Prostaglandin E1 administration post liver transplantation and renal outcomes:A retrospective single center experience

BACKGROUND Prostaglandin E1(PGE1),or alprostadil,is a potent vasodilator that improves hepatic blood flow and reduces ischemia-reperfusion injury post-liver transplantation(LT).However,the benefits of PGE1 on renal function after LT have not yet been well described.AIM To assess the impact of PGE1 administration on renal function in patients who underwent liver or liver-kidney transplant.METHODS This retrospective study included all patients who underwent liver or liverkidney transplant at our institution from January,2011 to December,2021.Patients were classified based on whether they received PGE1.PGE1 was administered post-LT to those with transaminases>1000 U/L in the immediate postoperative period.Demographics,post-LT treatments and/or complications,renal function,and survival were analyzed.Multivariable logistic regression analysis was performed,and a two-tailed P value<0.05 was considered statistically significant.RESULTS A total of 145 patients underwent LT,with 44(30%)receiving PGE1.Baseline patient characteristics were comparable,except the PGE1 group had significantly higher aspartate aminotransferase(AST)(1961.9 U/L±1862.3 U/L vs 878 U/L±741.4 U/L,P=0.000),alanine aminotransferase(1070.6 U/L±895 U/L vs 547.7 U/L±410 U/L,P=0.000),international normalized ratio on post-LT day 1(2±0.74 vs 1.8±0.4,P=0.03),a longer intensive care unit stay(8.1 days±11.8 days vs 3.8 days±4.6 days,P=0.003),more vasopressor use(55.53 hours±111 hours vs 16.33 hours±26.3 hours,P=0.002),and higher immediate postoperative complications(18.6%vs 4.9%,P=0.04).The PGE1 group also had a significantly higher 90-day readmission rate(29.6%vs 13.1%,P=0.02)and lower 1-year liver graft survival(87.5%vs 98.9%,P=0.005).However,30-day readmission(31.6%vs 27.4%,P=0.64),LT complications(hepatic artery thrombosis,biliary complications,rejection of liver graft,cardiomyopathy),1-year patient survival(96.9%vs 97.8%,P=0.77),overall liver graft survival,and overall patient survival were similar between the two groups(95.4%vs 93.9%,P=0.74 and 88.4%vs 86.9%,P=0.81 respectively).Although the PGE1 group had a significantly lower glomerular filtration rate(eGFR)on post-LT day 7(46.3 mL/minute±26.7 mL/minute vs 62.5 mL/minute±34 mL/minute,P=0.009),the eventual need for renal replacement therapy(13.6%vs 5.9%,P=0.09),the number of dialysis sessions(0.91 vs 0.27,P=0.13),and eGFR at 1-month(37.2 mL/minute±35.9 mL/minute vs 42 mL/minute±36.9 mL/minute,P=0.49),6-months(54.8 mL/minute±21.6 mL/minute vs 62 mL/minute±21.4 mL/minute,P=0.09),and 12-months(63.7 mL/minute±20.7 mL/minute vs 62.8 mL/minute±20.3 mL/minute,P=0.85)post-LT were similar to those in the non-PGE1 group.CONCLUSION In patients who received PGE1 for ischemia-reperfusion injury,despite immediate acute renal injury post-LT,the renal function at 1-month,6-months,and 12-months post-LT was similar compared to those without ischemiareperfusion injury.Prospective clinical trials are needed to further elucidate the benefits of PGE1 use in renal function.

Safety and outcomes of hip and knee replacement surgery in liver transplant recipients

BACKGROUND Liver transplant(LT)is becoming increasingly common with improved life expectancy.Joint replacement is usually a safe procedure;however,its safety in LT recipients remains understudied.AIM To evaluate the mortality,outcome,and 90-d readmission rate in LT patients undergoing hip and knee replacement surgery.METHODS Patients with history of LT who underwent hip and knee replacement surgery between 2016 and 2019 were identified using the National Readmission Database.RESULTS A total of 5046119 hip and knee replacement surgeries were identified.3219 patients had prior LT.Mean age of patients with no history of LT was 67.51[95%confidence interval(CI):67.44-67.58],while it was 64.05(95%CI:63.55-64.54)in patients with LT.Patients with history of LT were more likely to have prolonged length of hospital stay(17.1%vs 8.4%,P<0.001).The mortality rate for patients with no history of LT was 0.22%,while it was 0.24%for patients with LT(P=0.792).Patients with history of LT were more likely to have re-admissions within 90 d of initial hospitalization:11.4%as compared to 6.2%in patients without history of LT(P<0.001).The mortality rate between both groups during readmission was not statistically different(1.9%vs 2%,P=0.871)respectively.CONCLUSION Hip and knee replacements in patients with history of LT are not associated with increased mortality;increased readmissions were more frequent in this cohort of patients.Chronic kidney disease and congestive heart failure appear to predict higher risk of readmission.

Rangelands of Central Asia:challenges and opportunities

Rangelands of Central Asia (referring to Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan in this study), the largest contiguous area of grazed land in the world, serve as an important source of livelihood for pastoral and agro-pastoral communities in this region. They also play an important role in absorbing CO2 as a global carbon sink. However, unsustainable management of rangelands has led to their degradation hugely by downgrading their potential agro-ecological, environmental and socio-economical roles. This paper reviewed the rangeland degradation in Central Asia, a topic which so far has received only scant coverage in the international scientific literature. It also provided examples of successful experiences and outlined possible options that land managers can adopt to enhance the sustainable management of these vast degraded rangelands. The experiences and lessons described in this paper may also be relevant for other degraded rangeland areas, especially in the developing countries. The causes of rangeland degradation within the Central Asian region are numerous, complex and inter-related. Therefore, while addressing the factors associated with improper rangeland management may shed some light on the causes of rangeland degradation, the scope of this paper would not be all-encompassing for the major causes of degradation. There is a need to develop and widely apply the viable and locally accepted and adapted packages of technical, institutional and policy options for sustainable rangeland management. Incentivizing the collective action of small-scale pastoralists who group together to facilitate access to remote pastures can reduce the degree of overgrazing within community pastures, such as those near the settlements. We also found that migratory grazing through pooling of resources among small-scale pastoralists can increase household income. After their independence, most Central Asian countries adopted various rangeland tenure arrangements. However, the building of enhanced capacities of pasture management and effective local rangeland governance structures can increase the likelihood, which will be sustainable and equitable. Finally, this paper presented several promising technical options, aiming at reversing the trend of rangeland degradation in Central Asia.

