Objective To investigate the related factors of serum carnitine deficiency in critical ill patients, and the influence of its deficiency on the length of hospital stay. Methods A prospective study was conducted. Critical ill patients with acute physiology and chronic health evaluationⅡ(APACHEⅡ)score>12 admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Sun Yat-sen University from March 2013 to September 2013 were enrolled. Serum carnitine concentration and indexes of organ function were determined,and the tolerance of enteral nutrition within 5 days,the length of hospital stay,the length of intensive care unit(ICU)stay,and the hospital mortality were recorded. The relationship between serum carnitine and indexes mentioned above was analyzed. Results Thirty critically ill patients were enrolled. Serum carnitine concentration was very low in all critically ill patients,i.e. (8.92±5.05)μmol/L(normal reference value at 43.5 μmol/L)at hospital admission. Serum carnitine concentration in patients with APACHEⅡscore>23(7 cases)was significantly lower than that in those with APACHEⅡscore 12-23(23 cases,μmol/L:5.33±1.72 vs. 10.02±5.24,t=2.300,P=0.001). Serum carnitine concentration in patients with serum total bilirubin(TBil)>19μmol/L(9 cases)was significantly lower than that in those with TBil≤19μmol/L(21 cases,μmol/L:5.54±2.70 vs. 9.84±5.08,t=2.750,P=0.014). Serum carnitine concentration was negatively correlated with the APACHEⅡscore and the TBil(r=-0.387,P=0.035;r=-0.346,P=0.048). During the 5-day observation period,enteral feeding amount〔(5 134±1 173)mL〕was positively correlated with serum carnitine concentration(r=0.430,P=0.022). In 30 critical patients,the incidence of abdominal distension was 40.0%(12/30),and the serum carnitine concentration of patients with abdominal distension was lower compared with that of patients without abdominal distension(μmol/L:7.83±4.98 vs. 9.12±5.35,t=0.707,P=0.383). The incidence of diarrhea was 26.7%(8/30),and the serum carnitine concentration of diarrhea patients was lower compared with that of patients without diarrhea(μmol/L:8.27±5.78 vs. 9.73±4.78,t=0.607,P=0.576). The mean length of hospital stay was(34.72±16.66)days. The serum carnitine concentrations in patients with hospital stay≥45 days (8 cases)were lower compared with those in those<45 days(22 cases,μmol/L:5.71±3.23 vs. 9.95±5.26,t=1.627,P=0.020). No correlation was found between serum carnitine concentrations and the hospital stay(r=-0.165, P=0.385). The length of ICU stay was(18.60±10.72)days. Serum carnitine concentration in patients with the length of ICU stay>7 days(27 cases)was slightly lower than that in those with the length of ICU stay≤7 days (3 cases,μmol/L:8.44±5.00 vs. 13.24±3.65,t=1.610,P=0.119). No correlation was found between serum carnitine concentrations and the length of ICU stay(r=-0.019,P= 0.293). In-hospital mortality was 26.67%(8/30). No significant difference in serum carnitine concentrations was found between the death group and the survival group(μmol/L:12.24±6.52 vs. 7.72±3.91,t=-1.846,P=0.098). No correlation was found between serum carnitine concentrations and in-hospital mortality(r=0.340,P=0.066). Conclusions Carnitine deficiency is significant in critically ill patients,and it is correlated with disease severity and serum TBil. The total amount of lenteral feeding was lower,and hospital stay was prolonged in critically ill patients with low serum carnitine level.

