Hepatitis G virus infection in patients with hepatitis C virus infection undergoing liver transplantation

BACKGROUND & AIMS

Hepatitis G virus (HGV) is transmissible by blood transfusion, but its role in chronic liver disease is unknown. The aim of this study was to determine the prevalence of HGV infection in patients infected with hepatitis C virus (HCV) undergoing transplantation and evaluate the effects of HGV coinfection on the course of posttransplantation HCV infection.

METHODS

One hundred twenty-four patients infected with HCV undergoing liver transplantation were studied. Serum samples were tested for HCV and HGV RNA; HCV RNA was quantitated by branched DNA assay, and HCV genotype was determined.

RESULTS

The prevalence of pretransplantation and posttransplantation HGV infection was 24% and 28%, respectively. Pre-transplantation HGV infection was positively correlated with posttransplantation HGV infection (P < 0.001). Pretransplantation clinical features were not different in patients infected with HCV with and without HGV infection. Posttransplantation HCV RNA levels were not significantly different in patients with and without HGV coinfection, but HCV genotype 1b was more frequent in patients with HGV coinfection. There were no differences in the histological severity of posttransplantation liver disease, graft, and patient survival between patients with and without HGV infection.

CONCLUSIONS

Although HGV coinfection is frequent in patients with end-stage HCV disease undergoing liver transplantation, there is no association between the presence of HGV coinfection and the severity of liver disease post-transplantation, graft, or patient survival.

Prophylaxis in liver transplant recipients using a fixed dosing schedule of hepatitis B immunoglobulin

Prophylactic hepatitis B immunoglobulin (HBIg) reduces the risk of reinfection in hepatitis B surface antigen (HBsAg)-positive liver transplant recipients. In the medical center of this study, high-dose HBIg immunoprophylaxis is administered at a fixed dose of 10,000 IU monthly, and in this study, the long-term efficacy of this treatment regimen was examined. Of 52 HBsAg-positive liver transplant recipients, 24 were administered HBIg immunoprophylaxis, and 28 were administered no specific therapy; the 2-year recurrence rates (defined by the reappearance of HBsAg) were 19% and 76%, respectively. Fifty-four percent of the HBIg-treated patients were positive for HBeAg or hepatitis B virus (HBV) DNA (by hybridization assay) pretransplantation. In patients administered monthly HBIg, intrapatient and interpatient variability in trough antibody to HBsAg (anti-HBs) titer was significant, highlighting the potential difficulties of using anti-HBs titer to guide therapy. Trough anti-HBs titers were less in patients who became HBsAg positive than in patients who remained HBsAg-negative (490 vs. 1290 mIU/mL) (P = .0001), reflecting either the cause or effect of HBV reinfection. Of 9 patients who remained HBsAg-negative and who were administered monthly HBIg for at least 1 year, HBV DNA by polymerase chain reaction amplification was detectable in the sera of 67%, the lymphocytes of 50%, and the liver of 57%. In conclusion, a fixed monthly dose of HBIg reduces the recurrence of HBs antigenemia, even in patients with indices of active viral replication pretransplantation. The presence of residual virus in the majority of patients administered HBIg suggests that long-term HBIg administration may be necessary.

Severity of liver disease in liver transplantation recipients with hepatitis C virus infection: relationship to genotype and level of viremia

Infection with hepatitis C virus (HCV) genotype 1b has been reported to be associated with more severe posttransplantation liver disease than infection with non-1b genotypes. To address this issue, we evaluated the outcome in 124 patients who underwent liver transplantation for chronic HCV infection. The HCV genotype and/or serotype responsible for infection was determined by four different methods. HCV RNA was detected in serum samples by polymerase chain reaction (PCR) amplification, and quantified by branched DNA assay. Disease severity was expressed as a histological score (which included grading of portal inflammation, lobular activity, fibrosis, and cytopathic changes). Median duration of histological follow-up was 25 months (range 1-75 months). Genotype was assignable in 112 (92.5%) patients. Genotypes responsible for infection were as follows: 1a = 32.2%, 1b = 27.3%, 2a = 7.4%, 2b = 8.3%, 3a = 14%, and mixed infection (more than one subtype) = 3.3%. Level of viremia, alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, and total histological score were not significantly different in patients infected with type 1b compared with patients infected with other genotypes. While duration of histological follow-up was greater in patients infected with type lb versus other types (P = .02), by univariate and multivariate analysis neither HCV genotype (lb versus others), level of viremia nor duration of histological follow-up were associated with disease severity. Moreover, there was no significant difference in the actuarial graft survival in patients infected with type lb compared with that of patients infected with non-lb types (82% and 87% at 3 years, respectively). Reanalysis using HCV genotype 1 showed no association with disease severity, graft survival, and patient survival. We conclude that HCV genotype 1 and subtype 1b are not associated with disease severity or graft survival in liver transplantation recipients.

Functional analysis of grafts from living donors. Implications for the treatment of older recipients

OBJECTIVE

Living-related liver transplantation (LRLT) has established efficacy in children. In a larger recipient, LRLT requires the use of a small graft because of limits on the donor hepatectomy.

SUMMARY BACKGROUND DATA

The minimum graft weight required for successful transplantation has not been well established, although a characteristic pattern of graft dysfunction has been observed in our patients who receive small grafts. The authors present a clinicopathologic study of small liver grafts obtained from living donors.

