracorporeal carbon dioxide removal (ECCO ₂ R) may be useful when severe hypercapnia limits ultra-protective ventilation but full venovenous extracorporeal membrane oxygenation (VV-ECMO) is not pursued. We describe a 68 year old man with metastatic lung adenocarcinoma who developed amivantamab-associated immune-related interstitial lung disease complicated by acute respiratory distress syndrome (ARDS) and active airway hemorrhage. After endotracheal intubation, the dominant physiologic problem was hypercapnic acidosis (pH 7.12; PaCO ₂ 83.4 mm Hg) with very poor respiratory system compliance, whereas oxygenation impairment was moderate (PaO ₂ /FiO ₂ 160 mm Hg). Because of terminal malignancy and the burden of large-bore cannulation, VV-ECMO was not pursued. Electrical impedance tomography showed no benefit from prone positioning. A hybrid strategy was then initiated: inhaled nitric oxide to improve ventilation-perfusion (V/Q) matching and ECCO ₂ R to control carbon dioxide clearance. Within 2 hours, PaCO ₂ fell to 60.7 mm Hg and pH rose to 7.32; oxygenation also improved. The circuit remained functional for 13 days without recurrent airway bleeding or documented circuit thrombosis. This case illustrates the feasibility of concurrently applying inhaled nitric oxide and low-flow ECCO ₂ R as a physiology-guided, low-intensity rescue approach in a highly selected patient when VV-ECMO was not pursued.

BACKGROUND Liver transplant (LT) recipients are susceptible to carbapenem-resistant Klebsiella pneumoniae (CRKP) infections. Comprehensive research addressing the incidence, timing, infection sites, resistance patterns, treatment options, and associated risk factors among LT recipients with CRKP is now lacking. AIM To assess the incidence, resistance, therapy, and risk factors of CRKP infections post-LT, and to evaluate the impact of them on prognosis. METHODS A retrospective study was conducted, including 430 consecutive patients who underwent LT between January 2015 and June 2023. This study aimed to investigate the risk factors for CRKP infections and their influence on outcomes using logistic regression analysis. RESULTS Among the 430 patients who underwent LT, 20 (4.7%) experienced at least one documented CRKP infection within 3 months post-transplantation. The median time from LT to the onset of CRKP infections was 6.5 days. The lungs and bloodstream were the most common sites of CRKP infections. CRKP isolates were relatively susceptible to ceftazidime/avibactam (93.7%), polymyxin B (90.6%), and tigecycline (75.0%) treatment. However, all isolates were resistant to piperacillin/tazobactam, ceftazidime, cefepime, aztreonam, meropenem, and levofloxacin treatment. Recipients with CRKP infections had a mortality rate of 35%, the rate was 12.5% for those receiving ceftazidime/avibactam therapy. Multivariate analysis identified female sex [odds ratio (OR) = 3.306; 95% confidence interval (CI): 1.239-8.822; P = 0.017], intraoperative bleeding ≥ 3000 mL (OR = 3.269; 95%CI: 1.018-10.490; P = 0.047), alanine aminotransferase on day 1 post-LT ≥ 1500 U/L (OR = 4.370; 95%CI: 1.686-11.326; P = 0.002), and post-LT mechanical ventilation (OR = 2.772; 95%CI: 1.077-7.135; P = 0.035) as significant variables associated with CRKP. CRKP infections were related to an intensive care unit length (ICU) of stay ≥ 7 days and 6-month all-cause mortality post-LT. CONCLUSION CRKP infections were frequent complications following LT, with poor associated outcomes. Risk factors for post-LT CRKP infections included female sex, significant intraoperative bleeding, elevated alanine aminotransferase levels, and the need for mechanical ventilation. CRKP infections negatively impacted survival and led to prolonged ICU stays.

The primary objective of this study was to assess the incidence, timing, risk factors of fungal infections (FIs) within 3 months after liver transplantation (LT). The secondary objective was to evaluate the impact of FIs on outcomes. Four hundred and ten patients undergoing LT from January 2015 until January 2023 in a tertiary university hospital were included in the present retrospective cohort study to investigate the risk factors of FIs and to assess the impacts of FIs on the prognosis of LT recipients using logistic regression. The incidence of FIs was 12.4% (51/410), and median time from LT to the onset of FIs was 3 days. By univariate analysis, advanced recipient age, prolonged hospital stay prior to LT, high Model for End Stage Liver Disease (MELD) score, use of broad-spectrum antibiotics, and elevated white blood cell (WBC) count, increased operating time, massive blood loss and red blood cell transfusion, elevated alanine aminotransferase on day 1 and creatinine on day 3 after LT, prolonged duration of urethral catheter, prophylactic antifungal therapy, the need for mechanical ventilation and renal replacement therapy were identified as factors of increased post-LT FIs risk. Multivariate logistic regression analysis identified that recipient age ≥ 55 years[OR = 2.669, 95%CI: 1.292–5.513, P = 0.008], MELD score at LT ≥ 22[OR = 2.747, 95%CI: 1.274–5.922, P = 0.010], pre-LT WBC count ≥ 10 × 10⁹/L[OR = 2.522, 95%CI: 1.117–5.692, P = 0.026], intraoperative blood loss ≥ 3000 ml [OR = 2.691, 95%CI: 1.262–5.738, P = 0.010], post-LT duration of urethral catheter > 4 d [OR = 3.202, 95%CI: 1.553–6.602, P = 0.002], and post-LT renal replacement therapy [OR = 5.768, 95%CI: 1.822–18.263, P = 0.003] were independently associated with the development of post-LT FIs. Post-LT prophylactic antifungal therapy ≥ 3 days was associated with a lower risk of the development of FIs [OR = 0.157, 95%CI: 0.073–0.340, P < 0.001]. As for clinical outcomes, FIs had a negative impact on intensive care unit (ICU) length of stay ≥ 7 days than those without FIs [OR = 3.027, 95% CI: 1.558–5.878, P = 0.001] but had no impact on hospital length of stay and 1-month all-cause mortality after LT. FIs are frequent complications after LT and the interval between the onset of FIs and LT was short. Risk factors for post-LT FIs included high MELD score at LT, advanced recipient age, pre-LT WBC count, massive intraoperative blood loss, prolonged post-LT duration of urethral catheter, and the need for post-LT renal replacement therapy. However, post-LT prophylactic antifungal therapy was independently associated with the reduction in the risk of FIs. FIs had a significant negative impact on ICU length of stay.

