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M J Ricart

Publications and source records attributed to M J Ricart.

At least 19 recordsLinked to original sources
PubMed2005

Bacteremia and septic shock after solid-organ transplantation.

BACKGROUND: Bacteremia and septic shock remain important causes of morbidity and mortality after solid-organ transplantation. The aim of this study was to assess the characteristics and risk factors for mortality among patients with bloodstream infections and shock. METHODS: From January 1991 to December 2000, all episodes of bloodstream infection were prospectively examined, considering bacteremia or fungemia as significant according to the CDC criteria. Septic shock was diagnosed in a patient with systemic inflammatory response syndrome and persistent dysfunction of at least one organ caused by hypoperfusion despite hemodynamic support. RESULTS: There were 466 episodes of bacteremia in 382 patients, with 66 of them developing septic shock. Risk factors for developing shock were age >50 (P = .006), liver transplant (P = .029), nosocomial infection (P = .034), pulmonary focus (P = .0001), P. aeruginosa infection (P = .001), and polymicrobial etiology (P = .039). On multivariate analysis, only age, nosocomial infection, and pulmonary source were significant. Among 66 shock patients, bacteremia was due to gram-negative bacteria in 53%, gram-positive bacteria in 24%, fungal in 7.5%, and polymicrobial in 12% of patients. The most frequent source was the lung (26%). Empiric antimicrobial therapy was correctly chosen in 79%; however, 36 patients died (54%), including 27 despite correct therapy. Urinary tract infections had less mortality than other foci. CONCLUSIONS: Risk factors for developing septic shock in bacteremia were age more than 50 years, nosocomial acquisition, and pulmonary focus. Despite adequate empiric antibiotic therapy, the mortality remained high.

Bacteremia↗
PubMed2005

Invasive pulmonary aspergillosis in solid organ and bone marrow transplant recipients.

BACKGROUND: Invasive pulmonary aspergillosis (IPA) remains a major cause of mortality in transplant recipients. New strategies in therapy are needed. METHODS: We prospectively followed all solid organ and bone marrow transplant recipients from January 1998 to January 2003 who showed pulmonary infiltrates. We retrospectively analyzed all of the patients diagnosed as having IPA. Clinical and epidemiological data were collected. Influence of new treatment strategies on survival was also analyzed. RESULTS: Thirty-one cases of API were found: 8 definite, 18 probable, 5 possible among recipients of liver (11), bone marrow (9), kidney (7), kidney-pancreas (3), and heart (1) transplants. Five patients (16%) were previously receiving antifungal prophylaxis. The most common symptoms were fever (74%) and dyspnea and dry cough (48%). Six cases (19%) showed dissemination to extrapulmonary sites: central nervous system (CNS) in five and bone in one. The most common radiographic patterns were alveolar infiltrates (58%); the lesions were usually diffuse and bilateral (58%). The most common Aspergillus species identified was A. fumigatus (74%). The test to detect Aspergillus antigen (galactomannan) in serum performed in 13 cases, was positive in eight (61%). The crude mortality rate was 61% (19 of 31), but in patients on mechanical ventilation, it was 94% (OR 88, IC 95%: 7.1-1094), and in patients with CNS involvement, it was 100%. The influence of the different treatment regimens on survival was analyzed in definite and probable cases: Group 1 (12) included patients who received conventional monotherapy and group 2 (12) patients received combination antifungal therapy or liposomal amphotericin B (1-AMB) at high doses. The mortality in group 1 was 83% (10 of 12), and in group 2 it was 42% (5 of 12) (P < 0.05). CONCLUSIONS: The mortality rate of IPA remains high, especially among patients with CNS involvement or those under mechanical ventilation. Combined antifungal therapy or monotherapy with 1-AMB at high doses significantly reduced mortality compared with conventional monotherapy.

Amphotericin B↗
PubMed2004

Lessons from cyclosporine monotherapy in renal transplantation: the impact of acute rejection on long-term allograft outcome.