METHODS

Clinical and histologic data were reviewed for 25 patients receiving LRLT. In five older recipients (small group), the graft represented 50% or less of expected liver weight, whereas in 20 others (large group), the graft represented at least 60% of expected liver weight. A retrospective analysis of graft function was conducted by analyzing clinical parameters and histology.

RESULTS

In the small group, 2 of 5 grafts (40%) were lost due to poor function, leading to one patient death (20% mortality), whereas in the large group, 2 of 20 grafts (10%) were lost due to arterial thrombosis without patient mortality. Early ischemic damage related to transplant was comparable with aspartate aminotransferase 203 +/- 23 (small group) and 290 +/- 120 (large group) at 24 hours (p = not significant). Early function was significantly decreased in the small group, with prothrombin time 18.2 +/- 2.2 seconds versus 14.8 +/- 1.6 seconds (large group) on day 3 (p = 0.034). All small group patients developed cholestasis with significantly increased total bilirubin levels at day 7 (16 +/- 5.2 mg% vs. 3.7 +/- 2.7 mg%; p = 0.021) and day 14 (12.0 +/- 7.4 vs. 1.8 +/- 0.7; p = 0.021) compared with the large group. Protocol biopsies in the small group revealed a diffuse ischemic pattern with cellular ballooning on day 7, which progressed to cholestasis in subsequent biopsies. Large group biopsies showed minimal ischemic changes. Three small group patients recovered with normal liver function by 12 weeks.

CONCLUSIONS

Clinical recovery after a small-for-size transplant is characterized by significant functional impairment associated with paradoxical histologic changes typical of ischemia. These changes apparently are due to graft injury, which can only be the result of small graft size. These findings have significant implications for the extension of LRLT to adults.

Failure patterns of cryopreserved vein grafts in liver transplantation

Reports of early success with cryopreserved saphenous veins (CSV) as arterial conduits led us to develop cryopreserved iliac veins (CIV) as interposition grafts for portal vein reconstruction in living-related liver transplantation (LRLT). Despite encouraging short-term results, retrospective analysis of long-term cryopreserved vein graft performance in LRLT at our institution has revealed a high rate of late graft failures. Between July 1992 and JUly 1994, interposition grafts (CIV for portal vein interposition n=4, CSV for portal vein interposition n=3, and CSV for hepatic artery interposition n=2) were utilized in 7 LRLT. (Two transplanted organs had both CIV and CSV grafts.) Recipients included 5 children and two small adults (median: 3.5 years, range: 0.5--59 years). Posttransplant follow-up in excess of 36 months revealed portal vein (PV) and hepatic artery (HA) complications of cryopreserved grafts in each patient. PV complications included aneurysm (n=4) diagnosed at 28, 24, 18, and 1.5 mo, stricture (n=1) diagnosed at 11 mo, and thrombosis (n=1) diagnosed at 18 mo posttransplantation. All portal vein complications have been managed without retransplantation, but one (PV thrombosis) necessitated surgical shunt therapy. Each CSV hepatic artery interposition graft has been complicated by thrombosis (diagnosed at 11 days and 24 mo posttransplant) necessitating retransplantation. Based on these observations, we have adopted alternative strategies for HA and PV reconstruction. At present, 11 LRLT have been performed without cryopreserved vein conduits over 17 mo with no vascular complications. While this study does not permit statistical analysis, these results discourage the use cryopreserved iliac veins for portal interposition and cryopreserved saphenous veins for arterial interposition in liver transplantation.

SCID mouse as a model for transplantation studies

Mice expressing the severe combined immunodeficiency trait (SCID) lack functional T and B lymphocytes and have been widely used for the study of B- cell development and for cancer and HIV research. The purpose of this study was to evaluate the SCID mouse as a potential model for T-cell maturation and transplantation studies. C3H/HEN SCID mice screened by fluorescence-activated cell sorting (FACS) and radial immunodiffusion assay (RID) were verified homozygous recessive if CD3-, CD22-, and serum (IgG) <5 mg/liter. C3H/HEN SCID mice pretreated with 250 R total-body gamma irradiation were reconstituted with 2.5 to 4 x 10(7) donor bone marrow cells derived from [syngeneic (syn): male wild-type C3H/HEN, allogeneic (allo): male BALB/c or C57BL/6) mice by intravenous injection. Four weeks post-transplant, engraftment was determined by FACS; repopulation of blood, thymus, and spleen; RID; and histologic evaluation. Immune function against donor, recipient, and third-party antigen was assayed in vitro by mixed lymphocyte response (MLR) and in vivo by full-thickness skin grafting. Greater than 90% of both syngeneic and allogeneic reconstitutions expressed CD3+, CD4+, CD8+, and CD22+ cells of donor origin in peripheral blood and spleen. FACS analyses of lymphocyte subpopulations in blood and spleen were not significantly different between reconstituted SCID mice and wild-type C3H/HEN or BALB/c controls, with engraftment stable for >4 months. No evidence of graft-versus-host disease was observed in stable, long-term (>4 months postreconstitution) chimeras. White blood cell, total thymocyte, and total splenocyte counts were significantly elevated (P < 0.05: ANOVA, Student's t) following reconstitution of homozygous SCID mice to levels found in wild-type controls. Serum (IgG) for reconstituted allo- and syn-SCID mice was consistently > 150 mg/liter (n = 22), with histologic lymphocyte engraftment of spleen, duodenum, and thymus. Histologic examination of lymphocyte engraftment in spleen, duodenum, and thymus was indistinguishable from normal controls in SCID mice after reconstitution. Prior to reconstitution, scant lymphoid cells were observed at these sites. Allo-SCID splenocyte response against third-party antigen was significantly elevated (P < 0.01: ANOVA, Student's t) when compared with donor and recipient antigen response with a proliferation index (PI) comparable to wild-type controls. Unreconstituted SCID mice were unresponsive. In vivo, allo-SCID mice demonstrated rejection of only third-party skin grafts between postoperative days 9 and 14 (controls: postoperative days 7 and 11). The SCID mouse model demonstrates in vitro and in vivo B- and T-cell immune function comparable to that of wild-type mice and provides a useful model for T-cell maturation and transplantation studies.

