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      Acute respiratory failure in kidney transplant recipients: a multicenter study

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          Abstract

          Introduction

          Data on pulmonary complications in renal transplant recipients are scarce. The aim of this study was to evaluate acute respiratory failure (ARF) in renal transplant recipients.

          Methods

          We conducted a retrospective observational study in nine transplant centers of consecutive kidney transplant recipients admitted to the intensive care unit (ICU) for ARF from 2000 to 2008.

          Results

          Of 6,819 kidney transplant recipients, 452 (6.6%) required ICU admission, including 200 admitted for ARF. Fifteen (7.5%) of these patients had combined kidney-pancreas transplantations. The most common causes of ARF were bacterial pneumonia (35.5%), cardiogenic pulmonary edema (24.5%) and extrapulmonary acute respiratory distress syndrome (ARDS) (15.5%). Pneumocystis pneumonia occurred in 11.5% of patients. Mechanical ventilation was used in 93 patients (46.5%), vasopressors were used in 82 patients (41%) and dialysis was administered in 104 patients (52%). Both the in-hospital and 90-day mortality rates were 22.5%. Among the 155 day 90 survivors, 115 patients (74.2%) were dialysis-free, including 75 patients (65.2%) who recovered prior renal function. Factors independently associated with in-hospital mortality were shock at admission (odds ratio (OR) 8.70, 95% confidence interval (95% CI) 3.25 to 23.29), opportunistic fungal infection (OR 7.08, 95% CI 2.32 to 21.60) and bacterial infection (OR 2.53, 95% CI 1.07 to 5.96). Five factors were independently associated with day 90 dialysis-free survival: renal Sequential Organ Failure Assessment (SOFA) score on day 1 (OR 0.68/SOFA point, 95% CI 0.52 to 0.88), bacterial infection (OR 0.43, 95% CI 0.21 to 0.90), three or four quadrants involved on chest X-ray (OR 0.44, 95% CI 0.21 to 0.91), time from hospital to ICU admission (OR 0.98/day, 95% CI 0.95 to 0.99) and oxygen flow at admission (OR 0.93/liter, 95% CI 0.86 to 0.99).

          Conclusions

          In kidney transplant recipients, ARF is associated with high mortality and graft loss rates. Increased Pneumocystis and bacterial prophylaxis might improve these outcomes. Early ICU admission might prevent graft loss.

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          Most cited references30

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          Long-term survival in renal transplant recipients with graft function.

          Long-term survival in renal transplant recipients with graft function. Death with graft function (DWGF) is a common cause of graft loss. The risks and determinants of DWGF have not been studied in a recent cohort of renal transplant recipients. We performed a population-based survival analysis of U.S. patients with end-stage renal disease (ESRD) transplanted between 1988 and 1997. Registry data were used to evaluate long-term patient survival and cause-specific risks of DWGF in 86,502 adult (>/=18 years) renal transplant recipients. Out of 18,482 deaths, 38% (N = 7040) were deaths with graft function. This accounts for 42. 5% of all graft loss. Patient survival with graft function was 97, 91, and 86% at 1, 5, and 10 years, respectively. The risk of DWGF decreased by 67% (RR = 0.33, P 30%, African American donor race, age> 45 years, and donor death caused by cerebrovascular disease. Patients with graft function have a high long-term survival. Although DWGF is a major cause of graft loss, the risk has declined substantially since 1990. Cardiovascular disease was the predominant reported cause of DWGF. Other causes vary by post-transplant time period. Attention to atherosclerotic risk factors may be the most important challenge to further improve the longevity of patients with successful renal transplants.
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            The prognosis of acute respiratory failure in critically ill cancer patients.

