32 research outputs found
Omgaan met schaarste
Schaarste, het thema van mijn oratie, is Ă©Ă©n van de centrale begrippen in de economie.
Volgens Van Dale is schaarste de omstandigheid dat iets in onvoldoende hoeveelheid
beschikbaar is. Dagelijks ervaren we de schaarste aan een bepaald goed. Er zijn te
weinig betaalbare huizen voor jonge mensen en te weinig leraren in het onderwijs.
Soms is er een tekort aan bedden op de afdeling of onvoldoende MRI capaciteit. Maar
ook het ontbreken van tijd en geld om die wereldreis te maken met je geliefde is een
vorm van schaarste. Kortom schaarste hoort bij het leven…….. en bij de dood. Want die is
vaak heel nabij als door een tekort aan organen de transplantatie van een nier, lever of
hart niet mogelijk is. Schaarste dwingt tot het maken van keuzes. Schaarste stimuleert
ook het zoeken naar creatieve oplossingen. Soms is schaarste de reden voor revolutie
en misdaad, aldus de Griekse fi losoof Aristoteles. In het tweede gedeelte van mijn
oratie zal ik aantonen dat de zorg voor ernstig zieke leverpatiënten soms tekortschiet
door schaarste aan donororganen, nog ontbrekende wetenschappelijke kennis,
schaarste aan hepatologen en schaarste aan transplantatiechirurgen. Dat zijn geen
natuurverschijnselen die ons overkomen, maar problemen die of met politieke wil of
met voldoende onderzoeksgeld zijn op te lossen. Ik zal daarvoor een aantal suggesties
doen. Maar eerst zal ik in het kort de geschiedenis van de levertransplantatie (LTx)
schetsen. Uiteraard kijk ik daarbij ook speciaal naar Rotterdam
Diagnosis and prevention of cytomegalovirus infection after organtransplantation
Although the introduction of cyclosporin A (GsA) as the main
immunosuppressive agent seems to have influenced the incidence and severity of
CMV disease in a positive way, the reported incidence of clinical overt CMV infection
is still 2 - 23 % and 1 - 3 % of the transplant recipients die from CMV infection. It is
therefore obvious that this virus remains a major pathogen after organ transplantation. DIAGNOSIS OF CMV INFECTION
When CMV disease is diagnosed, reduction of immunosuppressive therapy will
markedly decrease morbidity and mortality without affecting graft survival. Moreover,
antiviral therapy with either ganciclovir or foscarnet can be considered in patients with
severe symptomatic disease. This management of symptomatic CMV infections
(tapering of immunosuppressive drugs and j or antiviral therapy) makes rapid and
early diagnosis necessary. Although the measurement of virus specific antibodies is
sensitive, the long physiological response-time of antibody synthesis (one to two
weeks ) during active CMV infection makes this method inappropriate for rapid and
early diagnosis. Moreover, in patients with immunosuppression antibody synthesis
can be impaired. Detection of a morphological cytopathological effect (CPE) of CMV
in tissue cultures has the same disadvantage. The method takes long time and is
sometimes impossible due to bacterial contaminated specimens or coinfection with
the herpes simplex virus.