Liver transplantation improves survival of rats bearing hepatoma-3924A

There was interest in developing a rat model of hepatocellular carcinoma with tumor dissemination that would respond to liver transplantation. Thus, a model of intrahepatic hepatoma implantation with micrometastases was developed by modifying a previously reported technique in the ACI rat. The pattern of tumor growth permits surgical resection with liver transplantation if done early in the course of disease. In addition, this model results in a reproducible rate of pulmonary metastatic disease. The pulmonary metastatic rate (number of rats developing pulmonary metastases) was 45.5% (n = 11) 2 weeks following intrahepatic tumor implantation and rose to 100% at the fifth week (n = 7). To examine the long-term outcome of animals with tumor, 46 animals were followed until death or 100 days after tumor implantation. Of these animals, 67.4% died from tumor within 100 days, all with pulmonary metastases. Several of the animals that were followed long term had advanced liver tumor as well, with intraperitoneal spread and ascites. To evaluate the effect of orthotopic liver transplantation (OLTX) in this model, syngeneic OLTX was performed 16 days after intrahepatic tumor implantation (n = 11). OLTX improved the 100-day survival of the recipients from 32.6% (control group) to 80.0% (P < 0.05). None of the long-term survivors had evidence of tumor on postmortem examination. The mechanisms responsible for decreased metastases following syngeneic liver transplantation are being investigated. The influence of immunosuppression, more advanced stage of tumor at the time of OLTX, and chemotherapeutic agents on this survival benefit could be be investigated with this model.

Decreased mortality from technical failure improves results in pediatric liver transplantation

BACKGROUND

Until recently, pediatric liver transplantation was associated with a high rate of technical failure, which contributed substantially to the overall prognosis.

OBJECTIVE

To assess the impact of technical failure on outcome in pediatric liver transplantation.

DESIGN AND SETTING

We retrospectively analyzed 90 pediatric transplant procedures in a university medical center.

PATIENTS

Between February 1988 and December 1995, 80 children ( < 15 years old) received 90 transplants. Fifty-three percent (n = 42) were less than 2 years of age, 45% (n = 36) had cholestatic liver disease, 26% (n = 21) had metabolic errors, and 11% (n = 9) had fulminant hepatitis.

INTERVENTION

Patients underwent grafting using previously reported techniques, including cadaveric whole (61% [n = 55]), reduced-size (17% [n = 15]), and living related (22% [n = 20]) liver transplantation.

MAIN OUTCOME MEASURES

Patient and graft survival and selected surgical complications. Outcomes were compared before (group 1) and after (group 2) the introduction of living related transplantation in July 1992.

RESULTS

In group 1, 32 patients received 36 grafts (4 retransplants [13%]), and in group 2, 48 patients received 54 grafts (6 retransplants [13%]). Six- and 12-month patient survival rates were 78% (n = 25) and 75% (n = 24), respectively, for group 1 and 98% (n = 47) and 94% (n = 45) for group 2. Of the 9 deaths in group 1, 6 occurred early as a consequence of surgical complications, while in group 2, all 5 deaths that occurred were caused by the consequences of immunosuppression (lymphoproliferative disease, n = 2; late infections, n = 3).

CONCLUSIONS

These results suggest that mortality caused by surgical complications has been reduced by improvement in management in recent years. Living related grafts have supplemented the graft supply and may be associated with the improved overall results. Despite these advances, children receiving transplants continue to experience the consequences of imperfect immunosuppression.

Hepatotoxins and liver transplantation decrease pulmonary metastases in rats with hepatoma

Results following liver transplantation for hepatocellular carcinoma have been dismal, attributed largely to recurrent disease locally or at distance sites. Undetected micrometastases or tumor that embolizes at the time of liver transplant from manipulation of the liver may account for these recurrences. A model and treatment protocol were developed to address this clinical problem. The protocol is modeled on the concept of bone marrow transplantation for leukemia. Hepatotoxins that are lethal to both normal hepatocytes and hepatoma cells are administered followed by liver transplantation to "rescue" the failing liver. The feasibility of this protocol was examined in a rat model. Male Buffalo rats were injected with 1 million Morris hepatoma MH-7777 cells intravenously at Day 0 as a model for micrometastatic disease. Three treatment groups were established. Group 1 received no treatment. Group 2 received 5% dextrose in water (D5W) followed by a syngeneic orthotopic liver transplant (OLTX). Group 3 received the hepatotoxin pyrazofuin (10 mg/kg) followed by OLTX. Animals were followed to Day 35, at which time they were sacrificed and examined for evidence of pulmonary metastases and quantitation of nodules with India ink insufflation. There was a significant decrease in the number with pulmonary nodules as well as the number of animals with pulmonary metastatic disease in the pyrazofurin-treated group compared with groups 1 and 2 (4.8 +/- 4.0 nodules/animal vs 45.2 +/- 11.2 nodules/animal--no treatment and 60.8 +/- 21.4 nodules animal--D5W/OLTX group) These data indicate that this model is reliable for examining metastatic hepatoma and that pyrazofurin is effective in preventing hematogenous micrometastases of hepatoma cells. Other hepatotoxins and the effect of allogeneic transplantation and immunosuppression could be examined in this model.