BACKGROUND Liver transplantation (LT) is the only curative treatment for end-stage liver disease. However, LT recipients are susceptible to infection, which is the leading cause of early mortality after LT. Klebsiella pneumoniae infections (KPIs) in the bloodstream are common in LT recipients. We hypothesized that KPIs and carbapenem-resistant Klebsiella pneumoniae (CRKP) infections may affect the outcomes of LT recipients. AIM To assess KPI incidence, timing, distribution, drug resistance, and risk factors following LT and its association with outcomes. METHODS This retrospective study included 406 patients undergoing LT at The Third Xiangya Hospital of Central South University, a tertiary hospital, from January 2015 to January 2023. We investigated the risk factors for KPIs and assessed the impact of KPIs and CRKP infections on the prognosis of LT recipients using logistic regression analysis. RESULTS KPI incidence was 7.9% (n = 32), with lung/thoracic cavity the most frequent site of infection; the median time from LT to KPI onset was 7.5 d. Of 44 Klebsiella pneumoniae isolates, 43 (97.7%) and 34 (77.3%) were susceptible to polymyxin B or ceftazidime/avibactam and tigecycline, respectively; > 70% were resistant to piperacillin/ tazobactam, ceftazidime, cefepime, aztreonam, meropenem, and levofloxacin. Female sex [odds ratio (OR) = 2.827, 95% confidence interval (CI): 1.256-6.364; P = 0.012], pre-LT diabetes (OR = 2.794, 95%CI: 1.070-7.294; P = 0.036), day 1 post-LT alanine aminotransferase (ALT) levels ≥ 1500 U/L (OR = 3.645, 95%CI: 1.671-7.950; P = 0.001), and post-LT urethral catheter duration over 4 d (OR = 2.266, 95%CI: 1.016-5.054; P = 0.046) were risk factors for KPI. CRKP infections, but not KPIs, were risk factors for 6-month all-cause mortality post-LT. CONCLUSION KPIs occur frequently and rapidly after LT. Risk factors include female sex, pre-LT diabetes, increased post-LT ALT levels, and urethral catheter duration. CRKP infections, and not KPIs, affect mortality.

Transoral endoscopic resections in treating upper gastrointestinal submucosal lesions have the advantages of maintaining the integrity of the gastrointestinal lumen, avoiding perforation and reducing gastrointestinal fistulae. They are becoming more widely used in clinical practice, but, they may also present a variety of complications. Gas-related complications are one of the most common, which can be left untreated if the symptoms are mild, but in severe cases, they can lead to rapid changes in the respiratory and circulatory systems in a short period, which can be life-threatening. Therefore, it is important to predict the occurrence of gas-related complications early and take preventive measures actively. Based on the authors' results in the prepublication of the article “Nomogram to predict gas-related complications during transoral endoscopic resection of upper gastrointestinal submucosal lesions,” and in conjunction with our evaluation and additions to the relevant content, radiographs may help screen patients at high risk for gas-related complications. Controlling blood glucose levels, shortening the duration of surgery, and choosing the most appropriate surgical resection may positively impact the prognosis of patients at high risk for gas-related complications during transoral endoscopic resection of upper gastrointestinal submucosal lesions.

Until now, acute respiratory distress syndrome (ARDS) has been a difficult clinical condition with a high mortality and morbidity rate, and is characterized by a build-up of alveolar fluid and impaired clearance. The underlying mechanism is not yet fully understood and no effective medications available. Autophagy activation is associated with ARDS caused by different pathogenic factors. It represents a new direction of prevention and treatment of ARDS to restrain autophagy to a reasonable level through pharmacological and molecular genetic methods. Na, K-ATPase is the main gradient driver of pulmonary water clearance in ARDS and could be degraded by the autophagy-lysosome pathway to affect its abundance and enzyme activity. As a normal growth hormone in human body, insulin has been widely used in clinical for a long time. To investigate the association of insulin with Na, K-ATPase, autophagy and inflammatory markers in LPS-treated C57BL/6 mice by survival assessment, proteomic analysis, histologic examination, inflammatory cell counting, myeloperoxidase, TNF-α and IL-1β activity analysis etc. This was also verified on mouse alveolar epithelial type II (AT II) and A549 cells by transmission electron microscopy. We found that insulin restored the expression of Na, K-ATPase, inhibited the activation of autophagy and reduced the release of inflammatory factors caused by alveolar epithelial damage. The regulation mechanism of insulin on Na, K-ATPase by inhibiting autophagy function may provide new drug targets for the treatment of ARDS.