OBJECTIVE: To investigate the correlation between postoperative driving pressure (DP) and the prognosis of lung transplantation, and to further evaluate the value of early DP monitoring in lung transplantation. METHODS: A observational study was conducted. The patients after lung transplantation who admitted to the intensive care unit (ICU) of Wuxi People's Hospital from February 1, 2022 to February 1, 2023 were collected. They were divided into low DP group (DP≤15 cmH₂O, 1 cmH₂O ≈ 0.098 kPa) and high DP group (DP > 15 cmH₂O) according to DP within 2 hours after operation. The clinical data including general information, primary disease, chronic diseases, cardiopulmonary function, laboratory indicators, intraoperative condition, postoperative lactic acid (Lac) and ventilator parameters were collected. Primary outcomes included 28-day and 90-day survival, and secondary outcomes included occurrence of primary graft dysfunction (PGD), duration of extracorporeal membrane oxygenation (ECMO), duration of mechanical ventilation, weaning of mechanical ventilation, and length of ICU stay. The general data and observations between the two groups were compared. Kaplan-Meier curve analysis was conducted to analyze the situation of mechanical ventilation and 90-day survival. Receiver operator characteristic curve (ROC curve) was used to evaluate the predictive ability of DP for failed weaning of mechanical ventilation and 90-day death. The dose-response relationship between DP and 90-day death risk was determined by restricted cubic spline model. Univariate analysis was performed using Cox proportional hazards model. RESULTS: A total of 101 patients were enrolled, with 68 patients (67.3%) in the low DP group and 33 patients (32.7%) in the high DP group. No statistically significant difference in general information, chronic diseases, primary diseases, cardiopulmonary function, laboratory indicators, intraoperative conditions, and postoperative Lac between the two groups was found. Compared with the low DP group, the patients in the high DP group had higher inspiratory pressure (Pinsp) and incidence of PGD with grade 3 at 24 hours after operation [Pinsp (cmH₂O): 21.0±0.6 vs. 20.0±0.7, PGD with grade 3 at 24 hours: 60.6% (20/33) vs. 39.7% (27/68), both P < 0.05], longer duration of ECMO, duration of mechanical ventilation, and the length of ICU stay [duration of ECMO (hours): 37 (21, 109) vs. 22 (14, 43), duration of mechanical ventilation (days): 3.1 (1.8, 10.7) vs. 1.9 (1.1, 3.2), length of ICU stay (days): 6 (3, 13) vs. 4 (3, 5), all P < 0.05], and lower successful weaning rate of mechanical ventilation [81.8% (27/33) vs. 95.6% (65/68), P < 0.05). The 28-day and 90-day survival rates in the high DP group were significantly higher than those in the low DP group [28-day: 69.7% (23/33) vs. 86.8% (59/68), 90-day: 63.6% (21/33) vs. 83.8% (57/68), both P < 0.05]. Kaplan-Meier curve showed that the patients in the low DP group were weaned and extubated earlier than high DP group, and the cumulative situation of weaning was better (Log-Rank test: χ ² = 14.054, P < 0.001), and the 90-day cumulative survival rate in the low DP group was significantly higher than that in the high DP group (Log-Rank test: χ ² = 4.791, P = 0.029). ROC curve analysis showed that the area under ROC curve (AUC) of DP for predicting 90-day death was 0.664 [95% confidence internal (95%CI) was 0.540-0.787, P = 0.017], and the AUC for predicting failed weaning of mechanical ventilation was 0.794 (95%CI was 0.667-0.921, P = 0.004). Results of restricted cubic spline model analysis showed that the 90-day death risk continued to increase with the DP < 18 cmH₂O; when DP≥18 cmH₂O, elevated DP did not continue to increase the 90-day death risk, showing a plateau effect. Univariate analysis showed that DP was independent risk factors of 90-day death, and the death risk increased by 9.3% for every 1 cmH₂O increase in DP [hazard ratio (HR) = 1.093, 95%CI was 1.007-1.186, P = 0.033]. CONCLUSIONS DP is an independent risk factor of death after lung transplantation, and early postoperative DP may be used as a predictor of failed weaning of mechanical ventilation and 90-day death after lung transplantation.
Humans ; Lung Transplantation ; Prognosis ; Respiration, Artificial ; Intensive Care Units ; Postoperative Period ; Pressure ; Primary Graft Dysfunction/epidemiology* ; Transplant Recipients ; Female ; Extracorporeal Membrane Oxygenation ; Male ; ROC Curve ; Middle Aged

Objective To identify the risk factors of prolonged mechanical ventilation (PMV) after lung transplantation. Methods Clinical data of 90 recipients undergoing lung transplantation were retrospectively analyzed. According to the duration of invasive mechanical ventilation after operation, all recipients were divided into the PMV group (ventilation duration > 48 h, n=30) and control group (ventilation duration≤48 h, n=60). Perioperative parameters were compared between two groups, including preoperative parameters [serum creatinine, estimated glomerular filtration rate (eGFR)], intraoperative parameters (cold ischemia time of donor lung, blood loss), and postoperative parameters [the first red blood cell, white blood cell, platelet count, hemoglobin, C-reactive protein, serum creatinine, total bilirubin, alanine aminotransferase (ALT), oxygenation index, eGFR and the mean arterial pressure in intensive care unit (ICU)]. The risk factors of PMV after lung transplantation were assessed by multivariate logistic regression analysis. Results Preoperative serum creatinine level in the PMV group was 62 (53, 67) μmol/L, significantly higher than 57 (47, 62) μmol/L in the control group. Preoperative eGFR in the PMV group was 97 (93, 107) mL/min, significantly lower than 106 (102, 116) mL/min in the control group. The first postoperative oxygenation index in the PMV group was 196 (157, 286) mmHg, significantly lower than 250 (199, 354) mmHg in the control group (all P < 0.05). Multivariate analysis showed that the first increase of postoperative total bilirubin, the first decrease of postoperative oxygenation index and preoperative eGFR decrease were the independent risk factors for PMV following lung transplantation. Conclusions The first increase of postoperative total bilirubin, the first decrease of postoperative oxygenation index and preoperative eGFR decrease are the independent risk factors for PMV after lung transplantation.