Fifty-percent partial liver transplantation in the rat

Reduced-size liver transplantation in the rat has been useful in the study of hepatic regeneration. We describe a modified technique for partial liver transplantation in the rat using a 50% reduced-size graft. Male Lewis rats (RT1(1)), weighing 250 to 280 g, were used as donors and recipients. The harvested donor liver was placed in 4 degrees C cold saline and graft reduction was performed ex situ by resecting the left lateral lobe, the left portion of the median lobe, and the caudate lobes. The reduced graft was composed of the right portion of the median lobe and the right lobe, weighing 5.33 +/- O.58 g (53.6 +/- 2.2% of the donor liver before reduction, n=7). The recipient 1-week survival rate was 85.7%. The use of reduced livers permits the study of host responses to a deficient graft. This technique provides another choice of liver volume to be implanted and allows the study of regeneration of small-for-size livers more precisely in combination with more extensive graft reduction.

Interferon alfa for recurrent hepatitis B infection after liver transplantation

Reinfection with hepatitis B virus (HBV) after liver transplantation is nearly universal in patients not receiving immunoprophylaxis. Because reinfection reduces graft and patient survival, treatment of recurrent infection is important. Interferon alfa (IFN-alpha) is an effective therapy for chronic hepatitis B infection in immunocompetent patients, but its efficacy in transplant recipients has not been established. Fourteen liver transplant recipients with recurrent hepatitis B infection (hepatitis B surface antigen [HBsAg] positive in serum; hepatitis on biopsy) were treated with IFN-alpha 2b (Intron A; Schering Inc, Kenilworth, NJ) 3 million units (MU) three times weekly for 23.5 weeks (median, range 4 to 41). The primary endpoint was loss of HBV DNA by the b-DNA assay (a virological response). Before treatment, all patients were HBV DNA positive and 9 were hepatitis B e antigen (HBeAg) positive. Pretreatment HBV DNA levels were 6,760 MEq/mL (median, range 2.0 to 11,888 MEq/mL). HBV DNA levels decreased significantly with treatment (P = .03). Four patients had a complete and sustained virological response. Virological responses did not consistently correlate with biochemical response because of concomitant hepatitis C. Two patients had a serological response; 1 lost HBeAg, another lost HBeAg and HBsAg. All responders remained HBV DNA negative in follow-up (mean, 32 months; range, 23 to 40), but 1 patient required retransplantation for cirrhosis. Of the nonresponders, 1 patient required retransplantation for chronic rejection, 3 required retransplantation for recurrent hepatitis B, 3 died with recurrent hepatitis B, and 3 are alive and remain HBV DNA positive. IFN-alpha can induce a sustained serological (14%) and virological response (29%) in liver transplant recipients with recurrent HBV infection.

Incidence and significance of Aspergillus cultures following liver and kidney transplantation

Aspergillus infection is a rare but devastating complication following solid organ transplantation, with mortality rates that approach 100%. Aspergillus species (sp) are also ubiquitous in our environment and may contaminate culture plates. To determine the significance of positive Aspergillus cultures, we analyzed all positive cultures from the liver and kidney transplant services at our center for the treatments used and clinical outcomes. Aspergillus sp. were cultured from 4.5% of liver and 2.2% of kidney transplant recipients. A. fumigatus was the most common isolate, followed by A. niger and A. flavus. The lung was the most common site of positive cultures. Body fluids (ascites, pleural fluid) were common sources of positive cultures but were never associated with clinical disease. Positive brain biopsies occurred in 10% of patients. Analysis of risk factors for significant infection revealed that cultures with >2 colonies or more than one site of infection were predictive of significant infection and portended a poor prognosis even with aggressive therapy. Two or fewer colonies from a single site likely represented contamination and may be followed with repeat cultures. The high mortality rate associated with Aspergillus sp. infections in transplant recipients highlights the need for better anti-fungal prophylaxis and treatment.

The use of the T tube after orthotopic liver transplantation

An end-to-end choledochocholedochostomy (CD) over a T tube or a Roux-en-Y choledochojejunostomy (CDJ) have been the standard method of biliary reconstruction following orthotopic liver transplantation (OLTx). The objective of this study was to assess whether or not use of the T tube leads to increased biliary tract complications. Biliary tract complications were categorized as bile leak, stenosis, or obstruction that required therapeutic intervention. OLTx was performed in 161 patients over an 18-month period. Fifty-one patients were excluded from the study leaving a total of 110 patients for evaluation. Fifty-nine had their bile duct reconstructed over a T tube (CD T tube, group I) while the remaining 51 patients underwent bile duct reconstruction without a T tube (CD, group II). No difference was noted between groups I and II in their survival rate, rate of conversion to Roux-en-Y CDJ, or biliary complication rates. Our results indicate that CD (i.e., without a T tube) is both a safe and effective technique to reconstruct the biliary tract following hepatic transplantation. Routine use of a T tube with a CD anastomosis is unnecessary in most liver transplant patients. In addition, the omission of a T tube has reduced the number of radiological procedures performed at our center.

