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BACKGROUND: Odronextamab, a CD20×CD3 bispecific antibody that engages cytotoxic T cells to destroy malignant B cells, has demonstrated encouraging activity across multiple subtypes of relapsed/refractory (R/R) B-cell non-Hodgkin lymphoma. PATIENTS AND METHODS: This phase II study (ELM-2; NCT03888105) evaluated odronextamab in patients with R/R follicular lymphoma after two or more lines of systemic therapy. Patients received intravenous odronextamab in 21-day cycles, with step-up dosing in cycle 1 to help mitigate the risk of cytokine release syndrome, until disease progression or unacceptable toxicity. The primary endpoint was objective response rate by independent central review. RESULTS: Among 128 patients evaluated, 95% completed cycle 1, and 85% completed four or more cycles. At 20.1 months' efficacy follow-up, objective response rate was 80.0% and complete response rate was 73.4%. Median duration of complete response was 25.1 months. Median progression-free survival was 20.7 months, and median overall survival was not reached. Discontinuation of odronextamab due to adverse events occurred in 16% of patients. The most common treatment-emergent adverse events were cytokine release syndrome [56%; grade ≥3 1.7% (1/60) with 0.7/4/20 mg step-up], neutropenia (39%), and pyrexia (38%). CONCLUSIONS: Odronextamab achieved high complete response rates with generally manageable safety in patients with heavily pretreated R/R follicular lymphoma.
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Rituximab hypersensitivity reactions are rare but are one of the main causes of rituximab elimination from antilymphoma immunochemotherapy treatments. While the clinical picture may be indistinguishable from other infusion-related reactions, hypersensitivity reactions (HSR) do not disappear and instead become more intense with subsequent administrations. Objective. To describe the use of the 12-step protocol for desensitization to intravenous rituximab in clinical practice and the complementary study of a possible IgE-mediated HSR in the context of B-cell lymphoma treatment. Methods. A 12-step rituximab desensitization protocol was performed prospectively within clinical practice in 10 patients with a history of severe infusion reactions or in patients who had a repeated reaction at subsequent doses despite taking more intense preventive measures. Skin prick tests were performed at the time of reaction and at a later time to eliminate false negatives due to possible drug interference. Results. Overall, with the desensitization protocol, 70% of patients were able to complete the scheduled immunochemotherapy. Two patients had to discontinue the therapy due to clinical persistence and the third due to lymphoma progression. Intradermal tests with 0.1% rituximab were positive in only 20% of cases, demonstrating a mechanism of hypersensitivity. Conclusions. The 12-step desensitization protocol is very effective and assumable within healthcare practice. There is a need to determine the mechanism underlying the infusion reaction in a large proportion of cases due to the risk of future drug exposure.
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Posttransplant high-dose cyclophosphamide (PTCy) effectively prevents GvHD after haploidentical SCT. However, its use in HLA-matched SCT has been less explored. Fifty-six consecutive patients who underwent allo-SCT for hematological malignancies have been included in this prospective single-center protocol. Donors have been HLA-identical siblings, fully-matched unrelated or 1-allele-mismatched unrelated donors in 30%, 32%, and 37% of cases, respectively. Nine patients have received a TBI-containing MAC regimen, while the remaining (84%) received RIC platforms based on Fludarabine plus Busulfan/Melphalan. Due to the high graft failure (GF) rate (21%) in a preliminary analysis in the allo-RIC cohort (n = 29), protocol amendments have been implemented, with no further cases of GF after the introduction of mini-thiotepa (0/18). The overall incidence of grade II-IV acute GvHD is 24% (95% CI: 17-31%) with four steroid-refractory cases. Severe chronic GvHD has occurred in only 1 of 43 evaluable cases. The 1-year NRM and relapse are 18% (95% CI: 12-26%) and 30% (18-42%) and the OS and DFS are 78% and 64%, respectively. These outcomes support the feasibility of using PTCy as a SOC outside the haplo-setting, albeit mini-thiotepa (3 mg/kg) was incorporated in the standard allo-RIC platforms to prevent GF. Despite the limitations of a single-center experience and the short follow-up, these protocols show promising results with particular benefit in reducing the occurrence of moderate-to-severe GvHD.
