Late acute rejection (LAR) after liver transplantation is often associated with poor clinical outcomes. We reviewed our experience of managing LAR in the current era to determine its natural history.
...A database of 970 consecutive adult liver transplants was reviewed retrospectively. LAR was defined as histologically proven acute cellular rejection occurring more than 90 days after transplantation.
The incidence of LAR was 11%, with a mean time of 565 days (median, 311 days; range, 90-2922 days) after transplantation. The highest rates for LAR were in seronegative hepatitis (17%), primary biliary cirrhosis (16%), and primary sclerosing cholangitis (13%) with an odds ratio of 2.3, 2.1, and 1.8, respectively. Logistic regression showed that younger recipients, primary biliary cirrhosis, and previous graft loss were independent predictors of LAR (P<0.001). Mean trough whole blood tacrolimus levels were at their lowest levels 1 week before the diagnosis of rejection (5.5 ng/mL; SD, 2.6) compared with levels of 7.7 ng/mL 4 weeks before rejection, showing a clear temporal relation. Graft survival was worse in those with LAR (P<0.01), whereas the best graft survival was among early acute rejection cases (85% 10-year survival; P<0.01). Poor response to treatment correlated with the development of ductopenic rejection (r=0.3; P<0.01). Approximately half with early ductopenic rejection eventually died (n=15).
LAR continues to provide a risk to patient and graft survival: understanding risk factors may allow an improvement in monitoring and early intervention and so prevent early graft loss.
Summary Introduction Previous studies have documented poor quality CPR during real life resuscitation attempts. This study investigated whether poor quality CPR during advanced life support training ...could be contributing to poor performance in clinical practice. Methods Observational study of quality of CPR during advanced life support training courses before and after the implementation of the European Resuscitation Council Guidelines 2005 into the ALS course. The quality of chest compressions were downloaded from a manikin and direct observations of no-flow time; pre-shock pauses were recorded. Results 94 cardiac arrest simulations were studied (46 before implementation of Guidelines 2005 and 48 after). Delays in starting CPR, inadequate compression depth, prolonged interruptions of chest compressions and excessive pre-shock pauses were identified. The introduction of Guidelines 2005 resulted in improvements in the number of compressions given per minute and a reduction in no-flow time and duration of pre-shock pauses, but overall the quality of CPR performed during the ALS course remained poor. There was little evidence of performance improving over successive simulations as the course progressed. Conclusion The implementation of Guidelines 2005 into the ALS course appear to have improved the process of CPR by reducing no-flow time during simulated CPR. However, the quality of CPR during ALS training remains sub-optimal. Delays in starting CPR, inadequate compression depth, excessive interruptions in chest compressions and prolonged pre-shock pauses mirror observations from clinical practice. Strategies to improve CPR performance during ALS training should be explored and potentially may result in improvements in clinical practice.