Cryoglobulinemia presenting after liver transplantation

Essential mixed cryoglobulinemia is frequently associated with chronic hepatitis C. Three patients undergoing transplantation for end-stage chronic hepatitis C in whom cryoglobulinemia with vasculitis developed after transplantation are described. Hepatitis C virus (HCV) infection was confirmed in the 3 patients by the presence of HCV RNA detected by polymerase chain reaction. The time interval between transplantation and the first expression of vasculitis was 1, 5, and 17 months. Type II cryoglobulins were detected in the sera of all 3 patients. All patients developed cutaneous vasculitis, requiring digital amputation in 1 case. Two patients developed membranoproliferative glomerulonephritis. Plasmapheresis and the addition of cyclophosphamide led to an improvement in the renal disease in 1 case, whereas no treatment was able to reverse the renal failure in the other case. One patient developed an autoimmune hemolytic anemia 4 years after transplantation. One patient died of multiorgan failure 5 months after transplantation. We propose that HCV-associated cryoglobulinemia could become clinically significant only after orthotopic liver transplantation, possibly due in part to posttransplant increase in viremia as reflected by HCV RNA levels. These results confirm previous observations suggesting that HCV infection is important etiologically in the pathogenesis of cryoglobulinemia.

Detection of hepatitis C after liver transplantation. Four serologic tests compared

To determine the best method for detecting HCV infection in immunosuppressed patients, stored frozen serum from 101 liver transplant recipients was tested for hepatitis C virus. Each sample was tested by four assays. HCV RNA was detected by both polymerase chain reaction (PCR) and branched DNA signal amplification. Antibody to HCV was determined using second-generation enzyme-linked immunoassay (EIA) and recombinant immunoblot assay. Forty one transplant recipients met the working definition for true positives of HCV infection. Of these "true positives," 98% were positive by HCV RNA PCR assay, 88% by b-DNA signal amplification assay, 88% by anti-HCV EIA, and 63% demonstrated two or more reactive bands on recombinant immunoblot. Five of 57 (9%) HCV-antibody negative recipients had HCV RNA detected by both methods. Of 44 HCV enzyme-linked immunoassay (EIA) repeatedly reactive samples, the recombinant immunoblot was negative in 2 and indeterminate in 13. HCV RNA was present in 9 of 13 recombinant immunoblot indeterminate sera. Nine EIA repeatedly reactive sera were negative by both tests for HCV RNA. In liver transplant recipients, HCV infection is best determined by measurement of HCV RNA. Antibody formation may be delayed or suppressed in a minority of patients despite > 10(9) equivalents/L (> 10(6)/mL) of HCV RNA in serum. Recombinant immunoblots with a single reactive band pattern often indicate HCV infection in immunosuppressed patients.

Increased efficacy of CSA following rearterialization in the rat OLTX model

Many investigators presently use a rat orthotopic liver transplant (OLTX) model without rearterialization of the graft. Rearterialization has been demonstrated to have a variable effect on the rejection response in various strain combinations. However, there are little data on the effects in a model with immunosuppression. The influence of rearterialization on the efficacy of cyclosporine (CSA) in such a model was examined, with the hypothesis that rearterialization may alter the rejection response and efficacy of cyclosporine. OLTX was performed between adult male D Agouti rats and Lewis rats. Rearterialization was performed between the recipient and donor celiac axis, and CSA was delivered at 1 mg/kg/day by continuous infusion for 14 days postoperatively. Treatment groups consisted of no rearterialization/no CSA, rearterialization/no CSA, no rearterialization/CSA, and rearterialization/CSA. Survival time and histology of liver grafts were measured. Rearterialization itself did not prolong survival in this strain combination (median survival no rearterialization/no CSA is 11 days versus median survival rearterialization/no CSA is 10 days). The addition of CSA at this dose without rearterialization also did not prolong survival (median survival no rearterialization/CSA is 15.5 days). The combination of CSA with rearterialization did prolong survival significantly (median survival rearterialization/CSA is 22 days; P < 0.05 versus the other three groups). The mechanism of this increased efficacy is unknown, but may involve altered MHC antigen expression, altered metabolism of CSA, decreased toxicity of CSA, or decreased nonspecific inflammation in the rearterialized grafts.

Liver transplantation for sclerosing cholangitis

The clinical course of 37 patients who underwent 46 liver transplantations for primary (n = 33) and secondary (n = 4) sclerosing cholangitis was reviewed. The median follow-up was 37 months. The patient and graft survivals for patients with primary sclerosing cholangitis at 1, 2, and 5 years were 96.9%, 91.6%, 87.9%, and 83.1%, 74.2%, 65.2%, respectively. In the patients with primary sclerosing cholangitis (PSC), prior surgery except for simple cholecystectomy was associated with significantly greater operative time and blood loss. No cholangiocarcinoma was identified at the time of transplantation. Human leukocyte antigen typing for PSC patients was heavily weighed toward B8 (58.8%) compared with control (11.8%). Sixty-two percent of patients with PSC also had inflammatory bowel disease. Moderate or severe rejection requiring OKT3, "rescue therapy" with FK506, or retransplantation was relatively higher in patients with inflammatory bowel disease (70%) versus patients without inflammatory bowel disease (36.4%) and a matched control group (37.5%). Progressive inflammatory bowel disease was seen in 6 of 19 patients, with 3 developing cancer and a dysplasia. Two patients in the entire group died of sepsis and 3 of colon cancer (2 recurrent and 1 primary). These data demonstrate that excellent survival results can be achieved in this group of patients. Rejection is frequent and often severe and steroid refractory. Colon cancer represents the most frequent cause of death in PSC patients after liver transplantation and demands constant attention.