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Enfermedad Injerto contra Huésped , Trasplante de Células Madre Hematopoyéticas , Ciclofosfamida , Enfermedad Injerto contra Huésped/prevención & control , Humanos , Recurrencia Local de Neoplasia , Estudios Prospectivos , Acondicionamiento Pretrasplante , Donante no EmparentadoRESUMEN
Guidelines recommend autologous stem cell transplantation (ASCT) consolidation in first complete or partial response after regimens including rituximab (R) and high-dose AraC (HDAC), but its use beyond that response is questioned. We present a retrospective analysis of 268 patients with MCL who received ASCT. With a median follow-up for survival patients of 54 months, progression-free survival and overall survival for the whole series were 38 and 74 months, respectively, and for patients transplanted in first CR 49 and 97 months, respectively. Patients without CR before transplant were analyzed separately, those who achieved CR after transplantation had better PFS (48 vs 0.03 months, p < 0.001) and OS (92 vs 16 months, p < 0.001) than the remaining. In univariate analysis, first CR at transplant (p = 0.01) and prior rituximab (p = 0.02) were the variables associated with PFS. For OS, the same variables resulted significant (p = 0.03 and p < 0.001, respectively). In multivariate analysis, only the status at transplant (first CR) remained significant. This retrospective study concludes that ASCT consolidation in first CR induces high survival rates. In other stages of disease, the need of ASCT as consolidation may be questioned.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Trasplante de Células Madre Hematopoyéticas/métodos , Linfoma de Células del Manto/terapia , Adulto , Anciano , Citarabina/administración & dosificación , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Evaluación de Resultado en la Atención de Salud/métodos , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Modelos de Riesgos Proporcionales , Inducción de Remisión , Estudios Retrospectivos , Rituximab/administración & dosificación , Acondicionamiento Pretrasplante , Trasplante Autólogo , Adulto JovenRESUMEN
This study aimed to characterize the incidence, etiology and outcome of infectious episodes in patients with steroid refractory acute GvHD (SR-GvHD). The cohort included 127 adults treated with inolimomab (77%) or etanercept (23%) owing to acute 2-4 SR-GvHD, with a response rate of 43% on day +30 and a 4-year survival of 15%. The 1-year cumulative incidences of bacterial, CMV and invasive fungal infection were 74%, 65% and 14%, respectively. A high rate (37%) of enterococcal infections was observed. Twenty patients (15.7%) developed BK virus-hemorrhagic cystitis and five percent had an EBV reactivation with only one case of PTLD. One-third of long-term survivors developed pneumonia by a community respiratory virus and/or encapsulated bacteria, mostly associated with chronic GvHD. Infections were an important cause of non-relapse mortality, with a 4-year incidence of 46%. In multivariate analysis, use of rituximab in the 6 months before SCT (hazard ratio; HR 4.2; 95% confidence interval; CI 1.1-16.3), severe infection before SR-GvHD onset (HR 5.8; 95% CI 1.3-26.3) and a baseline C-reactive protein >15 UI/mL (HR 2.9; 95% CI 1.1-8.5) were associated with infection-related mortality. High rates of opportunistic infections with remarkable mortality warrant further efforts to optimize long-term outcomes after SR-GvHD.
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Enfermedad Injerto contra Huésped/mortalidad , Infecciones/mortalidad , Enfermedad Aguda , Adolescente , Adulto , Anciano , Aloinjertos , Anticuerpos Monoclonales/administración & dosificación , Anticuerpos Monoclonales/efectos adversos , Supervivencia sin Enfermedad , Etanercept/administración & dosificación , Etanercept/efectos adversos , Femenino , Estudios de Seguimiento , Enfermedad Injerto contra Huésped/tratamiento farmacológico , Enfermedad Injerto contra Huésped/etiología , Neoplasias Hematológicas/mortalidad , Neoplasias Hematológicas/terapia , Humanos , Infecciones/etiología , Masculino , Persona de Mediana Edad , Trasplante de Células Madre , Tasa de SupervivenciaRESUMEN
INTRODUCTION: Alcoholic hepatitis (AH) is an acute-on-chronic inflammatory response affecting the liver. It has been recognized that white blood cells (WBCs) are involved in the pathogenesis and in the prognosis of AH. The aim of study was to use Adacolumn, which can selectively adsorb myeloid linage leucocytes (granulocytes and monocytes/macrophages) from the blood in the column and improve the clinical status of patients. MATERIALS: Six patients with a diagnosis of AH were treated with Adacolumn granulocyte-apheresis therapy. INCLUSION CRITERIA: patients not responders to corticosteroids therapy with Maddrey Discriminant Function (MDF) >32 and MELD score 20-26. The patients underwent five 1-hour sessions for 5 consecutive days with a follow-up at 28 days. The column was placed in an extracorporeal setting with a perfusion rate of 30 mL/min and a duration of 60 minutes. Liver parameters, WBC count, proinflammatory cytokines, coagulation, and predictive scores were valued before and after the cycle of apheresis treatment. RESULTS: After 5 days, the findings showed a significant improvement of WBC count (P < .014) and cytokines such as interleukin (IL)-6 (P < .019), tumor necrosis factor α (TNFα) (P < .02), and IL-8 (P < .029). The results probably determined a reduction of aspartate transaminase (AST; P < .02) and alanine transaminase (ALT; P < .011), although we did not observe a significant improve in bilirubin, prothrombin time (PT), and Maddrey score. The improvement of MELD score, depending on an improvement of international normalized ratio for administration of plasma, was not considered. At day 28 of follow-up, PT, IL-6, TNFα, AST and ALT results significantly improved. CONCLUSIONS: The Adacolumn apheresis was safe and was able to determine an improvement of clinical status of patients with reduction of inflammatory markers. More patients are needed to validate these results.