To explore the effect of geniposidic acid (GPA) on the signal pathway of small heterodimer dimer receptor (SHP) and liver receptor homologue 1 (LRH-1) in cholestasis rats induced by alpha-naphthalene isothiocyanate (ANIT).
 Methods: Fifty SD rats were randomly divided into five groups: a blank group, an ANIT group, an ANIT+GPA (100 mg/kg) group, an ANIT+GPA (50 mg/kg) group, and an ANIT+GPA (25 mg/kg) group (n=10 in each group). The GPA were intragastrically given to rats for 10 days, and the control group and the ANIT group were given normal saline. At the eighth day of administration, all rats except the blank group were given 65 mg/kg ANIT once until the tenth day. After the last administration, serum total cholesterol (TC), triglyceride (TG) and total bile acids (TBA) were measured. The primary hepatocytes (RPH) were isolated from normal rats and cultured. The cells were divided into a blank group, an ANIT (40 μmol/L) group, an ANIT (40 μmol/L)+GPA (4.00 mmol/L) group (A4.00G group), an ANIT (40 μmol/L)+GPA (1.00 mmol/L) group (A1.00G group), and an ANIT (40 μmol/L)+GPA (0.25 mmol/L) group (A0.25G group). The mRNA transcription levels of SHP and cholesterol 7 alpha hydroxylase (CYP7A1) in RPH were detected by real-time-PCR, and the protein levels of SHP and CYP7a1 were detected by Western blotting. In the LRH-1 silence experiment, the RPH were divided into a blank group, a negative transfection group, a siRNA-LRH group (ZR group), a siRNA-LRH+GPA (4.00 mmol/L) group (ZR4.00G group), a siRNA-LRH+GPA (1.00 mmol/L) group (ZR1.00G group) and a siRNA-LRH+GPA (0.25 mmol/L) group (ZR0.25G group). The protein and mRNA levels of SHP, CYP7a1, LRH-1 were detected. In the over-expression experiment, the RPH were also divided into a blank group, a negative transfection group, a LRH-1 over-expression plasmid group (OE group), a LRH-1 over-expression plasmid+GPA (4.00 mmol/L) group (OE4.00G group), a LRH-1 over-expression plasmid+GPA (1.00 mmol/L) group (OE1.00G group), and a LRH-1 over-expression plasmid+GPA (0.25 mmol/L) group (OE0.25G group). The protein and mRNA levels of SHP, CYP7a1 and LRH-1 were detected.
 Results: Compared with the blank control group, TC and TBA were significantly increased (both P<0.01) in the ANIT group, but there was no difference in TG; compared with the ANIT group, the contents of TC and TBA in the AG100 and AG50 groups were significantly reduced (all P<0.01). Compared with the blank control group, the proteins and mRNA levels of SHP were significantly decreased (P<0.01), while CYP7a1 were dramatically increased (P<0.01) in the ANIT group; compared with the ANIT group, the proteins and mRNA levels of SHP in the A4.00G group and the A1.00G group were significantly increased (both P<0.01), while the levels of CYP7a1 proteins and mRNA levels were evidently decreased in the A4.00G and A1.00G groups (both P<0.01). Compared with the negative transfection group, the proteins and mRNA levels of CYP7a1 and LRH-1 were dramatically restrained (all P<0.01), while there was no change in SHP in the ZR group; compared with the ZR group, the proteins and mRNA levels of SHP were significantly increased (all P<0.01), while LRH-1 and CYP7a1 were not changed in the ZR4.00G, ZR1.00G and ZR0.25G groups. Compared with the negative transfection group, the protein and mRNA levels of CYP7a1 and LRH-1 were significantly suppressed in the OE group (all P<0.01). Compared with the OE group, the protein and mRNA levels of SHP were evidently increased in the OE4G and OE1G groups (all P<0.01), while LRH-1 and CYP7a1 were not changed in the OE4G, OE1G and OE0.25G groups.
 Conclusion: The over-expression of LRH-1 in RPH can up-regulate the mRNA and protein levels of CYP7a1. GPA can improve the biochemical and liver pathology of ANIT-induced cholestasis rats, which may be related to the decrease of CYP7a1 by activating SHP through LRH-1 in RPH.
Animals ; Cholestasis ; Iridoid Glucosides ; Rats ; Rats, Sprague-Dawley ; Receptors, Cytoplasmic and Nuclear ; Signal Transduction