Posttransplantation lymphoproliferative disorder in patients under primary tacrolimus (FK 506) immunosuppression

Posttransplantation lymphoproliferative disorder (PTLD) is a well-described complication of the systemic immunosuppression required for successful organ transplantation. Lesions of PTLD often occur in the region of the head and neck and require otolaryngologic evaluations. Although the majority of reported cases of PTLD are associated with cyclosporine immunosuppression, recently, PTLD has been described in patients treated solely with the newer systemic immunosuppressive agent tacrolimus (FK 506). As an introduction to tacrolimus and to PTLD as one of its complications, a case of PTLD presenting as airway obstruction in a child treated solely with tacrolimus immunosuppression is described. In addition, a review of tacrolimus and PTLD in patients under tacrolimus immunosuppression is presented to familiarize the otolaryngologist with this important new immunosuppressive agent and a potential complication of its use.

Influence of donor age on graft survival after liver transplantation--United Network for Organ Sharing Registry

The waiting list for liver transplantation has more than doubled between 1988 and 1992, yet the number of liver transplantations during the same period increased by only 79%. This discrepancy is due to the limited availability of donors. The modest increase in donor pool is caused entirely by donors > or = 40 years of age, a trend likely to continue. To determine the impact of increasing donor age on the outcome of liver transplantation, we analyzed 6-month graft survival in 7,988 adults who received first liver graft between October 1987 and September 1992, and were observed through the United Network for Organ Sharing Scientific Liver Transplant Registry. Graft survival was measured by death and/or retransplantation, donor age by decades. The independent effect of donor age on graft survival was estimated by Cox regression analysis controlling for the possible confounding of donor, recipient, and institutional characteristics. Between 1987 and 1992, the percentage of donors over 50 years increased from 2.1% to 17.5% resulting in change of median donor age from 23 to 31 years. For donor age > or = 50, graft failure rate was 50% higher than with donor age less than 20 years (excess for mortality was 25% and for retransplantation 94%). Adjustment for characteristics associated to donor age or outcome did not eliminate the excess risk found with increasing donor age. Despite these adversities, graft failure rate in recipients from oldest donors (27.2%) in 1992 was nearly equivalent to recipients from the youngest donors (26.9%) in 1987 to 1988. Although increasing donor age has an adverse effect on 6-month graft survival, improvement in transplantation technology and patient care over time have more than compensated for poorer graft function associated with the simultaneous rise in median donor age.

Total vascular exclusion for major hepatectomy in patients with abnormal liver parenchyma

BACKGROUND

Total vascular exclusion (TVE) of the liver has been used to increase the safety of hepatectomy and the feasibility of difficult resections. Until recently, however, concern about the detrimental effect of warm ischemia has limited the use of this technique to patients with normal liver parenchyma.

OBJECTIVE

To compare surgical outcomes of 12 patients with abnormal livers (group 1) with outcomes of 48 patients with normal parenchyma (group 2), based on the hypothesis that uncontrolled bleeding may be more detrimental than planned hepatic ischemia.

DESIGN AND SETTING

Retrospective analysis of 60 consecutive patients undergoing liver resection under TVE in a university medical center.

PATIENTS

All 10 patients with cirrhosis had albumin levels of 30 g/L or higher and normal prothrombin times preoperatively; none had ascites. Two patients with cholestasis (one with cholangiocarcinoma and one with hepatocellular carcinoma) are included in group 1.

INTERVENTION

All 12 group 1 patients and 44 of 48 group 2 patients underwent total or extended lobectomy, with TVE induced by clamping the hilum and the vena cava above and below the liver during parenchyma division.

MAIN OUTCOME MEASURES

Hospital survival and selected surgical and laboratory parameters.

RESULTS

Operative times, ischemic times, and blood loss (1975 +/- 1601 vs 1255 +/- 1291 mL) (P = .10) were comparable in both groups. Sixty-day operative mortality was zero in both groups. There was an increased rate of complications in group 1 (44% vs 17% [P = 0.06]). Transient abnormal liver function was observed in both groups. However, significant delay in restoration of normal function was observed in group 1 with respect to bilirubin levels and prothrombin time.

CONCLUSIONS

Patients with cirrhosis can undergo successful resection using TVE. This conclusion must be limited to cirrhotic patients with good liver function. The trend toward increased blood loss may reflect greater difficulties in establishing hemostasis after reperfusion in group 1. While this group appears to have a higher risk for hepatic insufficiency, successful outcomes were achieved in all cases. Prospective study will be required to define the parameters for use of TVE in cirrhosis.