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Granulocitos , Hepatitis Alcohólica/terapia , Leucaféresis , Adulto , Alanina Transaminasa/metabolismo , Bilirrubina/sangre , Pruebas de Coagulación Sanguínea , Femenino , Hepatitis Alcohólica/metabolismo , Humanos , Interleucina-6/sangre , Interleucina-8/sangre , Pruebas de Función Hepática , Masculino , Persona de Mediana EdadRESUMEN
Very few data exist on the management of adult patients diagnosed with primary immune thrombocytopenia (ITP). The objectives of this study were to describe the diagnostic and treatment patterns for ITP and to compare the findings to recent ITP guidelines. We retrospectively analyzed the medical records of adult ITP patients diagnosed with primary ITP between January 2011 and June 2012 and examined whether management strategies were consistent or not with eight recent guideline-recommended practices. Overall, median age at the diagnosis of the disease (n = 101) was 58 years and median platelet count 12 × 10(9)/L with 75.2 % of patients having symptoms of ITP. The study perceived two major shortcomings in the diagnostic approach: (1) failure to perform peripheral blood film examination in 22.8 % of patients, a test that is mandatory by all guidelines, and (2) ordinary bone marrow assessment in more than half of the patients at diagnosis (50.5 %), a test not routinely recommended by guidelines. Low appropriateness in therapeutic management of patients included (1) unjustified use of intravenous immunoglobulin in the absence of bleeding in 54.8 % of patients and (2) splenectomy not being deferred until 6-12 months from diagnosis (median 161 days). Data also reflect a trend towards the early use of thrombopoietin receptor agonists in the treatment of patients who are refractory to any first-line therapy. We have recognized important areas of inapropriateness in the diagnostic and therapeutic management of adult ITP patients. Compliance with established guidelines should be encouraged in order to improve patient outcomes.
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Manejo de la Enfermedad , Adhesión a Directriz/normas , Guías de Práctica Clínica como Asunto/normas , Púrpura Trombocitopénica Idiopática/diagnóstico , Púrpura Trombocitopénica Idiopática/terapia , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
INTRODUCTION: Acute antibody-mediated rejection (AAMR) is the subject of much research. It is diagnosed by C4d staining at biopsy and circulating donor-specific antibodies (DSA). The combination of intensive plasmapheresis and intravenous immunoglobulin (IVIG) has been recognized as an effective treatment for AAMR. We report our single-center experience on AAMR treatment. MATERIALS AND METHODS: We treated 23 transplanted patients (group A) with protein-A immunoadsorption (IA) and 7 patients (group B) with double-filtration plasmapheresis. All patients were treated with IVIG (400 mg/kg/d). Basic immunosuppression included cyclosporine, steroids, azathioprine, and antilymphocyte globulin or monoclonal antibodies (OKT3). A subgroup of 3 patients (3/7; group B1) was treated with photopheresis. RESULTS: In both groups, the mean number of extracorporeal procedures was 7.3 ± 4.5 and 5.5, respectively; the mean duration of treatment was 12.3 ± 10.2 and 14.5 days, respectively. In group A, we observed negative cross-matching in 96% after mean of 18 days; 1 patient died from sepsis, and 6 lost their grafts. In group B, negative circulating DSA were observed in all patients after a mean of 25 days, and 1 patient lost their allograft. CONCLUSIONS: In our observation, the 2 extracorporeal procedures had similar effects in terms of graft survival, DSA removal, and cross-match negativity (group A 74% vs 86%; 95.6% vs 100%). IA was faster for DSA removal. In our opinion, the higher costs of IA suggests its use just in high-risk cases, such as in hyperimmune or sensitized patients. Further studies are necessary to improve our knowledge.