Objective To investigate whether the change of cardiac output (CO) with bed head raising (BHR) combined with passive leg raising (PLR) can be used to assess volume overload in critical patients.Methods A prospective observational diagnostic trial was designed. The patients who underwent fluid resuscitation 6 hours or more, and admitted to intensive care unit (ICU) of Meizhou People's Hospital in Guangdong Province from January to December in 2016 were enrolled. Volume overload were identified with the criteria including the increasing of pulmonary rales, the higher levels of N-terminal brain natriuretic peptide (NT-proBNP) and new pulmonary exudates in chest radiograph. CO and heart rate (HR) were monitored with impedance cardiography at supine position and BHR by 30°(BHR30), 60° (BHR60), and PLR in all patients. The changes of CO (?CO30,?CO60,?COPLR) and HR (?HR30,?HR60,?HRPLR) were calculated at different positions. The receiver operating characteristic curve (ROC) was used to evaluate the predictive values of?CO30,?CO60 and combination of?CO60 and?COPLR on volume overload.Results A total of 62 patients were enrolled in this study, with 44 males and 18 females, age of (58.9±15.9) years, a body mass index of (22.7±2.4) kg/m2, and an acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score of 18.7±4.4. The CO of 32 patients with volume overload was significantly increased at BHR30 or BHR60 compared with supine position [?CO30 was (14.5±11.5)%,?CO60 was (26.9±17.5)%, bothP< 0.01], and the?CO60 was increased more than the?CO30 (P < 0.01);while CO was slightly decreased after PLR,?COPLR was (-8.4±11.3)% (P > 0.05). There was no consistent change of CO at BHR30 or BHR60 compared with supine position in 30 patients without volume overload,?CO30 was (-3.4±9.1)% (P < 0.05),?CO60 was (-2.4±14.0)% (P > 0.05), while CO was significantly increased after PLR,?COPLR was (12.4±11.3)% (P < 0.01). There was no significant change of HR after BHR and PLR in patients with volume overload and non volume overload. ROC curve showed that when the cut-off value of ΔCO30≥3.3%, the area under ROC curve (AUC) was 0.903±0.039, the sensitivity was 90.6%, the specificity was 80.0%, and the accuracy was 85.5% for predicting volume overload; when the cut-off value of ΔCO60≥5.6%, the AUC was 0.911±0.036, the sensitivity was 96.9%, the specificity was 73.3%, and the accuracy was 85.5% for predicting volume overload. If volume overload was assessed by the increase of ΔCO60 combining with the decrease of ΔCOPLR, the AUC was 0.928±0.034, the optimal cut-off value for the new combined predictive indicator in predicting volume overload was -0.008, and the sensitivity, specificity, accuracy was 96.9%, 83.3%, 90.3%, respectively, and its evaluation effect is better than the use of ΔCO30 or ΔCO60 alone.Conclusion The change of CO with BHR combined with PLR can be used to accurately evaluate volume overload in patient with critically illness.

Objective To analyze the risk factors for the occurrence of post transplantation diabetes mellitus (PTDM) in renal transplant recipients, establish a prediction model for PTDM and evaluate its prediction value. Methods Clinical data of 915 renal transplant recipients were retrospectively analyzed. According to the occurrence of PTDM, all recipients were divided into the PTDM group (n=78) and non-PTDM group (n=837). The main indexes of recipients were collected. The risk factors for the occurrence of PTDM in renal transplant recipients were analyzed by univariate and multivariate analysis. The prediction model for PTDM was established and its prediction value was evaluated. Results Family history of diabetes mellitus, body mass index (BMI), preoperative 2 h postprandial blood glucose and preoperative glycosylated hemoglobin were the independent risk factors for the occurrence of PTDM in renal transplant recipients. The prediction model for PTDM was logit (P)=2.199×family history of diabetes (yes=1, no=0)+0.109×BMI+0.151×2 h postprandial blood glucose (mmol/L)+0.508×glycosylated hemoglobin (%)-9.123. The results of receiver operating characteristic (ROC) curve showed that the area under the curve (AUC) of these 4 predictors combined for predicting PTDM in renal transplant recipients was 0.830 [95% confidence interval (CI) 0.786-0.873], the cut-off value was 0.0608, the sensitivity was 0.821, the specificity was 0.700, and the Youden index was 0.521 (P < 0.05). Conclusions Family history of diabetes mellitus, BMI, preoperative 2 h postprandial blood glucose and preoperative glycosylated hemoglobin are the independent risk factors for the occurrence of PTDM in renal transplant recipients. The prediction model for PTDM combined with4 predictors yield relatively high prediction value for PTDM.