UNLABELLED: The introduction of cyclosporine in kidney transplantation rapidly improved short and medium term graft and patient survival rates. Initially many trials used cyclosporine monotherapy to avoid steroid toxicity, but high acute rejection rates lead to a change in the immunosuppressant scheme. The use of prophylactic steroids significantly decreased acute rejection rates, but the long-term benefit of such a reduction has not been assessed. METHODS: Retrospective analysis of the impact of early acute rejection on long-term outcome (10 years) in 264 consecutive renal transplants performed in a single institution between 1986 and 1993 using cyclosporine monotherapy (CM) (n=139) versus cyclosporine and prednisone (CS) (n=125). Different protocols were used for elderly or immunological high-risk patients and for transplants with delayed graft function and therefore these patients are not included. The incidence and severity of acute rejection episodes and long-term patient and graft survivals were analyzed. RESULTS: At 1 year, acute rejection episodes showed significantly higher frequency in the CM group than in the CS group (72.66% vs 46.40%). Nevertheless, graft and patient survival rates were similar at 1, 5, and 10 years (Graft: 96.38%, 78.77%, and 59.84% vs 92.59%, 75.62%, and 53.44%; PATIENT: 99.27%, 95.06%, and 84.76% and 95.9%, 93.09%, and 88.28%). CONCLUSION: The addition of prophylactic steroids decreases the incidence of acute rejection but does not improve the long-term graft survival. These findings suggest that in an era of new immunosuppressants, fewer acute rejection episodes will be evident requiring more effort to detect and treat subclinical rejections.

Adult↗
PubMed2003

Diffuse large B-cell lymphoma arising from donor lymphoid cells after renal and pancreatic transplantation.

A patient with both a renal and pancreatic transplantation developed a diffuse large B-cell lymphoma, Epstein-Barr virus-related, 14 months after the surgical procedure. Tumor was confined to the transplanted organs: head of the pancreas and hilar lymph node of the transplanted kidney. Chimerism analysis demonstrated the tumor origin from donor lymphoid cells. Immunosuppression was discontinued and chemotherapy with cyclophosphamide, hydroxydaunomycin, vincristine, and prednisone (CHOP) was started. However, no response was observed after three courses of this regimen. Finally, a transplantectomy was carried out, followed by rituximab (anti-CD20 antibody), with the patient achieving a complete response (CR). Two years later the patient remains in CR.

Adult↗
PubMed2003

[Pure red blood cell aplasia associated with neutralizing antibodies against erythropoietin induced by epoetin alfa:a new form of acquired erythroblastopenia in auremic patients].

We report the case of a woman with end-stage renal disease on maintenance hemodialysis and treated with recombinant human erythropoietin (epoetin alfa) administered subcutaneously, who developed a pure red cell aplasia secondary to the development of neutralizing antibodies anti-erythropoietin after 8 months of treatment. Despite epoetin withdrawal and immunosuppressive treatment with corticosteroids and gammaglobulins the patient still has high red blood cell transfusion requirements and undetectable plasma erythropoietin levels. Pure red cell aplasia secondary to the development of neutralizing antibodies anti-erythropoietin is a rare but severe complication associated with the use of recombinant human erythropoietin in uremic patients. In recent years, the incidence of this complication has sharply increased, specially associated with the use of epoetin alfa administered subcutaneously. For this reason, the Spanish Drug Agency has recently contraindicated treating uremic patients with epoetin alfa administered subcutaneously.

Adult↗
PubMed2002

Treatment and outcome of pancreatic venous graft thrombosis after kidney--pancreas transplantation.

BACKGROUND: Pancreas venous graft thrombosis after transplantation is the main non-immunological cause of graft failure and usually results in pancreatectomy. Duplex Doppler ultrasonography is the primary imaging technique for monitoring vascular patency after pancreas transplantation. This study reports the results of rescue treatments for pancreas graft thrombosis after simultaneous pancreas--kidney transplantation. METHODS: One hundred and ninety-six patients with insulin-dependent diabetes mellitus received a simultaneous pancreas--kidney transplantation. Venous graft thrombosis was diagnosed in 25 of these patients based on Doppler ultrasonographic findings. RESULTS: Total venous graft thrombosis was diagnosed in 20 symptomatic patients, of whom 14 required graft pancreatectomy. Surgical thrombectomy was attempted in six patients with preserved arterial supply and was successful in four. Partial venous graft thrombosis was diagnosed in five asymptomatic patients; one also had partial splenic artery thrombosis. Rescue graft procedures included systemic anticoagulation (one patient), arterial thrombolysis (one) and venous thrombolysis and/or mechanical venous thrombectomy (four episodes in three patients). Graft rescue was achieved in three patients treated by venous thrombolysis/thrombectomy. CONCLUSION: Doppler ultrasonography allows the appropriate selection of rescue treatment based on the findings of total or partial thrombosis.