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Anticuerpos/inmunología , Rechazo de Injerto/terapia , Inmunoglobulinas Intravenosas/uso terapéutico , Trasplante de Riñón/efectos adversos , Fotoféresis/estadística & datos numéricos , Plasmaféresis/estadística & datos numéricos , Adulto , Anticuerpos/efectos adversos , Anticuerpos/sangre , Femenino , Rechazo de Injerto/inmunología , Humanos , Terapia de Inmunosupresión/métodos , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
We monitored 133 high-risk allo-SCT recipients for 6 months after transplant for EBV reactivation by quantitative real-time PCR. Rituximab was given as pre-emptive therapy for viremia >1000 copies/mL. The 1-year cumulative incidence of EBV reactivation was 29.4% (95% confidence interval (CI): 18-40) in patients monitored due to initial high-risk characteristics (n=93) and 31.8% (95% CI: 19.7-44) in those followed because of the development of refractory GVHD (n=40). Overall response rate to Rituximab was 83%. Nine patients (9.6%) developed post-transplant lymphoproliferative disorder (PTLD) at a median of +62 days after SCT. Eight of them showed a concomitant CMV reactivation. Second SCT was the only risk factor associated with EBV infection and PTLD in multivariate analysis (hazard ratio (HR) 2.6 (95% CI: 1.1-6.4; P=0.04) and HR 6.4 (95%CI: 1.3-32; P=0.02)). The development of EBV reactivation was not associated with non-relapse mortality or OS (P=0.97 and P=0.84, respectively).
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Infecciones por Virus de Epstein-Barr , Neoplasias Hematológicas/terapia , Herpesvirus Humano 4/fisiología , Factores Inmunológicos/administración & dosificación , Rituximab/administración & dosificación , Trasplante de Células Madre , Activación Viral/efectos de los fármacos , Adolescente , Adulto , Anciano , Aloinjertos , Infecciones por Virus de Epstein-Barr/epidemiología , Infecciones por Virus de Epstein-Barr/etiología , Infecciones por Virus de Epstein-Barr/prevención & control , Femenino , Neoplasias Hematológicas/epidemiología , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Several widespread occurrences of anomalous blue coloration of Mozzarella cheese have been recorded in the United States and some European countries. Official laboratory analysis and health authorities have linked the occurrences to contamination of the processing water with strains of Pseudomonas fluorescens, although several experts questioned how to unequivocally link the blue color to the presence of the microorganism. To establish a method to determine whether a given Pseudomonas spp. strain is responsible for the defect and study the evolution of the coloration under different storage conditions, we developed an in vitro system for the evaluation of blue coloration of Mozzarella cheese intentionally contaminated with strains of P. fluorescens. The purpose of the system was to determine whether P.fluorescens strains, isolated from Mozzarella cheese with anomalous blue coloration, were able to reproduce the blue coloration under controlled experimental conditions. Thirty-six trials of experimental inoculation of Mozzarella cheese in different preservation liquids were conducted using various suspensions of P.fluorescens (P. fluorescens ATCC 13525, P.fluorescens CFBP 3150, and P. fluorescens 349 field strain isolated from blue-colored Mozzarella cheese) at different concentrations and incubated at different temperatures. Growth curves of all tested P.fluorescens strains demonstrated that after 3 d of incubation the concentration was generally >10(6) cfu/g of Mozzarella cheese incubated in either tryptic soy broth (control) or conditioning brine. Prolonged incubation for 5 d at either 20 °C or 8 °C led to concentrations up to 10(9) cfu/g of Mozzarella cheese incubated in tryptic soy broth and up to 10(8) cfu/g of Mozzarella cheese incubated in preservation liquid. All Mozzarella cheeses inoculated with the field strain of P. fluorescens, except those opened 1h after packaging and stored at 8 °C, showed the characteristic anomalous blue coloration, which appeared from 1 to 72 h after opening the packaging, and was proportional to colony count, duration of storage, and storage temperature. With the proposed system, which enabled a larger number of samples to be analyzed under controlled experimental conditions and a large amount of data to be generated in a short time, we described precisely how and under which conditions the presence of P. fluorescens in Mozzarella cheese is responsible for the anomalous blue coloration. The system will help producers intercept contaminated batches and help consumers avoid the conditions under which the defect can appear.
