With the increase in patients having impaired renal function at liver transplant due to MELD, accurate predictors of posttransplant native renal recovery are needed to select candidates for ...simultaneous liver–kidney transplantation (SLK). Current UNOS guidelines rely on specific clinical criteria for SLK allocation. To examine these guidelines and other variables predicting nonrecovery, we analyzed 155 SLK recipients, focusing on a subset (n = 78) that had post‐SLK native GFR (nGFR) determined by radionuclide renal scans. The 77 patients not having renal scans received a higher number of extended criteria donor organs and had worse posttransplant survival. Of the 78 renal scan patients, 31 met and 47 did not meet pre‐SLK UNOS criteria. The UNOS criteria were more predictive than our institutional criteria for all nGFR recovery thresholds (20–40 mL/min), although at the most conservative cut‐off (nGFR ≤ 20) it had low sensitivity (55.3%), specificity (75%), PPV (67.6%) and NPV (63.8%) for predicting post‐SLK nonrecovery. On multivariate analysis, the only predictor of native renal nonrecovery (nGFR ≤ 20) was abnormal pre‐SLK renal imaging (OR 3.85, CI 1.22–12.5). Our data support the need to refine SLK selection utilizing more definitive biomarkers and predictors of native renal recovery than current clinical criteria.
This analysis of radionuclide imaging following simultaneous liver–kidney transplantation demonstrates the need for more definitive predictors of native renal recovery than current clinical criteria to better guide the selection of acceptable candidates for this procedure versus liver transplant alone. See editorial by Feng and Trotter on page 2869.
Summary A major threat to tuberculosis (TB) control programs is the emergence of drug resistant Mycobacterium tuberculosis strains that cause TB that cannot be cured by standard anti-TB drug ...regimens. Because few data exist on MDR-TB in this region of the country, we performed an epidemiologic study that combined conventional and molecular analysis of MDR-TB cases from Rio Grande do Sul (RS) that were diagnosed in this period and included cases that were under treatment with second line drug schemes. Included were 121 MDR cases and sequencing of rpo B and kat G showed that 106 (87.6%) strains were mutated in rpo B and 97 (80.2%) in kat G. Spoligotyping demonstrated that the LAM genotype was predominant ( n = 70, 57.8%) and included the largest group composed by 22 (18.1%) strains with the LAM5 ST93 genotype. Other main genotypes belonged to the families T ( n = 22, 18.2%), U family ( n = 16, 13.2%), Haarlem ( n = 5, 4.1%) and X ( n = 1, 0.8%). Genotyping by IS 6110- RFLP analysis showed 51 distinct fingerprints, 38 (31.4%) of these observed only once and the other 13 patterns being shared among the rest of the isolates ( n = 83, 68.6%). Among the 22 strains that were LAM5 ST93, only two had different IS 6110 -RFLP genotypes. In conclusion, there exists a high degree of M. Tuberculosis genotype clustering among MDR-TB cases in Rio Grande do Sul. Moreover, we observed a large MDR-TB outbreak.
Cytomegalovirus (CMV) is the most common viral infection among lung transplant recipients and is associated with chronic lung allograft dysfunction. There is a need for better therapeutics as well as ...biomarkers to enable effective stratification of CMV seropositive patient risk for developing CMV DNAemia to inform prophylaxis duration.
CMV-specific immunoglobulin G (IgG) binding and functional responses were evaluated in a discovery cohort of longitudinal plasma samples from 51 CMV seropositive human lung transplant recipients, collected as part of the clinical trials in organ transplantation (CTOT)-20 and CTOT-22 consortium studies. Pre-transplant plasma from an additional 43 CMV seropositive lung transplant recipients was evaluated as a validation cohort.
In the discovery cohort with longitudinal samples, pre-transplant plasma IgG binding to CMV surface glycoproteins glycoprotein H (gH)/glycoprotein L (gL), gH/gL/glycoprotein O (gO), and pentameric complex, as well as neutralization of CMV in epithelial cells, is associated with increased risk of CMV DNAemia post-prophylaxis. However, these results were not confirmed by the validation cohort.
While quantification of pre-transplant CMV-specific antibody responses showed association with DNAemia in the discovery cohort, additional clinical variables and/or known risk factors for CMV, such as patient CMV-specific T-cell responses, may need to be considered in combination with humoral immunity to effectively stratify risk of CMV DNAemia.