In this thesis two methods for rapid and early diagnosis of CMV infection are
described. First, we compared in our patients the results obtained by a low-speed
centrifugation assay in combination with immunofluorescence by a monoclonal
antibody against early antigen of CMV with the results from the conventional tissue
culture method. Second, an indirect method for detection of active CMV infection is
described. In the peripheral blood of renal transplant recipients mononuclear
subpopulations were monitored with monoclonal antibodies before, during and after CMV infection
Incidence of osteonecrosis after renal transplantation
The incidence of osteonecrosis was 24% in 248 patients who had received 262 kidney transplants 1971-1982. However, based only on patients at risk, i.e. alive with functioning transplants, the incidence at 1, 3 and 6 years was found to be 13, 27 and 36%; after six years no new cases were found. the relative increase in body-weight at 180 days was predictive as regards risk for osteonecrosis, while the cumulative dose of steroids was not. This suggests that individual sensitivity to steroids rather than the absolute cumulative dose is involved in the development of osteonecrosis
Fibrinolysis during liver transplantation is enhanced by using solvent/detergent virus-inactivated plasma (ESDEP)
After the introduction of solvent/detergent-treated plasma (ESDEP) in our
hospital, an increased incidence of hyperfibrinolysis was observed (75% vs
29%; P = 0.005) compared with the use of fresh frozen plasma for liver
transplantation. To clarify this increased incidence, intraoperative
plasma samples of patients treated with fresh frozen plasma or ESDEP were
analyzed in a retrospective observational study. During the anhepatic
phase, plasma levels of D-dimer (6.58 vs 1.53 microg/mL; P = 0.02) and
fibrinogen degradation products (60 vs 23 mg/L; P = 0.018) were
significantly higher in patients treated with ESDEP. After reperfusion,
differences increased to 23.5 vs 4.7 microg/mL (D-dimer, P = 0.002) and
161 vs 57 mg/L (fibrinogen degradation products, P = 0.001). The amount of
plasma received per packed red blood cell concentrate, clotting tests, and
levels of individual clotting factors did not show significant differences
between the groups. alpha(2)-Antiplasmin levels, however, were
significantly lower in patients receiving ESDEP during the anhepatic phase
(0.37 vs 0.65 IU/mL; P < 0.001) and after reperfusion (0.27 vs 0.58 IU/mL;
P = 0.001). Analysis of alpha(2)-antiplasmin levels in ESDEP alone showed
a reduction to 0.28 IU/mL (normal >0.95 IU/mL) because of the
solvent/detergent process. Therapeutic consequences for the use of ESDEP
in orthotopic liver transplantation are discussed in view of an increased
incidence of hyperfibrinolysis caused by reduced levels of
alpha(2)-antiplasmin in the solvent/detergent-treated plasma.
IMPLICATIONS: The use of solvent/detergent virus-inactivated plasma is of
increasing importance in the prevention of human immunodeficiency virus
and hepatitis C virus transmission. Since the use of this plasma during
orthotopic liver transplantation has increased, the incidence of
hyperfibrinolysis was observed. Clotting analysis of the patients revealed
small alpha(2)-antiplasmin concentrations because of the solvent/detergent
process
Adherence to a plant-based, high-fibre dietary pattern is related to regression of non-alcoholic fatty liver disease in an elderly population
Dietary lifestyle intervention is key in treating non-alcoholic fatty liver disease (NAFLD). We aimed to examine the longitudinal relation between well-established dietary patterns as well as population-specific dietary patterns and NAFLD. Participants from two subsequent visits of the Rotterdam Study were included. All underwent serial abdominal ultrasonography (median follow-up: 4.4 years) and filled in a food frequency questionnaire. Secondary causes of steatosis were excluded. Dietary data from 389 items were collapsed into 28 food groups and a posteriori dietary patterns were identified using factor analysis. Additionally, we scored three a priori dietary patterns (Mediterranean Diet Score, Dutch Dietary Guidelines and WHO-score). Logistic mixed regression models were used to examine the relation between dietary patterns and NAFLD. Analyses were adjusted for demographic, lifestyle and metabolic factors. We included 963 participants of whom 343 had NAFLD. Follow-up data was available in 737 participants. Incident NAFLD was 5% and regressed NAFLD was 30%. We identified five a posteriori dietary patterns (cumulative explained variation [R2] = 20%). The patterns were characterised as: vegetable and fish, red meat and alcohol, traditional, salty snacks and sauces, high fat dairy & refined grains pattern. Adherence to the traditional pattern (i.e. high intake of vegetable oils/stanols, margarines/butters, potatoes, whole grains and sweets/desserts) was associated with regression of NAFLD per SD increase in Z-score (0.40, 95% CI 0.15–1.00). Adherence to the three a priori patterns all showed regression of NAFLD, but only the WHO-score showed a distinct association (0.73, 95% CI 0.53–1.00). Hence, in this large elderly population, adherence to a plant-based, high-fibre and low-fat diet was related to regression of NAFLD
