Rajakumar Akila, Ramanan Prijith, Sam Amal F, Devarajan Vidya, Sundaramoorthy Subha, Jothimani Dinesh, Rammohan Ashwin, Rela Mohamed
Department of Liver Intensive Care and Anaesthesia, Dr. Rela Institute and Medical Centre, Chennai, India.
Department of Transplant Anaesthesia and Critical Care, KIMS Hospital, Trivandrum, India.
J Clin Exp Hepatol. 2025 Jul-Aug;15(4):102508. doi: 10.1016/j.jceh.2025.102508. Epub 2025 Jan 25.
Pretransplant colonization with carbapenem-resistant Enterobacterales (CRE) is associated with poorer post-liver transplantation (LT) outcomes. We aimed to analyze the incidence and risk factors for CRE colonization in adult living-donor LT recipients from January 2019 to September 2022 and its impact on post-LT outcomes.
Relevant perioperative parameters including bacteremia within one month post LT were recorded. Rectal swabs were used for screening living-donor liver transplantation (LDLT) recipients for CRE colonization and divided into CRE-positive (CRE-POS) and CRE-negative (CRE-NEG) groups.
A total of 499 patients were included in study, and 163 (32.6%) were CRE colonized and received pre-emptive probiotics. Median Model for End-Stage Liver Disease score (odds ratio [OR]: 1.05 [95% confidence interval {CI}: 1.02-1.08]) and preoperative acute kidney injury (AKI) (OR: 1.95 [95% CI: 1.28-2.98]) were independently associated with preoperative CRE colonization. CRE-POS patients had higher intraoperative packed red blood cell transfusion (5 [3, 7] vs 3 [1, 6]) along with a higher incidence of post-LT bacteremia (19.6% vs 9.8%, = 0.004), chest infections (25.7% vs 13.6%, = 0.04), and longer intensive care unit stay (7 days [interquartile range {IQR}: 5-10] vs 6 days [IQR: 5-8] = 0.006). All other perioperative parameters including survival were comparable between the two groups. Bacteremia developed in 65 of 499 patients of which 61 (93.8%) were Enterobacterales. Preoperative CRE colonization (OR: 1.9 (95% CI: 1.08-3.7]), metabolic dysfunction-associated steatotic liver disease as an etiology of liver disease (OR: 2.0 [95% CI: 1.03-3.89]), preoperative AKI (OR: 2.4 [95% CI: 1.3-4.5]), and massive transfusion (OR: 2.0 (95% CI: 1.03-3.89]) were independently associated with postoperative Enterobacterales septicemia. Patients with bacteremia due to CRE had a higher 90-day mortality (38.4% vs 14.2% = 0.03). Postoperative CRE bacteremia was not associated with preoperative CRE colonization (42.8% CRE-POS vs 57.1% CRE-NEG).
One-third of patients presenting for LDLT are already colonized with CRE. Preoperative CRE colonization is a risk factor for postoperative Enterobacterales septicemia but not with CRE bacteremia. Post-liver transplant CRE bacteremia has a significantly higher mortality. Active pre-LT surveillance for CRE, along with the use of targeted pre-emptive therapy as probiotics and a low threshold for discretionary use of appropriate guideline-based antibiotic therapy based on CRE colonization status, in the event of sepsis, can help improve outcomes in this cohort of LDLT recipients.
耐碳青霉烯类肠杆菌科细菌（CRE）移植前定植与肝移植（LT）术后较差的预后相关。我们旨在分析2019年1月至2022年9月期间成人活体肝移植受者中CRE定植的发生率、危险因素及其对肝移植术后结局的影响。
记录包括肝移植术后1个月内菌血症在内的相关围手术期参数。采用直肠拭子对活体肝移植（LDLT）受者进行CRE定植筛查，并分为CRE阳性（CRE-POS）组和CRE阴性（CRE-NEG）组。
本研究共纳入499例患者，其中163例（32.6%）发生CRE定植并接受了预防性益生菌治疗。终末期肝病模型评分中位数（比值比[OR]：1.05[95%置信区间{CI}：1.02-1.08]）和术前急性肾损伤（AKI）（OR：1.95[95%CI：1.28-2.98]）与术前CRE定植独立相关。CRE-POS组患者术中浓缩红细胞输注量更高（5[3,7]对3[1,6]），肝移植术后菌血症发生率更高（19.6%对9.8%，P=0.004）、肺部感染发生率更高（25.7%对13.6%，P=0.04），重症监护病房住院时间更长（7天[四分位间距{IQR}：5-10]对6天[IQR：5-8]，P=0.006）。两组间所有其他围手术期参数包括生存率均具有可比性。499例患者中有65例发生菌血症，其中61例（93.8%）为肠杆菌科细菌。术前CRE定植（OR：1.9（95%CI：1.08-3.7]）、代谢功能障碍相关脂肪性肝病作为肝病病因（OR：2.0[95%CI：1.03-3.89]）、术前AKI（OR：2.4[95%CI：1.3-4.5]）和大量输血（OR：2.0[95%CI：1.03-3.89]）与术后肠杆菌科细菌败血症独立相关。CRE导致的菌血症患者90天死亡率更高（38.4%对14.2%，P=0.03）。术后CRE菌血症与术前CRE定植无关（CRE-POS组为42.8%，CRE-NEG组为57.1%）。
接受LDLT的患者中有三分之一已发生CRE定植。术前CRE定植是术后肠杆菌科细菌败血症的危险因素，但与CRE菌血症无关。肝移植术后CRE菌血症的死亡率显著更高。对CRE进行积极的肝移植前监测，同时使用针对性的预防性治疗作为益生菌，并在发生脓毒症时根据CRE定植状态酌情使用基于指南的适当抗生素治疗的阈值较低，有助于改善这组LDLT受者的结局。