Liver transplantation for sclerosing cholangitis

The clinical course of 37 patients who underwent 46 liver transplantations for primary (n = 33) and secondary (n = 4) sclerosing cholangitis was reviewed. The median follow-up was 37 months. The patient and graft survivals for patients with primary sclerosing cholangitis at 1, 2, and 5 years were 96.9%, 91.6%, 87.9%, and 83.1%, 74.2%, 65.2%, respectively. In the patients with primary sclerosing cholangitis (PSC), prior surgery except for simple cholecystectomy was associated with significantly greater operative time and blood loss. No cholangiocarcinoma was identified at the time of transplantation. Human leukocyte antigen typing for PSC patients was heavily weighed toward B8 (58.8%) compared with control (11.8%). Sixty-two percent of patients with PSC also had inflammatory bowel disease. Moderate or severe rejection requiring OKT3, "rescue therapy" with FK506, or retransplantation was relatively higher in patients with inflammatory bowel disease (70%) versus patients without inflammatory bowel disease (36.4%) and a matched control group (37.5%). Progressive inflammatory bowel disease was seen in 6 of 19 patients, with 3 developing cancer and a dysplasia. Two patients in the entire group died of sepsis and 3 of colon cancer (2 recurrent and 1 primary). These data demonstrate that excellent survival results can be achieved in this group of patients. Rejection is frequent and often severe and steroid refractory. Colon cancer represents the most frequent cause of death in PSC patients after liver transplantation and demands constant attention.

Liver transplantation for hepatocellular carcinoma: results with preoperative chemoembolization

At the University of California, San Francisco, 17 patients who met the following criteria-hepatic tumor unresectable because of location or inadequate liver reserve, no metastases, HBsAg negative, no tumor larger than 5 cm in diameter, and no more than three tumors--were enrolled prospectively in a protocol employing preoperative chemoembolization to assess whether orthotopic liver transplantation (OLT) could cure a majority of highly selected patients with hepatocellular carcinoma (HCC). Thirteen patients had biopsy-proven HCC, 2 had the fibrolamellar variant, and 2 had radiological findings of HCC but no biopsy confirmation. Fourteen had underlying liver disease. All arteriographically apparent lesions were chemoembolized using a mixture including Gelfoam powder, doxorubicin, mitomycin-c, and cisplatin. Eight patients with poor hepatic reserve were chemoembolized when a donor organ became available, whereas 9 patients were chemoembolized and then placed on the waiting list. The only complication of chemoembolization was a gangrenous gallbladder in 1 patient. Thirteen patients underwent liver transplantation (2 patients without prior histological confirmation of carcinoma had no identifiable tumor at OLT); 3 patients developed metastases between the time of enrollment and donor organ availability and subsequently died; and 1 patient underwent a trisegmentectomy. Ten of the 11 patients with biopsy-proven HCC who underwent transplantation remain free of recurrent cancer at a median of 40 months; 1 patient died at 6 months of lymphoproliferative disease with no cancer found at autopsy. Although the role of chemoembolization is uncertain, these data show that the majority of carefully selected patients with HCC may achieve long-term survival with OLT.

Time course of cyclosporine and ist motabolites in blood, liver and spleen of naive Lewis rats: comparison with preliminary data obtained in transplanted animals

the time course of intravenously administered cyclosporine (1 mg kg-1) and its metabolite AM1, AM9, and AM1c were examined in the blood, liver, and spleen of naive Lewis rats. Cyclosporine concentration versus time data for all three tissues were qualitatively similar, following a biexponential model C = Ae-gamma 1t + Be-gamma 2t with maximum cyclosporine concentrations reached at 1 h. Whole-blood cyclosporine clearance, terminal half-life, mean residence time, steady state volume of distribution, and hepatic extraction ratio (calculated from blood data) were similar to previously reported results. Cyclosporine in the liver showed the largest area under the concentration-time curve, mean residence time, and disposition and terminal half-lives. Spleen cyclosporine mean residence time and and terminal half-life were not significantly different from blood parameters. Metabolites AM1, AM9, and AM1c showed almost parallel time courses in all three tissues. The hydroxylated derivative AM9 was the major metabolite found in all tissues, with twofold greater levels in the liver compared to the blood and spleen. Slightly less AM1 was found in the liver relative to blood and spleen, where it was present in equal amounts. AM1c levels in the liver were not different from those in the spleen and were greater than observed for blood. The results obtained above were reflected in preliminary studies using liver transplanted rats treated with multiple doses of cyclosporine. Both blood and liver biopsy levels of CyA, AM1, and AM9 post-transplant showed twofold to fourfold decreases from day 3 ( samples taken 4 h post-CyA-dose) and concentrations were not significantly different from similarly sampled naive controls. More importantly, the metabolite/CyA ratios did not vary significantly between liver and blood in the two groups. For naive rats, and liver transplanted animals not undergoing rejection, changes in blood cyclosporine levels seem to predict variations in tissue concentrations.

Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients

BACKGROUND/AIMS

Transjugular intrahepatic portosystemic shunt (TIPS) is a new therapy for variceal bleeding. Immediate technical and short-term clinical results have been reported. This study was undertaken to evaluate mid-term outcome after TIPS in patients who successfully underwent the procedure for variceal bleeding.

METHODS

Ninety patients were followed up prospectively by clinical examination and radiological shunt evaluation including Doppler sonography and transjugular portal venography.

RESULTS

The average follow-up in surviving patients was 2.2 years. The cumulative survival rate was 60% at 1 year and 51% at 2 years. The rate of cumulative rebleeding was 26% at 1 year and 32% at 2 years. A shunt abnormality was noted in all rebleeding patients. Rebleeding was successfully controlled in all but 1 of the patients who underwent shunt revision. Cumulative detection of stenosis or occlusion was 31% at 1 year and 47% at 2 years. Thirty-eight percent of shunt abnormalities were detected by routine surveillance. Percutaneous shunt revision was attempted in 22 patients and was successful in 21 (95%).

CONCLUSIONS

Although mid-term primary patency is limited in many patients by the development of a shunt stenosis or occlusion, shunt function can be maintained in most patients by careful surveillance and periodic percutaneous intervention.