Prevalence of Drug Prescriptions and Potential Safety in Patients with Cirrhosis: A Retrospective Real-World Study
Introduction: Patients with cirrhosis are at risk for adverse drug reactions (ADRs) due to altered pharmacokinetics and pharmacodynamics. We aimed to determine the prevalence of drug prescriptions and the potential safety of these prescriptions in a real-world cohort of patients with cirrhosis. Methods: This was a retrospective cohort study based on linked real-world data from the Out-patient Pharmacy Database and the Hospitalisation Database of the PHARMO Database Network. Patients with a diagnosis of cirrhosis between January 1998 and December 2015 were included. Follow-up ended when the patient underwent a liver transplant, died, transferred out of the database, or on 31 December 2015. Prescription data were derived from a community pharmacy database and were compared with our previously developed safety recommendations for 209 drugs. Results: In total, 5618 patients were included and followed for a median of 3 years (interquartile range [IQR] 1–7). In the first year after the diagnosis, patients used a median of nine drugs (IQR 5–14), with proton pump inhibitors (prevalence 53.9%), aldosterone antagonists (43.6%), and sulfonamide diuretics (41.3%) being the most commonly used drug groups. Almost half (48.3%) of 102,927 prescript
Infections after auxiliary partial liver transplantation. Experiences in the first ten patients
Summary
In ten auxiliary partial liver transplant recipients selective bowel decontamination (SBD) was used to reduce infections due to gram-negative microorganisms and fungi. During SBD no gram-negative infections occurred. Candida peritonitis was observed in one patient. After discontinuation of SBD serious infections of gram-negative origin did occur and three fungal infections were seen. SBD seems to have a favourable effect in reducing infections by gram-negative microorganisms and fungi. Most striking was the number of enterococcal infections that occurred. Five out of ten patients developed enterococcal infections which in two cases contributed to a fatal outcome. These infections occurred after increase of the number of enterococci in faeces and concomitant positive cultures of bile, ascites or wound drains. This increase could be due to the use of SBD. Also, the kind of biliary anastomosis may play an important role in the relatively high incidence of enterococcal infections. In the postoperative period, recurrence of hepatitis B infection in the liver graft was observed in all patients with cirrhosis due to this virus. Problems caused by other viral infections or protozoal infections remained limited in these ten patients.
Zusammenfassung
Bei Patienten, bei denen eine auxiliäre, partielle Lebertransplantation durchgeführt wurde, wurde die selektive Darmdekontamination (SBD) eingesetzt, um Infektionen durch gramnegative Mikroorganismen und Pilze zu vermindern. Während SBD traten keine Infektionen durch gramnegative Bakterien auf. Bei einem Patienten wurde eine Candida-Peritonitis beobachtet. Nach Beendigung der SBD kam es zu schweren Infektionen durch gramnegative Bakterien, außerdem zu drei Pilzinfektionen. SBD hat offensichtlich einen günstigen Einfluß im Hinblick auf eine Verminderung von Infektionen durch gramnegative Erreger und Pilze. Bemerkenswert hoch war die Zahl der aufgetretenen Enterokokkeninfektionen. Bei fünf der zehn Patienten traten Enterokokkeninfektionen auf, die in zwei Fällen den letalen Ausgang mitbestimmten. Diesen Infektionen gingen ein Anstieg der Enterokokkenzahlen im Stuhl und zugleich positive Kulturen in Galle, Aszites und Wunddrainagen voraus. Es ist möglich, daß die SBD die Zunahme von Enterokokkeninfektionen begünstigte. Auch die Art der Gallengangsanastomose kann hierzu wesentlich beigetragen haben. Bei allen Patienten, bei denen die Zirrhose durch Hepatitis B Virus verursacht war, kam es postoperativ zu einem Rezidiv durch dieses Virus im Lebertransplantat. Probleme durch andere virale oder Protozoeninfektionen hielten sich bei diesen zehn Patienten in Grenzen