Acute respiratory failure in kidney transplant recipients: a multicenter study

International audienceINTRODUCTION: Data on pulmonary complications in renal transplant recipients are scarce. The aim of this study was to evaluate acute respiratory failure (ARF) in renal transplant recipients. METHODS: We conducted a retrospective observational study in nine transplant centers of consecutive kidney transplant recipients admitted to the intensive care unit (ICU) for ARF from 2000 to 2008. RESULTS: Of 6,819 kidney transplant recipients, 452 (6.6%) required ICU admission, including 200 admitted for ARF. Fifteen (7.5%) of these patients had combined kidney-pancreas transplantations. The most common causes of ARF were bacterial pneumonia (35.5%), cardiogenic pulmonary edema (24.5%) and extrapulmonary acute respiratory distress syndrome (ARDS) (15.5%). Pneumocystis pneumonia occurred in 11.5% of patients. Mechanical ventilation was used in 93 patients (46.5%), vasopressors were used in 82 patients (41%) and dialysis was administered in 104 patients (52%). Both the in-hospital and 90-day mortality rates were 22.5%. Among the 155 day 90 survivors, 115 patients (74.2%) were dialysis-free, including 75 patients (65.2%) who recovered prior renal function. Factors independently associated with in-hospital mortality were shock at admission (odds ratio (OR) 8.70, 95% confidence interval (95% CI) 3.25 to 23.29), opportunistic fungal infection (OR 7.08, 95% CI 2.32 to 21.60) and bacterial infection (OR 2.53, 95% CI 1.07 to 5.96). Five factors were independently associated with day 90 dialysis-free survival: renal Sequential Organ Failure Assessment (SOFA) score on day 1 (OR 0.68/SOFA point, 95% CI 0.52 to 0.88), bacterial infection (OR 0.43, 95% CI 0.21 to 0.90), three or four quadrants involved on chest X-ray (OR 0.44, 95% CI 0.21 to 0.91), time from hospital to ICU admission (OR 0.98/day, 95% CI 0.95 to 0.99) and oxygen flow at admission (OR 0.93/liter, 95% CI 0.86 to 0.99). CONCLUSIONS: In kidney transplant recipients, ARF is associated with high mortality and graft loss rates. Increased Pneumocystis and bacterial prophylaxis might improve these outcomes. Early ICU admission might prevent graft loss

Comparison of prognostic factors between bacteraemic and non-bacteraemic critically ill immunocompetent patients in community-acquired severe pneumococcal pneumonia: a STREPTOGENE sub-study.

BACKGROUND: The presence of bacteraemia in pneumococcal pneumonia in critically ill patients does not appear to be a strong independent prognostic factor in the existing literature. However, there may be a specific pattern of factors associated with mortality for ICU patients with bacteraemic pneumococcal community-acquired pneumonia (CAP). We aimed to compare the factors associated with mortality, according to the presence of bacteraemia or not on admission, for patients hospitalised in intensive care for severe pneumococcal CAP. METHODS: This was a post hoc analysis of data from the prospective, observational, multicentre STREPTOGENE study in immunocompetent Caucasian adults admitted to intensive care in France between 2008 and 2012 for pneumococcal CAP. Patients were divided into two groups based on initial blood culture (positive vs. negative) for Streptococcus pneumoniae. The primary outcome was hospital mortality, which was compared between the two groups using odds ratios according to predefined variables to search for a prognostic interaction present in bacterial patients but not non-bacteraemic patients. Potential differences in the distribution of serotypes between the two groups were assessed. The prognostic consequences of the presence or not of initial bi-antibiotic therapy were assessed, specifically in bacteraemic patients. RESULTS: Among 614 included patients, 274 had a blood culture positive for S. pneumoniae at admission and 340 did not. The baseline difference between the groups was more frequent leukopaenia (26% vs. 14%, p = 0.0002) and less frequent pre-hospital antibiotic therapy (10% vs. 16.3%, p = 0.024) for the bacteraemic patients. Hospital mortality was not significantly different between the two groups (p = 0.11). We did not observe any prognostic factors specific to the bacteraemic patient population, as the statistical comparison of the odds ratios, as an indication of the association between the predefined prognostic parameters and mortality, showed them to be similar for the two groups. Bacteraemic patients more often had invasive serotypes but less often serotypes associated with high case fatality rates (p = 0.003). The antibiotic regimens were similar for the two groups. There was no difference in mortality for patients in either group given a beta-lactam alone vs. a beta-lactam combined with a macrolide or fluoroquinolone. CONCLUSION: Bacteraemia had no influence on the mortality of immunocompetent Caucasian adults admitted to intensive care for severe pneumococcal CAP, regardless of the profile of the associated prognostic factors

Autoantibodies against type I IFNs in patients with critical influenza pneumonia

In an international cohort of 279 patients with hypoxemic influenza pneumonia, we identified 13 patients (4.6%) with autoantibodies neutralizing IFN-alpha and/or -omega, which were previously reported to underlie 15% cases of life-threatening COVID-19 pneumonia and one third of severe adverse reactions to live-attenuated yellow fever vaccine. Autoantibodies neutralizing type I interferons (IFNs) can underlie critical COVID-19 pneumonia and yellow fever vaccine disease. We report here on 13 patients harboring autoantibodies neutralizing IFN-alpha 2 alone (five patients) or with IFN-omega (eight patients) from a cohort of 279 patients (4.7%) aged 6-73 yr with critical influenza pneumonia. Nine and four patients had antibodies neutralizing high and low concentrations, respectively, of IFN-alpha 2, and six and two patients had antibodies neutralizing high and low concentrations, respectively, of IFN-omega. The patients' autoantibodies increased influenza A virus replication in both A549 cells and reconstituted human airway epithelia. The prevalence of these antibodies was significantly higher than that in the general population for patients 70 yr of age (3.1 vs. 4.4%, P = 0.68). The risk of critical influenza was highest in patients with antibodies neutralizing high concentrations of both IFN-alpha 2 and IFN-omega (OR = 11.7, P = 1.3 x 10(-5)), especially those <70 yr old (OR = 139.9, P = 3.1 x 10(-10)). We also identified 10 patients in additional influenza patient cohorts. Autoantibodies neutralizing type I IFNs account for similar to 5% of cases of life-threatening influenza pneumonia in patients <70 yr old