Pathophysiology of periventricular leukomalacia:what we learned from animal models

Periventricular leukomalacia （PVL）, a white matter injury （WMI） affecting the premature infant＇s brain is commonly associated with ce- rebral palsy （CP）. Among premature infants 〈 1,500 g, approximately 7,000 develop CP yearly and 20,000-30,000 exhibit major cognitive deficits yearly （Volpe, 2009）. PVL results from hypoxia-ischemia （HI） with or without infection and is characterized by white matter necrotic lesions, hypomyelination, microglial activation, astrogliosis, and neuronal death. Risk factors for the development of PVL include： prematurity associated with immature cerebrovascular development, HI insults with lack of appropriate auto-regulation of cerebral blood flow, free radical production, energy deprivation, intrauterine infec- tion and chorioamnionitis. Affected infants show definitive signs of cerebral palsy such as spastic diplegia, seizures, developmental delay, visual and hearing impairment, scoliosis and incontinence by 6-9 months of age. PVL can also occur in term infants with certain con- genital cyanotic heart disease which will not be our focus here （Volpe, 2001）.

Best practices for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Acute pancreatitis is of one the most common gastroenterology-related indications for hospital admissions worldwide.With the widespread reliance on endoscopic retrograde cholangiopancreatography(ERCP)for the management of pancreaticobiliary conditions,post-ERCP pancreatitis(PEP)has come to represent an important etiology of acute pancreatitis.Despite many studies aiming to better understand the pathogenesis and prevention of this iatrogenic disorder,findings have been heterogeneous,and considerable variation in clinical practice exists.Herein,we review the literature regarding PEP with the goal to raise awareness of this entity,discuss recent data,and present evidence-based best practices.We believe this manuscript will be useful for gastrointestinal endoscopists as well as other specialists involved in the management of patients with PEP.

Safety of gastrointestinal endoscopy in patients with acute coronary syndrome and concomitant gastrointestinal bleeding

BACKGROUND Gastrointestinal bleeding(GIB)is a major concern in patients hospitalized with acute coronary syndrome(ACS)due to the common use of both antiplatelet medications and anticoagulants.Studies evaluating the safety of gastrointestinal endoscopy(GIE)in ACS patients with GIB are limited by their relatively small size,and the focus has generally been on upper GIB and esophago-gastroduodenoscopy(EGD)only.AIM To evaluate the safety profile and the hospitalization outcomes of undergoing GIE in patients with ACS and concomitant GIB using the national database for hospitalized patients in the United States.METHODS The Nationwide Inpatient Sample database was queried to identify patients hospitalized with ACS and GIB during the same admission between 2005 and 2014.The International Classification of Diseases Code,9th Revision Clinical Modification was utilized for patient identification.Patients were further classified into two groups based on undergoing endoscopic procedures(EGD,small intestinal endoscopy,colonoscopy,or flexible sigmoidoscopy).Both groups were compared regarding demographic information,outcomes,and comorbidities.Multivariate analysis was conducted to identify factors associated with mortality and prolonged length of stay.Chi-square test was used to compare categorical variables,while Student’s t-test was used to compare continuous variables.All analyses were performed using SAS 9.4(Cary,NC,United States).RESULTS A total of 35612318 patients with ACS were identified between January 2005 and December 2014.269483(0.75%)of the patients diagnosed with ACS developed concomitant GIB during the same admission.At least one endoscopic procedure was performed in 68%of the patients admitted with both ACS and GIB.Patients who underwent GIE during the index hospitalization with ACS and GIB had lower mortality(3.8%)compared to the group not undergoing endoscopy(8.6%,P<0.001).A shorter length of stay(LOS)was observed in patients who underwent GIE(mean 6.59±7.81 d)compared to the group not undergoing endoscopy(mean 7.84±9.73 d,P<0.001).Multivariate analysis showed that performing GIE was associated with lower mortality(odds ratio:0.58,P<0.001)and shorter LOS(-0.36 factor,P<0.001).CONCLUSION Performing GIE during the index hospitalization of patients with ACS and GIB was correlated with a better mortality rate and a shorter LOS.Approximately twothirds of patients with both ACS and GIB undergo GIE during the same hospitalization.

Experience with Post Transplant Parathyroidectomy in Gulf Region and Literature Review

Sustained elevation of parathyroid hormone (PTH) levels is not uncommon post renal transplantation. Though in the majority of patients, it gradually normalizes, on average 5% of transplanted patients require parathyroidectomy (PTX). However, PTX itself has been associated with deterioration in allograft function and even completes graft loss seen with both total and subtotal PTX as well as an increased rate of acute rejection. The aim of this study was to determine the effect of post transplant partial PTX on allograft function in our patients as well as the incidence of acute rejection. Our results show that post transplantation, subtotal PTX, was successful in achieving metabolic control while preserving graft function without an increased incidence of acute rejection. Retention of sufficient residual parathyroid tissue with partial PTX might account for favorable outcome in our study. Despite this, surgery for advanced hyperparathyroidism should optimally take place in the pre-transplant period.