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Queso/microbiología , Conservación de Alimentos/métodos , Pigmentos Biológicos/análisis , Pigmentos Biológicos/biosíntesis , Pseudomonas fluorescens/metabolismo , Animales , Evolución Biológica , Queso/análisis , Recuento de Colonia Microbiana , Europa (Continente) , Pseudomonas fluorescens/aislamiento & purificación , Temperatura , Estados UnidosRESUMEN
Initial poor graft function (IPGF) is a major factor influencing the clinical outcome after liver transplantation (LT), but there is no reliable method to assess and predict graft dysfunction. To help clinicians determine prognosis in the early postoperative period, individual parameters and complex scoring systems have been suggested, but most of them are inaccurate because of the multifactorial nature of transplantation courses. Therefore, the aim of our study was to retrospectively evaluate predictive criteria for retransplantation. Forty-two patients were enrolled in this study: 18 who experienced primary non-function (PNF) and 24 with delayed graft function (DGF). All of the patients were treated with the Molecular Adsorbent Recirculating System (MARS). They were into 3 subgroups: patients who survived without LT (n = 20; 47.7%); patients who underwent LT (n = 16; 37%), and patients who died before transplantation (n = 6; 14%). Stepwise multivariable logistic regression analysis was performed with the intent to find the risk factors for LT or death after MARS treatment (second analysis). Receiver operating characteristic (ROC) curves were performed on significant variables in the logistic regression model with the intent to individually predict variables for LT or death. After a stepwise multivariable logistic regression analysis enrolling all of the previously reported features only 2 variables, tumor necrosis factor (TFN)-α and Glasgow coma score (GCS) score, were statistically significant. TNF-α was an unique independent risk factor for retransplantation or death after MARS treatment (odds ratio [OR] 1.235; P = .013). Conversely, GCS score was protective against retransplantation or death (OR 0.150; P = .003). Starting from these assumptions, a predictive model was created using these 2 variables. On ROC analysis, the combined score showed an area under the curve greater than that of the 2 variables considered separately. Validating these results with a larger number of patients, we considered these 2 factors as subjective parameters to determine outcomes and the difference between PNF and DGF.
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Escala de Coma de Glasgow , Supervivencia de Injerto , Trasplante , Factores de Necrosis Tumoral/sangre , Humanos , Análisis Multivariante , Curva ROC , Estudios RetrospectivosRESUMEN
The first endpoint of this study was to find new markers that document the progression of hepatic steatosis through quantitative histomorphometric analysis in the absence of hemodynamic changes. The second endpoint was to start building a mathematical database to help to achieve a score in the future. For this study we enrolled 130 random patients, including 10 with normal histology despite suspected disease, 70 positive for steatosis, 20 affected by nonalcoholic steato hepatitis, and 30 with hepatitis virus C or B-related cirrhosis. One hundred thirty images were analyzed for a total of 1,320 sinusoids. Each image was processed with a custom program written with the use of the Vision toolbox of the Labview platform, following a semiautomated procedure. The mean sinusoidal areas (SAs) and percentage fractions of parenchymal area occupied by sinusoids (SA/PA) were subdivided into 3 groups. Finally, we analyzed the form of sinusoids, approximating them to an ellipse, to be able to define the relationship between the 2 axes with the aim of proposing a parameter, "local hydraulic resistance" (LHR), that was proportional to the resistance to blood flow within the bounds of the histologic specimen. Among the images, we observed a difference in the size of SAs among the 3 groups of patients, namely, normal, steatotic of different stages, and cirrhotic patients. In fact, there was evidence of a reducted SA when steatosis was <30%, with an average value of 0.0032 mm(2), patients with steatosis of 30%-50% showed an average SA of 0.0024 mm(2), and there was a further reduction among subjects with steatosis grades >50% (mean 0.0017 mm(2)). The LHR value showed that the morphometric parameter SA/PA could be quantitatively interpreted also as a functional impairment relative to the increased resistance opposing blood flow in pathologic conditions.
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Hígado Graso/patología , HumanosRESUMEN
Infection represents one of the primary barriers to successful organ transplantation. Our principal end point was to use a new assay, Entotoxin Activity Assay (EAA), which was developed to rapidly detect endotoxin activity (EA) for an early diagnosis of this complication. We also sought to prove the validity and safety of endotoxin removal using polymyxin-B-based hemoperfusion (PMX-DHP). The criterion for inclusion in the study was suspected infection when a patient experienced at least 2 of the 4 criteria of the systemic inflammatory response syndrome. EAA was performed on 71 patients: 29 liver transplantations and 42 kidney transplantations. Twenty-eight patients (39.5%) with EA >0.60 underwent PMX-DHP treatment to remove endotoxins. Each treatment was performed for 2 hours with a blood flow of 100 mL/min. All of the patients were treated with PMX-DHP until achieving an EA <0.4. Stabilization of hemodynamic and inflammatory frameworks was observed after the PMX-DHP. At 30 days follow-up, all of the patients were alive with good graft function and low levels of EA. We think it might be useful to determine EA routinely in transplant patients and look forward to large multicenter clinical trials to accurately assess the benefits of the EAA plus DHP-PMX to treat transplant patients with sepsis.