Objective:To analyze the association of pre-transplant risk factors with diabetes mellitus after renal transplantation and examine the significance of preventing the occurrence in kidney transplantation recipients.Methods:A total of 290 kidney transplantation recipients were retrospectively reviewed at our transplantation center from August 2018 to May 2020.Diabetes mellitus after renal transplantation was employed as a primary outcome index.Multivariate Logistic regression model was utilized for constructing A (without adjusting for covariates)、B(covariates include: gender, dialysis mode, type of donation)and C(covariates include: gender, dialysis mode, type of donation, calcineurin inhibitor, antiproliferative drugs, primary disease, fasting blood glucose, 1 h postprandial blood glucose, fasting C peptide, 1 h and 2 h postprandial C peptide, fasting C-peptide index, 1 h postprandial C-peptide index, albumin, triglycerides, total cholesterol)to evaluate the relationship between diabetes mellitus after transplantation and age, body mass index, 2 h postprandial blood glucose(2 h-PG), HbA1c, and 2 h postprandial C-peptide index(2 h-CPI).Results:In model A, age [odds ratio(OR)1.1, 95% confidence interval( CI)1.0~1.1], BMI(OR 1.2, 95% CI 1.0~1.3), 2 h PG(OR 1.2, 95% CI 1.1~1.4), HbA1c(OR 2.7, 95% CI 1.5~4.9), 2 h-CPI(OR 0.7, 95% CI 0.5~1.0), model B/C had similar results with A. Age, BMI, 2 h PG and HbA1c were all risk factors for diabetes mellitus after transplantation while 2 h-CPI was a protective factor.Quartile stratification was analyzed by regression model.And trend test was significant( P<0.05). Conclusions:Age, BMI, 2 h PG, HbA1c and 2 h-CPI are correlated with diabetes mellitus after kidney transplantation.

Objective To investigate the distribution and drug resistance characteristics of pathogens in donors and recipients undergoing simultaneous pancreas-kidney transplantation (SPK). Methods Clinical data of 231 pairs of donors and recipients undergoing SPK were analyzed retrospectively. The pathogens of samples from donors and recipients were identified by VITEK-2 analyzer, and drug sensitivity test was performed by K-B method. The source distribution and composition ratio of pathogens in donor and recipient samples, distribution characteristics of multi-drug resistant organism, infection of recipients and drug resistance characteristics of pathogens were analyzed. Results A total of 395 strains of pathogens were cultured from 1 294 donor samples, and the detection rate was 30.53%. Gram-negative bacteria mainly consisted of klebsiella pneumoniae, Gram-positive bacteria mainly comprised staphylococcus aureus, and fungi primarily included candida albicans, respectively. In total, 2 690 strains of pathogens were cultured from 10 507 recipient samples, and the detection rate was 25.60%. Gram-negative bacteria mainly consisted of pseudomonas maltophilia, Gram-positive bacteria primarily comprised enterococcus faecalis, and fungi mainly included candida albicans, respectively. Among 395 pathogens of donors, 15 strains of methicillin-resistant staphylococcus aureus (MRSA), 16 strains of extended-spectrum β-lactamase (ESBL) positive drug-resistant bacteria, 8 strains of carbapenem-resistant pseudomonas aeruginosa (CR-PA), 21 strains of carbapenem-resistant acinetobacter baumannii (CR-AB), 2 strains of carbapenem-resistant enterobacteriaceae (CRE) and 1 strain of multiple-drug/pan-drug resistant pseudomonas aeruginosa (MDR/PDR-PA) were identified. Among 2 690 strains of recipient pathogens, 73 strains of ESBL positive drug-resistant bacteria, 44 strains of CR-PA, 31 strains of CR-AB and 3 strains of MDR/PDR-PA were detected. One recipient developed donor-derived infection, 69 cases of pneumonia, 52 cases of urinary tract infection, 35 cases of abdominal infection and 2 cases of hematogenous infection were reported within postoperative 1 year. Gram-negative bacteria were resistant to certain antibiotics. Gram-positive bacteria were sensitive to vancomycin. Fungi were sensitive to amphotericin B. Conclusions Gram-negative bacteria are the main pathogens of SPK recipients, which are resistant to certain antibiotics. Empirical use of antibiotics can be delivered before culture results are obtained. Subsequently, sensitive antibiotics should be chosen according to the culture results to improve the survival rate of SPK recipients.