Adult↗
PubMed2001

[Pancreas and kidney transplantation: long-term metabolic results].

STUDY AIM: Pancreas and kidney transplantation (PKTx) is indicated in uremic patients with insulin-dependent diabetes mellitus (IDDM). The aim of this study was to determine its long-term effect on metabolic control in order to establish the real efficacy of this treatment in diabetic patients. PATIENTS AND METHOD: Among a total experience of 191 pancreas and kidney transplantations, a metabolic control was performed in 80 patients who underwent PKTx in our center, with both grafts functioning for more than one year. Immunological markers of diabetes mellitus were also evaluated (ICA and GADab) in 50 patients. RESULTS: Basal glycemia and glycosylated hemoglobin (HbA1c) levels throughout follow-up were within the normal range. Hyperinsulinemia was present throughout follow-up till the fourth year. The oral glucose tolerance test (OGTT) was normal in 82.5% of the patients beyond one year after the graft. Over time, no differences were detected on basal glucose and insulin levels and areas under the curve (AUC) of glycemia and insulinemia. During the evolution, no differences were found in the fasting insulin resistance index (FIRI), in spite of increasing body weight. ICA were + in 2 patients before graft and + in 7 after graft (14%). GADab were + in 10 patients before graft and + in 11 after graft (22%). CONCLUSION: Pancreas and kidney transplantation provides without any insulin treatment and diet long-term normalization of glycemic control, assessed by HbA1c and OGTT, despite the existence of sustained hyperinsulinemia. Our results strongly suggest that pancreas and kidney transplantation is the most efficient treatment for uremic patients with insulin-dependent diabetes mellitus from a metabolic point of view.

Adult↗
PubMed2000

Noninvasive assessment of cardiac risk in type I diabetic patients being evaluated for combined pancreas-kidney transplantation using dipyridamole-MIBI perfusion tomographic scintigraphy.

This study was performed to determine the value of dipyridamole-99m Tc-methoxy-isobutyl isonitrile perfusion (99mTC-MIBI) tomographic scintigraphy in the assessment of cardiac risk in patients being evaluated prior to combined pancreas-kidney transplantation (PKT). We performed perfusion tomographic scintigraphy using single photon emission computed tomography (SPECT) on 77 patients. The tomographic images did not show clinically relevant findings in 65 patients. In the remaining 12 patients, coronary arteriography was performed: 2 showed normal results, 4 showed no stenosis, and 6 showed significant stenosis ( > or = 70%). Seventy-two patients underwent PKT. During the follow-up (6-48 months), there were seven cardiac events, 4 patients with significant stenosis, and 3 with nonsignificant stenosis upon coronary arteriography, and all had pathological tomographic images. 99mTc-MIBI tomographic scintigraphy may be useful in identifying patients at low risk of incurring cardiac events after PKT and may, in a large group of patients, obviate the need for routine coronary angiography.

Adult↗
PubMed1998

Recurrence of immunological markers for type 1 (insulin-dependent) diabetes mellitus in immunosuppressed patients after pancreas transplantation.

BACKGROUND: Type 1 (insulin dependent) diabetes mellitus (IDDM) is an autoimmune disease in which autoantibodies against islet cells develop concomitantly with or even preceding diagnosis. Because the recurrence of diabetes can be the cause of graft failure in patients with pancreas transplantation, we studied the possible recurrence of IDDM immunomarkers after transplantation. METHODS: The following determinations were performed every 1-2 years after transplantation in 50 immunosuppressed IDDM patients with simultaneous kidney and pancreas transplantation (bladder drainage of exocrine secretion): islet cell antibodies (ICA) by direct immunofluorescence, antibodies against glutamic acid decarboxylase (GADab) by radiobinding assay, and the oral glucose tolerance test. The mean follow-up was 4.1+/-6.3 (range 1 to 9 years). RESULTS: GADab were detected in 11 patients after transplantation, 10 of whom had been positive beforehand. ICA reappearance after transplantation was detected in seven patients (14%). The presence of ICA was related to GADab positivity (P=0.001) and HLA DR3 patients (P=0.04), but not with pancreatitis and rejection episodes, immunosuppression induction therapy, or donor HLA haplotype. During follow-up, an abnormal oral glucose tolerance test was more frequent in ICA-positive patients (P=0.02), with no differences in metabolic control or insulin secretion. CONCLUSION: We conclude that GADab persist and ICA reappear despite immunosuppressive therapy in patients with functioning pancreas transplants. The relevance and the risk that this implies for IDDM development should be determined.