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Hemoperfusión , Trasplante de Riñón , Trasplante de Hígado , Polimixina B/uso terapéutico , Humanos , Polimixina B/efectos adversosRESUMEN
To analyze the incidence, characteristics and risk factors of hyperbilirubinemia after allogeneic hematopoietic cell transplantation with reduced-intensity conditioning (allo-RIC), we conducted a retrospective study in three Spanish centers. We analyzed 452 consecutive patients receiving allo-RIC. Of these, 92 patients (20%) developed marked hyperbilirubinemia (>4 mg/day or >68.4 µM) after allo-RIC. The main causes of marked hyperbilirubinemia after transplant were cholestasis due to GVHD or sepsis (n=57, 62%) and drug-induced cholestasis (n=13, 14%). A total of 22 patients with marked hyperbilirubinemia (24%) underwent liver biopsy. The most frequent histological finding was iron overload alone (n=6) or in combination with other features (n=6). In multivariate analysis, the risk factors for marked hyperbilirubinemia after allo-RIC were non-HLA-identical sibling donors (hazard ratio (HR) 2.2 (95% confidence interval (CI) 1.4-3.6) P=0.001), female donors to male recipients (HR 2.1 (95% CI 1.3-3.3) P=0.003) and high levels of bilirubin and γ-glutamyl transpeptidase before transplant (HR 4.5 (95% CI 2.5-8.4) P<0.001 and HR 4.6 (95% CI 2.6-8.1) P<0.001, respectively). Patients with marked hyperbilirubinemia showed higher 4-year nonrelapse mortality (HR 1.3 (95% CI 1-1.7), P=0.02) and lower 4-year OS (HR 1.4 (95%CI 1.3-1.7), P<0.001) than patients without. In conclusion, we confirm that marked hyperbilirubinemia is frequent and diverse after allo-RIC. Development of marked hyperbilirubinemia after allo-RIC is associated with worse outcome of the procedure.
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Trasplante de Células Madre Hematopoyéticas , Hiperbilirrubinemia/mortalidad , Hermanos , Donantes de Tejidos , Acondicionamiento Pretrasplante , Adolescente , Adulto , Anciano , Biopsia , Supervivencia sin Enfermedad , Femenino , Humanos , Hiperbilirrubinemia/sangre , Hiperbilirrubinemia/etiología , Hiperbilirrubinemia/patología , Incidencia , Hígado/metabolismo , Hígado/patología , Masculino , Persona de Mediana Edad , Factores de Riesgo , Tasa de Supervivencia , Trasplante HomólogoRESUMEN
INTRODUCTION: The aim of our study was a 30-day follow-up of the use of early detection of endotoxin by the endotoxin activity assay (EAA) for patients with acute liver failure superimposed on chronic liver disease (AoCLF) and treated with polymyxin-B hemoperfusion-based (PMX-DHP) treatment and albumin dialysis in the molecular adsorbent recirculating system (MARS). MATERIALS AND METHODS: From February 2008 to July 2010, we evaluated 10 AoCLF patients experiencing systemic inflammatory response syndrome (SIRS) in association with suspected infection and an EAA-positive test (>0.60). These patients awaiting liver transplantation (OLT) showed similar Model End-Stage Liver Disease (MELD) scores (range, 19-25) and encephalopathy grade ≤ 2. Five patients received therapy to remove endotoxins with PMX-DHP with MARS treatment for liver failure (group A); the other 5 patients received MARS treatment only (group B). RESULTS: Two PMX-DHP treatments were performed in 4 group A patients (average EA=0.66 [range, 0.61-0.70]) and 3 treatments for 1 patient (EA=0.92). All 5 subjects underwent an average of 4 MARS treatments (range, 3-5). At the end of therapy, the median EA level was 0.42 (range, 0.37-0.48). As reported in the literature, we achieved a significant improvement in liver and kidney functions using MARS. Measurements of lactate, interleukin (IL)-6, and tumor necrosis factor (TNF)-α were significantly improved among patients treated with the extracorporeal therapies. At 30 days of observation, all 5 patients treated with MARS plus PMX-DHP are alive. In group B, a mean of 7.5 MRAS treatments were performed. We observed an improvement in hemodynamic and liver functions with reduced levels of proinflammatory cytokines and lactates in 4 patients. One patient showed no improvement in clinical status with the development of sepsis and subsequent multiorgan failure after 24 days. CONCLUSION: The possibility of an early diagnosis using the EAA in AoCLF patients could prevent the progression of the sepsis cascade. The use of PMX-DHP and MARS in these patients, could lead to resolution of clinical status in a short time.