Objective:To summarize the clinical characteristics and risk factors of acute rejection(AR)of transplanted pancreas and kidney after simultaneous pancreas-kidney transplantation(SPK)and explore the effects of AR on the survival of transplanted pancreas, kidney and recipients.Methods:From September 2016 to July 2022, the relevant clinical data were retrospectively reviewed for 218 recipients undergoing SPK.According to whether or not AR occurred after SPK, they were assigned into two groups of AR(n=53)and non-AR(n=165). The relevant clinical data were compared for two groups of donors and recipients and the risk factors of AR analyzed by binary Logistic regression.Kaplan-Meier method was employed for comparing the survival rates of recipients/transplanted pancreas and kidneys in two groups.Results:A total of 53 cases(24.3%)developed ARs of transplanted pancreas(n=31, 14.2%)(5 of 2 ARs), transplanted kidney(n=15, 6.9%)(1 of 2 ARs)and transplanted pancreas & kidney AR(n=11, 5.0%)(2 of 2 ARs). Tacrolimus blood levels in AR and non-AR groups were(5.8±1.2)and(6.3±1.6)μg/L and failed to attain targets in 36(67.9%)and 78(47.3%)cases.During follow-ups, the incidence of pneumonia and urinary tract infections in AR group versus non-AR group were[43.4%(23/53)vs.27.3%(45/165)and 39.6%(21/53)vs.18.8%(31/165)]and the differences were statistically significant( P=0.028 & 0.002). The results of multifactorial regression analysis revealed that sub-optimal blood level of tacrolimus was an independent risk factor for an occurrence of AR in grafts of SPK recipients( OR=2.254, 95% CI: 1.167-4.353, P=0.016). Comparisons of 1/5-year postoperative survival rates between recipients in AR and no-AR group(98.1% vs.93.9% and 92.1% vs.92.4%)indicated that the differences were not statistically significant( P=0.233 & 0.806). Through comparing 1/5-year survival rates of transplanted pancreas in AR and non-AR groups(94.3% vs.100%, 89.4% vs.98.6%), the differences were statistically significant( P=0.003 & 0.004). And 1/5-year survival rates of transplanted kidneys in AR and non-AR groups(92.5% vs.100% and 90.2% vs.100%)were compared and the differences were statistically significant(all P<0.001). Conclusions:The incidence of AR is higher in transplanted pancreas and kidney after SPK.And the incidence of pneumonia and urinary tract infection is higher in AR group than that in non-AR group.Sub-optimal blood level of tacrolimus is an independent risk factor for the occurrence of AR.The 1/5-year survival rates of transplanted pancreas and transplanted kidney are lower in AR group than those in non-AR group.It has some effect on the survival of transplanted pancreas and kidney.

One case of COVID-19 infection secondary to pulmonary mucormycosis in a recipient of simultaneous pancreas-kidney transplantation was described. Early identification of the pathogen was achieved by metagenomic next-generation sequencing. On the basis of disease status and liver function changes, targeted treatments included intravenous amphotericin B liposome, amphotericin B nebulization& gargling and subsequently a maintenance therapy of oral posaconazole. This regimen resulted in the absorption of lung infection, stabilization of transplanted pancreas function and reduced levels of creatinine and urea as compared to pre-infection period. The therapeutic efficacy was decent.