            Acute respiratory failure (ARF) in patients with cancer is frequently a fatal event. To identify factors associated with survival of cancer patients admitted to an intensive care unit (ICU) for ARF, we conducted a prospective 5-year observational study in a medical ICU in a teaching hospital in Paris, France. The patients were 203 cancer patients with ARF mainly due to infectious pneumonia (58%), but also noninfectious pneumonia (9%), congestive heart failure (12%), and no identifiable cause (21%). We measured clinical characteristics and ICU and hospital mortality rates.ICU mortality was 44.8% and hospital mortality was 47.8%. Noninvasive mechanical ventilation was used in 79 (39%) patients and conventional mechanical ventilation in 114 (56%), the mortality rates being 48.1% and 75.4%, respectively. Among the 14 patients with late noninvasive mechanical ventilation failure (>48 hours), only 1 survived. The mortality rate was 100% in the 19 noncardiac patients in whom conventional mechanical ventilation was started after 72 hours. By multivariable analysis, factors associated with increased mortality were documented invasive aspergillosis (odds ratio [OR], 2.13; 95% confidence intervals [CI], 1.05-14.74), no definite diagnosis (OR, 3.85; 95% CI, 1.26-11.70), vasopressors (OR, 3.19; 95% CI, 1.28-7.95), first-line conventional mechanical ventilation (OR, 8.75; 95% CI, 2.35-35.24), conventional mechanical ventilation after noninvasive mechanical ventilation failure (OR, 17.46; 95% CI, 5.04-60.52), and late noninvasive mechanical ventilation failure (OR, 10.64; 95% CI, 1.05-107.83). Hospital mortality was lower in patients with cardiac pulmonary edema (OR, 0.16; 95% CI, 0.03-0.72). Survival gains achieved in critically ill cancer patients in recent years extend to patients requiring ventilatory assistance. The impact of conventional mechanical ventilation on survival depends on the time from ICU admission to conventional mechanical ventilation and on the patient's response to noninvasive mechanical ventilation.
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              Transplantation 50 years later--progress, challenges, and promises.

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                Author and article information

                Journal
                Crit Care
                Critical Care
                BioMed Central
                1364-8535
                1466-609X
                2011
                8 March 2011
                : 15
                : 2
                : R91
                Affiliations
                [1 ]Medical Intensive Care Unit and Biostatistics Departments, Saint-Louis Teaching Hospital, 1 avenue Claude Vellefaux, Paris F-75010, France
                [2 ]Medical Intensive Care Unit, Bicêtre Teaching Hospital, 78 rue du Général Leclerc, Kremlin-Bicêtre F-94275, France
                [3 ]Medical Intensive Care Unit, Hôtel-Dieu Teaching Hospital, Place Alexis Ricordeau, Nantes, 44093, France
                [4 ]Departments of Intensive Care Medicine, Nephrology and Transplantation, Gabriel Montpied Teaching Hospital, 58 rue Montalembert, Clermont-Ferrand F-63003, France
                [5 ]Medical Intensive Care Unit, Edouard Herriot Teaching Hospital, 5 Place d'Arsonval, Lyon, 69437, France
                [6 ]Medical Intensive Care Unit, Nephrology and Transplantation, Lapeyronnie Teaching Hospital, 371 Avenue du doyen Gaston Giraud, Montpellier F-34295, France
                [7 ]Department of Nephrology and Transplantation, Necker Teaching Hospital, 149 rue de Sèvres, Paris F-75743, France
                [8 ]Medical Intensive Care Unit, A. Michallon Teaching Hospital, Avenue de Chantourne, Grenoble F-38043, France
                [9 ]Department of Nephrology and Transplantation, Tenon Teaching Hospital, 4 Rue de la Chine, Paris F-75970, France
                [10 ]Department of Nephrology and Transplantation, Hôtel-Dieu Teaching Hospital, Place Alexis Ricordeau, Nantes F-44093, France
                [11 ]Nephrology and Transplantation, Bicêtre Teaching Hospital, 78 rue du Général Leclerc, Kremlin-Bicêtre F-94275, France
                [12 ]Department of Nephrology and Transplantation, Saint-Louis Teaching Hospital, 1 avenue Claude Vellefaux, Paris F-75010, France
                Article
                cc10091
                10.1186/cc10091
                3219351
                21385434
                3300ff42-eb3b-4e3f-a041-1063a4d5d93e
                Copyright ©2011 Canet et al.; licensee BioMed Central Ltd.

                This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 20 October 2010
                : 27 January 2011
                : 8 March 2011
                Categories
                Research

                Emergency medicine & Trauma
                Emergency medicine & Trauma

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