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Albúminas/administración & dosificación , Antibacterianos/administración & dosificación , Circulación Extracorporea , Hemoperfusión , Hepatopatías/terapia , Fallo Hepático Agudo/terapia , Polimixina B/administración & dosificación , Sepsis/terapia , Síndrome de Respuesta Inflamatoria Sistémica/terapia , Adulto , Albúminas/efectos adversos , Antibacterianos/efectos adversos , Biomarcadores/sangre , Enfermedad Crónica , Endotoxinas/sangre , Circulación Extracorporea/efectos adversos , Femenino , Hemoperfusión/efectos adversos , Humanos , Italia , Hepatopatías/sangre , Hepatopatías/complicaciones , Fallo Hepático Agudo/sangre , Fallo Hepático Agudo/etiología , Masculino , Persona de Mediana Edad , Polimixina B/efectos adversos , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Sepsis/sangre , Sepsis/etiología , Sepsis/microbiología , Síndrome de Respuesta Inflamatoria Sistémica/sangre , Síndrome de Respuesta Inflamatoria Sistémica/etiología , Síndrome de Respuesta Inflamatoria Sistémica/microbiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
AIM: The aim of study was to highlight parameters that in association with Model for End-stage Liver Disease (MELD) provide predictive criteria for long-term survival after treatment with the Molecular Adsorbent Recirculating System (MARS). Two homogenous groups were studied: one treated with standard medical therapy (SMT) and the other, with MARS. MATERIALS AND METHODS: Twenty acute-on-chronic liver failure patients on the waiting list for liver transplantation and affected by alcoholic cirrhosis with similar MELD scores (20-29) were evaluated for 7 days from inclusion and for 6-month survival. Ten patients (seven males and three females) were treated with MARS. Their mean age was 48.5 years (range = 35-61). The number of MARS applications was six for 6 consecutive days, and the length of the applications was 8 hours. Ten other patients (seven males and three females) were treated with SMT, including prophylaxis against bacterial infections and judicious use of diuretics. The precipitating factors were also treated appropriately. The mean age of the patients was 51 years (range = 37-64). All the variables that were significant upon univariate analysis were enrolled in a receiver operating characteristic analysis, with the intention to detect predictive parameters for patient death at 6 months. We considered a significant area under curve (AUC) value to be greater than 0.5. RESULTS: Among 11 patients who died within 6 months there were in the MARS group and eight in the SMT group: the 3- and 6-month patient survival rates were 90% and 70% versus 30% and 20% in the two groups, respectively. Nine measures resulted in an AUC > 0.5: DeltaMELD; interleukin (IL)-8; IL-6; tumor necrosis factor- alpha, MELD score; creatinine, bilirubin international normalized ratio (INR) and cardiac index. DeltaMELD and postoperative IL-8 concentrations showed better results (AUC = 0.899), followed by postoperative creatinine (AUC = 0.879), postoperative cardiac index (AUC = 0.833), and postoperative INR (AUC = 0.818). Postoperative creatinine showed the best sensitivity (100%), while IL-8, the best specificity (88.9%). CONCLUSION: A combination of biochemical and clinical variables probably represent the best way to predict the survival of patients, allowing physicians to select the best therapies for each patient.
Asunto(s)
Circulación Hepática , Fallo Hepático Agudo/complicaciones , Fallo Hepático/complicaciones , Trasplante de Hígado , Adsorción , Adulto , Enfermedad Crónica , Femenino , Humanos , Fallo Hepático/mortalidad , Fallo Hepático/patología , Fallo Hepático/cirugía , Fallo Hepático Agudo/mortalidad , Fallo Hepático Agudo/patología , Fallo Hepático Agudo/cirugía , Trasplante de Hígado/métodos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Tasa de Supervivencia , Sobrevivientes , Listas de EsperaAsunto(s)
Anemia/congénito , Antígenos CD/genética , Proteínas de Neoplasias/genética , Trombocitopenia Neonatal Aloinmune/sangre , Adulto , Alelos , Anemia/etiología , Anemia/genética , Femenino , Proteínas Ligadas a GPI , Frecuencia de los Genes , Genotipo , Humanos , Recién Nacido , Masculino , España , Trombocitopenia Neonatal Aloinmune/genéticaRESUMEN
INTRODUCTION: Acute-on-chronic liver failure (ACLF) is a systemic inflammatory reaction, which is characterized by a predominantly proinflammatory cytokine profile, causing the transition from stable cirrhosis to ACLF. The aim of the present study was to evaluate the changes in several cytokines associated with inflammatory liver disease and liver regeneration among 15 ACLF patients treated with the Molecular Adsorbent Recirculating System (MARS) compared with 15 patients treated with standard medical therapy (SMT). The subjects showed various disease etiologies but similar values for Model End-stage Liver Disease scores. METHODS: In the MARS group, 15 (10 male and 5 female) patients were treated with MARS (Gambro). The number of MARS applications was nine; the length of applications was 8 hours. In the SMT group; 15 (10 male and 5 female) patients were treated with SMT. The patients were monitored for 30 days from inclusion with a survival follow-up at 3 months. Statistical results were calculated with SPSS14.0 (SPSS Inc, Chicago, Ill). A P < .07 was considered significant. RESULTS: In the MARS group, we observed significant changes in the levels of Interleukin (IL)-6, IL-1, IL-10, and tumor necrosis factor (TNF)-alpha in association with improved hepatocyte growth factor. Patient survival at 3 months was 60%. The SMT group showed only a significant change in TNF-alpha (P = .03). Patient survival at 3 months was 30%. CONCLUSION: The MARS liver support device corrected pathophysiologies of ALF and may be used to enhance spontaneous recovery or as a bridge to transplantation.
