碳青霉烯耐药肠杆菌定殖的活体肝移植受者的结果

IF 3.3 Q2 GASTROENTEROLOGY & HEPATOLOGY

Journal of Clinical and Experimental Hepatology Pub Date : 2025-01-25 DOI:10.1016/j.jceh.2025.102508

Akila Rajakumar , Prijith Ramanan , Amal F. Sam , Vidya Devarajan , Subha Sundaramoorthy , Dinesh Jothimani , Ashwin Rammohan , Mohamed Rela

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引用次数: 0

摘要

背景移植前耐碳青霉烯类肠杆菌（CRE）定植与肝移植（LT）后较差的预后有关。我们旨在分析2019年1月至2022年9月期间成人活体肝移植受者CRE定植的发生率和风险因素及其对肝移植术后预后的影响。直肠拭子用于筛查活体肝移植（LDLT）受者的 CRE 定植情况，并将其分为 CRE 阳性组（CRE-POS）和 CRE 阴性组（CRE-NEG）.结果研究共纳入 499 例患者，其中 163 例（32.6%）有 CRE 定植，并接受了预防性益生菌治疗。终末期肝病模型中位数评分（几率比 [OR]：1.05 [95%置信区间{CI}：1.02-1.08]）和术前急性肾损伤（AKI）（OR：1.95 [95% CI：1.28-2.98]）与术前 CRE 定植独立相关。CRE-POS 患者的术中包装红细胞输血量更高（5 [3, 7] vs 3 [1, 6]），LT 后菌血症（19.6% vs 9.8%，P = 0.004）、胸部感染（25.7% vs 13.6%，P = 0.04）和重症监护室住院时间更长（7 天[四分位数间距{IQR}：5-10] vs 6 天[IQR：5-8] P = 0.006）。两组患者的所有其他围手术期参数（包括存活率）相当。499 例患者中有 65 例出现菌血症，其中 61 例（93.8%）为肠杆菌。术前 CRE 定植（OR：1.9 [95% CI：1.08-3.7]）、代谢功能障碍相关性脂肪肝（OR：2.0 [95% CI：1.03-3.89]）、术前 AKI（OR：2.4 [95% CI：1.3-4.5]）和大量输血（OR：2.0 [95% CI：1.03-3.89]）与术后肠杆菌败血症独立相关。CRE菌血症患者的90天死亡率较高（38.4% vs 14.2% P = 0.03）。术后 CRE 菌血症与术前 CRE 定植无关（42.8% CRE-POS vs 57.1% CRE-NEG）。术前 CRE 定植是术后肠杆菌败血症的风险因素，但不是 CRE 菌血症的风险因素。肝移植后 CRE 菌血症的死亡率明显更高。在肝移植前积极监测 CRE，同时使用益生菌等有针对性的先期治疗，以及在发生败血症时根据 CRE 定植情况酌情使用适当的指导性抗生素治疗的低门槛，有助于改善这部分 LDLT 受者的预后。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

Outcomes of Living Donor Liver Transplantation in Recipients Colonized With Carbapenem-Resistant Enterobacterales

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Outcomes of Living Donor Liver Transplantation in Recipients Colonized With Carbapenem-Resistant Enterobacterales

Background

Pretransplant colonization with carbapenem-resistant Enterobacterales (CRE) is associated with poorer post–liver transplantation (LT) outcomes. We aimed to analyze the incidence and risk factors for CRE colonization in adult living-donor LT recipients from January 2019 to September 2022 and its impact on post-LT outcomes.

Methods

Relevant perioperative parameters including bacteremia within one month post LT were recorded. Rectal swabs were used for screening living-donor liver transplantation (LDLT) recipients for CRE colonization and divided into CRE-positive (CRE-POS) and CRE-negative (CRE-NEG) groups.

Results

A total of 499 patients were included in study, and 163 (32.6%) were CRE colonized and received pre-emptive probiotics. Median Model for End-Stage Liver Disease score (odds ratio [OR]: 1.05 [95% confidence interval {CI}: 1.02–1.08]) and preoperative acute kidney injury (AKI) (OR: 1.95 [95% CI: 1.28–2.98]) were independently associated with preoperative CRE colonization. CRE-POS patients had higher intraoperative packed red blood cell transfusion (5 [3, 7] vs 3 [1, 6]) along with a higher incidence of post-LT bacteremia (19.6% vs 9.8%, P = 0.004), chest infections (25.7% vs 13.6%, P = 0.04), and longer intensive care unit stay (7 days [interquartile range {IQR}: 5–10] vs 6 days [IQR: 5–8] P = 0.006). All other perioperative parameters including survival were comparable between the two groups. Bacteremia developed in 65 of 499 patients of which 61 (93.8%) were Enterobacterales. Preoperative CRE colonization (OR: 1.9 (95% CI: 1.08–3.7]), metabolic dysfunction–associated steatotic liver disease as an etiology of liver disease (OR: 2.0 [95% CI: 1.03–3.89]), preoperative AKI (OR: 2.4 [95% CI: 1.3–4.5]), and massive transfusion (OR: 2.0 (95% CI: 1.03–3.89]) were independently associated with postoperative Enterobacterales septicemia. Patients with bacteremia due to CRE had a higher 90-day mortality (38.4% vs 14.2% P = 0.03). Postoperative CRE bacteremia was not associated with preoperative CRE colonization (42.8% CRE-POS vs 57.1% CRE-NEG).

Conclusion

One-third of patients presenting for LDLT are already colonized with CRE. Preoperative CRE colonization is a risk factor for postoperative Enterobacterales septicemia but not with CRE bacteremia. Post–liver transplant CRE bacteremia has a significantly higher mortality. Active pre-LT surveillance for CRE, along with the use of targeted pre-emptive therapy as probiotics and a low threshold for discretionary use of appropriate guideline-based antibiotic therapy based on CRE colonization status, in the event of sepsis, can help improve outcomes in this cohort of LDLT recipients.

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