Objectives. To evaluate the relationship between disease damage and bone mineral density (BMD) in women with systemic lupus erythematosus (SLE). Methods. A cross-sectional study was conducted among ...307 women with SLE. Patients attended a single clinic visit that included an interview, physical examination, laboratory testing and BMD measurements (hip and/or lumbar spine). Women were stratified by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology cumulative disease damage index (SDI) ≥1 (Damage) vs SDI=0 (No Damage), and prior use of corticosteroids (CS), yielding four groups: (1) Damage/CS+ (n=138), (2) Damage/CS− (n=23), (3) no Damage/CS− (n=100), and (4) no Damage/CS− (n=46). Results. Mean age at SLE diagnosis was 32.7 ± 11.8 yr, 24.4% were African American, 65.0% were premenopausal, and mean SDI ± s.d. was 1.3 ± 1.8. In the unadjusted and adjusted models controlling for significant univariate risk factors for osteoporosis, the reference group (Group 1) had significantly lower mean BMD T-scores at the hip and lumbar spine than groups having no disease damage (Groups 3 and 4) independent of CS use status. Similar hip and lumbar spine mean BMD T-scores were observed in women with disease damage with and without CS exposure (Groups 1 and 2). Conclusions. Women with SLE having disease damage and no CS use had BMD T-scores at the hip and lumbar spine similar to those of women with disease damage and prior CS use. These findings suggest an association between disease damage and lower BMD T-scores in women with SLE.
Purpose: Radioembolization of hepatic metastases with
90
Y
microspheres requires that the user can accurately measure the source activity and consistently determine the completion of dose delivery. ...To determine the most effective technique for determining the completion of a single dose application, we have retrospectively examined dose rate measurements and source vial assays from 263 radioembolizations using Y‐90 glass microspheres. Method and Materials: Y‐90 glass microspheres were measured in an Atomlab 100 dose calibrator. Unit doses were supplied in 0.6 mL of sterile water contained in a v‐bottom vial secured within a 12 mm clear acrylic vial shield. Assays were obtained for the point source configuration (microspheres concentrated into the 0.3 ml v‐bottom) and for a distributed source configuration (microspheres distributed in 0.6 ml). Assayed values were compared to the nominal activity. Source dose rates were measured using Inovision 451P. Manufacturer's recommended measurements were followed. In addition, the beta dose rate from the top of the unshielded source vial was measured using Thermo Eberline RO7BM ionization chamber. Initial and final dose rate measurements were compared to the measured residual activity. Results: The axial dependence of the dose calibrators ranged from 0 to 5%. Measured activity in the point source configuration was on average 94.5% of the decayed calibrated activity (R2=0.996). However, measured activity in the distributed source configuration was on average 84.5% of the decayed calibrated activity (R2=0.998). Residual activity as a function of the beta specific dose rate measurements was linear (r2 = 0.4). Conclusion: This study has shown that using a point source configuration for source vial assays and using the beta specific dose rate measurements to accurately determine dose delivery does provide a more consistent and accurate determination of yttrium‐90 glass microsphere activity delivery and improve radioembolization quality assurance.
Riad Salem, MD consultant for MDS‐Nordion.
Gated blood-pool SPECT (GBPS), inherently 3-dimensional (3D), has the potential to replace planar equilibrium radionuclide angiography (ERNA) for computation of left ventricular ejection fraction ...(LVEF), analysis of regional wall motion (RWM), and analysis of right heart function. The purpose of this study was to compare GBPS and ERNA for the assessment of ventricular function in a large, multicenter cohort of patients.
One hundred seventy-eight patients referred in the usual manner for nuclear medicine studies underwent ERNA followed by GBPS. Each clinical site followed a GBPS acquisition protocol that included 180 degrees rotation, a 64 by 64 matrix, and 64 or 32 views using single- or double-head cameras. Transverse GBPS images were reconstructed with a Butterworth filter (cutoff frequency, 0.45-0.55 Nyquist; order, 7), and short-axis images were created. All GBPS studies were processed with a new GBPS program, and LVEF was computed from the isolated left ventricular chamber and compared with standard ERNA LVEF. Reproducibility of GBPS LVEF was evaluated, and right ventricular ejection fraction (RVEF) was computed in a subset of patients (n = 33). Using GBPS, RWM and image quality from 3D surface-shaded and volume-rendered cine displays were evaluated qualitatively in a subset of patients (n = 30).
The correlation between GBPS LVEF and planar LVEF was excellent (r = 0.92). Mean LVEF was 62.2% for GBPS and 54.1% for ERNA. The line of linear regression was GBPS LVEF = (1.04 x ERNA LVEF) + 6.1. Bland-Altman plotting revealed an increasing bias in GBPS LVEF with increasing LVEF (Y = 0.13x + 0.61; r = 0.30; mean difference = 8.1% +/- 7.0%). Interoperator reproducibility of GBPS LVEF was good (r = 0.92). RVEF values averaged 59.8%. RWM assessment using 3D cine display was enhanced in 27% of the studies, equivalent in 67%, and inferior in 7%.
GBPS LVEF was reproducible and correlated well with planar ERNA. GBPS LVEF values were somewhat higher than planar ERNA, likely because of the exclusion of the left atrium.
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