Asunto(s)
Citocinas/sangre , Fallo Hepático/terapia , Adsorción , Adulto , Femenino , Humanos , Fallo Hepático/sangre , Fallo Hepático/fisiopatología , Regeneración Hepática , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Patients with acute liver failure (ALF) show an aggravated hyperdynamic circulation. We evaluated potential changes in systemic hemodynamics and improved kidney function induced by the molecular adsorbent recirculating system (MARS) in a group of patients with primary nonfunction (PNF). PATIENTS AND METHODS: In the intensive care unit we treated 18 patients with PNF (6 females and 12 males) after orthotopic liver transplantation (OLT) of overall mean age 47.8 years (range, 28-60 years). Continuous MARS treatment was performed on all patients with a kit change every 8 hours during a mean of 10 days (range, 1-20 days). Double-lumen catheter type veno-venous access was used for the blood supply. The blood flow rate was 150 to 250 mL/min, depending on the hemodynamic situation of the patient. Blood passed through an albumin nonpermeable, high flux dialysis membrane. During MARS treatment we monitored the hemodynamic condition, using a series of parameters: heart rate (HR), mean arterial pressure (MAP), cardiac index (CI), systemic vascular resistance index (SVRI), and pulmonary vascular resistance index (PVRI) before (baseline value) as well as after 1 hour (T1), 3 hours (T2), and the end of treatment (T3). RESULTS: There was a progressive decrease in positive inotropic support (dobutamine, norepinephrine) and significant improvement in hemodynamic parameters, such as MAP (P< .01), PVRI/SVRI/V(mean) (P< .002), and KARI (P< .01). The improved kidney functions were shown by significant improvements in serum creatinine (P< .03), urea (P< .02), and urine volume (P< .005). Eleven patients were alive: 6 with OLT and 5 without OLT. Seven patients died: 4 after OLT and 3 before OLT due to multiorgan failure. CONCLUSIONS: The MARS device significantly improved the hemodynamic parameters and kidney function that also determine patient survival in ALF (61.1%) with PNF while awaiting retransplantation presumably by removal of certain vasoactive substances.
Asunto(s)
Hemodinámica/fisiología , Trasplante de Hígado/fisiología , Complicaciones Posoperatorias/clasificación , Reoperación/estadística & datos numéricos , Adolescente , Adulto , Gasto Cardíaco , Circulación Extracorporea , Femenino , Frecuencia Cardíaca , Humanos , Pruebas de Función Renal , Fallo Hepático/cirugía , Fallo Hepático Agudo/cirugía , Trasplante de Hígado/efectos adversos , MasculinoRESUMEN
BACKGROUND: The prognosis of pediatric acute liver failure (PALF) has been significantly improved by emergency orthotopic liver transplantation (OLT). Since 2004, the molecular adsorbent recirculating system (MARS) has been proposed as a bridging procedure. The aim of our study was to assess its efficacy in children with PALF. PATIENTS AND METHODS: Since 1999 we performed treatment of 39 fulminant hepatic failure (FHF) cases with MARS. Since September 2004 we treated 6 pediatric patients with FHF who were of mean age 10.6 years (range, 3-15 years) including 4 females and 2 males. In 3 cases the cause of FHF was unknown; in 2 cases, it was induced by paracetamol overdose; and in 1, by acute hepatitis B virus. Inclusion criteria were: bilirubin >15 mg/dL; creatinine >or=2 mg/dL; encephalopathy grade >II; and International normalized ratio (INR) >2.5. Other estimated parameters were: AST and ALT serum levels, lactate, and urine volume. Neurological status was monitored using the Glasgow Coma Scale (GCS). Continuous MARS treatment was performed in all patients with a kit change every 8 hours. Intensive care unit (ICU) treatment was applied to optimize regeneration and to prevent cardiovascular complications. RESULTS: We observed a significant improvement among levels of bilirubin (P< .009), ammonia (P< .005), creatinine (P< .02), GCS (P< .002), and predictive criteria and as Sequential Organ Failure Assessment (SOFA) and Pediatric End-Stage Liver Disease (PELD). Three children underwent OLT: 1 died after 5 days due to primary nonfunction and 2 children are alive after a median follow-up of 14 months. In 2 children the MARS treatment led to resolution of clinical status without liver transplantation. One child died before OLT due to sepsis and multiorgan failure. CONCLUSIONS: We concluded that application of the MARS liver support device in combination with experienced ICU management contributed to improve the clinical status in children with PALF awaiting liver transplantation.