Objective:To summarize the distributional characteristics of postoperative occurrence of multi-drug resistant organism (MDRO) infections and their risk factors in simultaneous pancreas-kidney transplantation (SPK) recipients and examine the impact of MDRO infections on the survival of SPK recipients.Method:From January 2016 to December 2022, the relevant clinical data were retrospectively reviewed for 218 SPK recipients. The source of donor-recipient specimens and the composition percentage of MDRO pathogens were examined. According to whether or not MDRO infection occurred post-transplantation, they were assigned into two groups of MDRO (98 cases) and non-MDRO (120 cases). The clinical data of two groups of donors and recipients were analyzed. And the risk factors for an onset of MDRO infection were examined by binary Logistic regression. The survival rate of two recipient groups was compared by Kaplan-Meier method.Result:A total of 98/218 recipients (45%) developed MDRO infections. And 46 (46.9%) of sputum and 34 (34.7%) of urine were cultured positively and 49 (50%) pathogens expressed extended spectrum beta-lactamase. There were pneumonia (46 cases, 46.9%), urinary tract infections (34 cases, 34.7%), abdominal infections (16 cases, 16.3%) and bloodstream infections (2 cases, 2.0%). Univariate regression analysis revealed that length of renal failure ( P=0.037), length of hospitalization ( P<0.001), length of antibiotic use ( P<0.001), novel antibiotics ( P=0.014), albumin ( P<0.001) and leukocyte count ( P<0.001) were risk factors for an onset of MDRO infections. The results of multifactorial regression indicated that low albumin ( OR=0.855, 95% CI: 0.790~0.925, P<0.001) and leukopenia ( OR=0.656, 95% CI: 0.550~0.783, P<0.001) were independent risk factors for an onset of MDRO infections. The survival rates of recipients in MDRO group at Year 1/3 post-operation were 92.9% (91/98) and 89.8% (88/98). And the survival rate of recipients in non-MDRO group was 96.7% (116/120) at Year 1/3 post-operation. Inter-group difference was not statistically significant in 1-year survival rate of two recipient groups ( P=0.201); statistically significant inter-group difference in 3-year survival rate between two recipient groups ( P=0.041) . Conclusion:Low albumin and leukopenia are risk factors for MDRO infection. Infection with MDRO has some impact on the survival of recipients.

Objective:To explore the diagnostic value of color Doppler ultrasonography for transplanted pancreatic venous thrombosis after simultaneous pancreas-kidney transplantation(SPK).Methods:From June 2019 to September 2022, retrospective analysis was conducted for the relevant clinical data of 181 recipients of SPK.Based upon a presence or absence of clinical high-risk factors, such as a sudden decline of blood/urine amylase, elevated fasting blood glucose and D-dimer, they were assigned into two groups of high-risk(n=48)and non-high-risk(n=133). Color Doppler ultrasonography was performed for evaluating the status of transplanted pancreas and reconstructed blood vessels and diagnosing pancreatic thrombosis post-SPK.Also they were divided into two groups of donor splenic vein thrombosis(n=6)and non-thrombosis(n=39)based upon the presence or absence of splenic vein thrombosis.Various laboratory parameters(fasting blood glucose, blood/urine amylase, fatty acids & D-dimer)and transplanted pancreatic ultrasonic measurements(thickness of transplanted pancreatic head/body/tail, inner diameter & blood flow velocity of donor splenic vein, transplanted pancreatic parenchymal arterial blood flow velocity and resistance index)were recorded.Measurement data were tested for normal distribution and homogeneity of variances.Group comparisons for measurement data fulfilling the criteria of normal distribution and homogeneity of variances were conducted by t-test.For data not fulfilling these criteria, Mann-Whitney