CONTRIBUTION AU DIAGNOSTIC MICROBIOLOGIQUE DES INFECTIONS RESPIRATOIRES ACQUISES EN REANIMATION (DOCTORAT (REANIMATION MEDICALE))

CLERMONT FD-BCIU-Santé (631132104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Biopsie chirurgicale pulmonaire en réanimation (impact diagnostique et thérapeutique)

La biopsie chirurgicale pulmonaire (BCP) est parfois proposée aux patients de réanimation développant un syndrome de détresse respiratoire aiguë de l'adulte (SDRA) persistant pour guider leur prise en charge thérapeutique. Le but de cette étude est d'analyser l'apport diagnostique, la contribution dans la prise en charge thérapeutique et la morbi-mortalité liée à la réalisation de BCP en réanimation au cours de l'insuffisance respiratoire aiguë d'origine indéterminée. Il s'agit d'une étude rétrospective conduite dans une unité de réanimation médicale de 9 lits sur une période de 7 ans. Les patients en insuffisance respiratoire avec anomalies parenchymateuses à la tomodensitométrie thoracique et sans diagnostic établi par le lavage broncho-alvéolaire chez lesquels une BCP avaient été réalisée étaient inclus. La BCP était dite "contributive" si elle apportait un diagnostic spécifique qui permettait la mise en place d'une statégie thérapeutique incluant la décision de limitation thérapeutique. L'étude a inclus 26 patients, (sex ratio = 2,6, âge moyen = 65 +/- 13 ans, SAPS II moyen à l'admission = 44 +/- 19) ; 80% étaient sous ventilation mécanique invasive, 50% présentaient des critères de SDRA, 73% bénéficiaient d'un traitement probabiliste. La BCP fut réalisée au lit du patient 3 fois. Elle a mis en évidence 25 diagnostics spécifiques chez 23 patients (88%), les plus fréquents étaient une fibrose pulmonaire (N=11), une pneumopathie infectieuse (N=6 dont une à Cytomégalovirus), une bronchiolite oblitérante organisée en pneumopathie (N=5). La BCP fut contributive chez 19 patients (73%), les principales conséquences thérapeutiques étaient l'introduction ou le maintien d'une corticothérapie (N=11), la limitation thérapeutique (N=5). Chez 4 patients un diagnostic spécifique fut établi mais la BCP n'a pas modifié la stratégie thérapeutique (adénovirose, protéinose alvéolaire, pneumopathie interstitielle des quamative, fibrose pulmonaire radique). La BCP s'est compliquée chez 17 patients (65%) ; 2 patients sont décédés dans les 24 heures après la BCP. En réanimation, la valeur diagnostique de la BCP et sa contribution à la prise en charge des patients sont élevées, même en dehors du SDRA. La BCP est cependant associée à une lourde morbi-mortalité.CLERMONT FD-BCIU-Santé (631132104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Acute respiratory distress syndrome related to Mycoplasma pneumoniae infection

M. pneumoniae respiratory infection is usually mild and self-limiting. We report a case of acute respiratory distress syndrome (ARDS) due to M. pneumoniae infection in a 60 years old woman. Quick diagnosis was established by multiplex PCR assay for detection of pneumonia-causing bacteria. Outcome was favorable. The factors accounting for the severity of pneumonia caused by M. pneumoniae are discussed

Risk of infections in intravascular catheters in situ for more than 10 days: a post hoc analysis of randomized controlled trials

Objectives: We aimed to describe the infectious risk during the dwell time for different catheter types. Furthermore, we wanted to identify risk factors for infections from catheters in place for >10 days.Methods: We performed a post hoc analysis using prospectively collected data from four randomized controlled trials. First, we evaluated the infectious risk after 10 days of analysing the significance of the interaction between dwell time and catheter type in a Cox model. Second, we investigated risk factors for infection in catheters in place for >10 days using multivariable marginal Cox models.Results: We included 15 036 intravascular catheters from 24 intensive care units. Infections occurred in 46 (0.7%) of 6298 arterial catheters (ACs), 62 (1.0%) of 6036 central venous catheters (CVCs) and 47 (1.7%) of 2702 short-term dialysis catheters (DCs). The interaction between dwell time beyond 10 days and catheter type was significant for CVCs (p 0.008) and DCs (p 10 days for further analyses. In the multivariable marginal Cox model, we observed an increased hazard ratio (HR) for infection for femoral CVC (HR, 6.33; 95% CI, 1.99-20.09), jugular CVC (HR, 2.82; 95% CI, 1.13-7.07), femoral DC (HR, 4.53; 95% CI, 1.54-13.33) and jugular DC (HR, 4.50; 95% CI, 1.42-14.21) compared with subclavian insertions.Discussion: We showed that the risk of catheter infection for CVCs and DCs increased 10 days after insertion, thus suggesting routine replacement for nonsubclavian catheters in situ for >10 days

Renal artery thrombosis induced by COVID-19

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