Adult↗
PubMed1998

Successful pancreas and kidney transplantation: a view of metabolic control.

BACKGROUND: Pancreas and kidney transplantation (PKTx) has become the treatment of choice in uremic patients with insulin-dependent diabetes mellitus (IDDM). In these patients, the pancreatic graft provides an endogenous source of insulin. However, the determination of its long-term effect on metabolic control is crucial in order to establish the real efficacy of this treatment in diabetic patients. In this article, we describe the experience of the University of Barcelona in short- and long-term metabolic control in PKTx recipients. SUBJECTS AND METHODS: We performed seriated determinations of glycosilated hemoglobin (HbA1c) and oral glucose tolerance tests (OGTT) in 55 patients who underwent PKTx at our center from 1983 to 1996 with both grafts functioning for more than 1 yr (mean follow-up 4.2 +/- 2.3 yr). Basal glucose and insulin levels, areas under the curve (AUC) of glycemia and insulinemia after OGTT were analyzed throughout follow-up, as well as fasting insulin resistance index (FIRI). RESULTS: HbA1c levels throughout follow-up were within the normal range. The OGTT was normal in 80% of the patients 5 yr after transplantation. Hyperinsulinemia was present throughout follow-up. Over time, no differences were detected in the AUC of glycemia and insulinemia between controls and patients with PKTx. During the evolution, no differences were found in FIRI, in spite of increasing body weight. CONCLUSION: When successful, PKTx provides long-term normalization of glycemic control, assessed by HbA1c and OGTT, despite the existence of sustained hyperinsulinemia. Our results strongly suggest that PKTx is the most effective treatment for uremic patients with IDDM from a metabolic point of view.

Adult↗
PubMed1996

Study of kidney rejection following simultaneous kidney-pancreas transplantation.

Simultaneous kidney-pancreas (SKP) transplantation is associated with increased risk of kidney rejection (KR) due to an unknown mechanism. The aim of this study is to analyze the characteristics of KR in 44 SKP transplantations under quadruple immunosuppressive therapy and to evaluate the response to treatment and its effect on renal allograft survival and renal function. The mean follow-up was 25 +/- 14 months. Seventy-seven percent of the patients (34 of 44) presented an acute renal allograft rejection. Sixty-six percent (29 of 44) had one rejection episode and 11% (5 of 4) 2 episodes. KR was early (85% in the first month after transplantation), intense (3.7-fold increase in creatinine) and had great clinical features. Twenty-eight percent of the patients had an early relapse during the first month after treatment. KR did not affect the survival of the renal allograft in the short-term (1 and 2 years). Overall, 62% were corticosensitive (CS) and the remaining 38% were corticoresistant (CR). The group with an isolated rejection without relapse was CS in 69% of the cases, achieved complete remission in 73% and renal function was not affected at 1 and 2 years [115 +/- 26 mumol/l (1.3 +/- 0.3 mg/dl) and 150 +/- 53 mumol/l (1.7 +/- 0.6 mg/dl)] in comparison with the group without rejection [97 +/- 18 mumol/l (1.1 +/- 0.2 mg/dl) and 115 +/- 35 mumol/l (1.3 +/- 0.4 mg/dl); p = NS]. On the other hand, the group with an early relapse of the first rejection and the group with two rejections were principally CR (62 and 60%, respectively), had partial remission with treatment (50 and 60%) and had worse renal function at 1 and 2 years [212 +/- 71 mumol/l (2.4 +/- 0.8 mg/dl) and 221 +/- 53 mumol/l (2.5 +/- 0.6 mg/dl)] than in the group with isolated KR (p < 0.05 and p < 0.001). In conclusion, despite intense immunosuppressive treatment, the frequency of rejection of a renal allograft in SKP is high. The response to treatment is satisfactory and does not affect the survival of the allograft in the short-term. However, multiple episodes or early relapse of rejection are associated with higher creatinine levels.

Adult↗