U test was utilized.Results:Among 9 cases of pancreatic thrombosis as diagnosed by color Doppler ultrasonography, pancreatic venous thrombosis(n=6)occurred in donor splenic vein.The proportion of transplanted pancreatic thrombosis occurring within Week 2 was 88.9%(8/9)and the proportion of transplanted pancreatic venous thrombosis occurring within Week 2 3.3%(5/6). Fasting blood glucose, blood amylase, urine amylase and D-dimer of high-risk group were(14.7±1.9)U/L, (92.6±15.4)mmol/L, (9.7±1.7)U/L and(6.1±2.2)mg/L.The corresponding values for non-high-risk group were(4.9±0.6)U/L, (209.4±34.4)mmol/L, (168.2±95.7)U/L and(1.3±0.6)mg/L respectively.Statistically significant inter-group differences existed( P=0.021, 0.035, 0.001, 0.017). Pancreatic thrombosis was diagnosed by color Doppler ultrasonography in 9 patients in high-risk group and 8 cases occurred within Week 2 post-SPK.Among 6 cases of pancreatic venous thrombosis, 5 cases occurred in donor splenic veins within Week 2 post-SPK.No significant differences existed in the above parameters between group with donor splenic vein thrombosis and group without donor splenic vein thrombosis( P>0.05). Inner diameters of splenic veins in groups with and without splenic vein thrombosis were(11.7±0.5)and(3.9±0.2)mm.Blood flow velocities in splenic veins were(18.3±8.4)and(40.3±16.6)cm/s respectively.The inter-group differences were statistically significant( P=0.001, 0.006). No significant differences existed in thickness of transplanted pancreatic head/body/tail, as well as blood flow velocity or resistance index in transplant pancreatic artery( P>0.05). Conclusions:Fasting blood glucose, blood amylase, urine amylase, fatty acid and D-dimer are important and yet non-specific biochemical parameters in the diagnosis of pancreatic transplantation thrombosis.Color Doppler ultrasonography may provide valuable imaging diagnostic rationales for making an early diagnosis and providing timely interventions of transplanted pancreatic venous thrombosis post-SPK.It is imperative to enhance dynamic monitoring using color Doppler ultrasound within 1-2 weeks post-SPK.Greater attention should be paid to internal diameter and blood flow velocity of donor splenic vein.

Objective To discuss the efficacy and safety of transarterial chemoembolization(TACE)and hepatic arterial infusion chemotherapy(HAIC)combined with tyrosine kinase inhibitors(TKI)and immune checkpoint inhibitors(ICI)for advanced hepatocellular carcinoma(HCC).Methods A total of 101 patients with unresectable HCC,who were admitted to the Affiliated Cancer Hospital of Harbin Medical University of China between January 2021 and October 2022 to receive treatment,were enrolled in this study.Of the 101 patients,50 received TACE+TKI+ICI therapy(TACE+TKI+ICI group)and 51 received HAIC+TKI+ICI therapy(HAIC+TKI+ICI group).The overall survival(OS)and the progression-free survival(PFS)were compared between the two groups,and the adverse events were analyzed to assess the safety of the therapeutic scheme.Results The median PFS in the TACE+TKI+ICI group was 12.0 months,which in the HAIC+TKI+ICI group was 11.0 months(P=0.030).The median OS was not achieved in the TACE+TKI+ICI group,which in the HAIC+TKI+ICI group was 14.6 months(P=0.005).The most common adverse effects in the TACE+TKI+ICI group were the elevation of total bilirubin(46.0％)and hepatic function injury(26.0％),which in the HAIC+TKI+ICI group were the decrease of albumin level(62.7％),fatigue(39.2％),and gastrointestinal reactions(31.4％).Conclusion For the treatment of advanced HCC,the therapeutic scheme of TACE+TKI+ICI has a better long-term survival benefits and the therapeutic scheme of HAIC+TKI+ICI can better maintain the liver function reserve of the patients.Neither therapeutic scheme shows any unexpected toxicity,and both therapeutic schemes have high clinical safety.(J Intervent Radiol,2024,33:543-548)