FK506 (tacrolimus) compared with cyclosporine for primary immunosuppression after pediatric liver transplantation. Results from the U.S. Multicenter Trial

We report on the efficacy and safety of FK506 (tacrolimus) compared with a cyclosporine (CsA)-based immunosuppressive regimen after 1 year of treatment in pediatric liver allograft recipients (< 12 years) participating in a multicenter U.S. randomized trial. Patients received either FK506 or CsA as primary immunosuppression following a first ABO-compatible liver transplant. Intravenous FK506 was initiated at 0.1 mg/kg per day, followed by oral FK506 beginning at 0.3 mg/kg per day. The dose was adjusted to maintain plasma trough levels of 0.5-2.0 ng/ml. The CsA group was treated according to each center's usual protocol. Both groups received the same initial doses of corticosteroids. All rejection episodes were biopsy-proven and a standardized algorithm was adopted for the treatment of rejection. Thirty patients were randomized to the FK506 group and 20 to the CsA group. After twelve months of follow-up 20 patients remained in the FK506 group and 13 in the CsA group. Patient survivals were 80% and graft survival 70% in the FK506 group compared with 81% and 71% respectively, in the CsA group. 48% of the FK506 group remained rejection-free compared with 21% of the CsA group, and 79% of FK506-treated patients did not require OKT3 compared with 68% of CsA treated patients. The cumulative corticosteroid dose was less at each time point throughout the first year in the FK506 group. The incidence of serious and minor infections was similar in both groups. Nephrotoxicity, neurotoxicity, and gastrointestinal disturbances were the major toxicities reported. Differences did not reach statistical significance between the two groups although major neurologic events, diarrhea and dyspepsia were more often reported in the FK506 group. There was no difference in mean serum creatinine at 12 months between the two groups. There was a tendency toward lower mean serum cholesterol in the FK506 group. There was no hirsuitism in the FK506 group compared with a 30% incidence in the CsA group. In conclusion, compared with CsA, there is a trend toward less rejection in FK506-treated pediatric allograft recipients, while both drugs have a similar spectrum of side effects.

The risk of transmission of hepatitis B from HBsAg(-), HBcAb(+), HBIgM(-) organ donors

Liver allografts from HBcAb(+), IgM(-), HBsAg(-) donors can transmit HBV to uninfected recipients. We currently no longer accept these livers for transplantation while continuing to accept the kidneys. The purpose of this study is to determine the risk of donor-transmitted HBV infections from HBcAb(+), HBIgM(-), HBsAg(-) organ donors and determine if the risk of donor-transmitted HBV infections and their severity is dependent on the organ being transplanted. This study consists of a retrospective review of the posttransplant course of recipients of HBcAb(+), HBIgM(-), HBsAg(-) donors accepted at UCSF from 6/85 to 12/93. Transmitted HBV infection was defined as one in which the recipient changed from HBsAg(-) prior to transplantation to HBsAg(+) posttransplant, with no other source. There were 25 of 1190 donors who were HBcAb(+), HBIgM(-), HBsAg(-); 1/42 kidney, 3/6 liver, and 0/7 heart HBsAg(-) transplant recipients of organs from these donors became HBsAg(+) after transplantation. This difference in infection rate (liver vs. kidney and heart) is statistically significant. The clinical course of the liver recipients was also more severe. All of the patients who became infected were HBsAb(-) and HBcAb(-) prior to transplant. We conclude that (1) HBV can be transmitted from HBcAb(+), HBIgM(-), HBsAg(-) organ donors, (2) the rate of transmission is highest and severity of infection is worst in the liver recipients; and (3) we will continue to transplant kidneys from these donors, preferably into immunized recipients.

Liver transplantation for hepatitis C virus-related cirrhosis

Since the introduction of techniques to reliably identify antibody to the hepatitis C virus and quantitation of hepatitis C virus, there has been an increasing interest in the behavior of chronic hepatitis C infection with liver transplantation. Ninety-seven patients with chronic active hepatitis C and fifty-nine patients with cryptogenic cirrhosis underwent 100 and 62 liver transplantation procedures, respectively, at a single institution. This represents 35% of the total liver transplantations performed during this time period. Twenty-three percent of transplants were performed in patients with evidence of chronic active hepatitis C. Patients and graft survival were excellent in both groups. One-, 2- and 3-yr patient survival rates for chronic active hepatitis C and cryptogenic cirrhosis were 94%, 89% and 87% and 84%, 84% and 73%, respectively. Hepatitis C can frequently be identified after transplantation. More than 95% of patients show persistence of antibody to the hepatitis C virus. Forty-one of 95 patients (surviving > 1 mo) showed recurrent hepatitis (initially seen 3 to 20 mo after transplantation), and 12 progressed to chronic active hepatitis. In 16 patients of the cryptogenic group in whom hepatitis developed, 11 were associated with de novo hepatitis C infection. Seven of these 11 cases went on to a chronic state. Of 11 deaths after transplant in the hepatitis C group, 2 were directly related to recurrent disease. There were 15 deaths in the cryptogenic group, 2 related to de novo hepatitis C. Patients were not serotyped. Interferon therapy was attempted in a small number of patients with disease, with inconclusive results.(ABSTRACT TRUNCATED AT 250 WORDS)

Predicting recidivism after orthotopic liver transplantation for alcoholic liver disease

With appropriate selection criteria, patients with end-stage alcoholic liver disease who undergo orthotopic liver transplantation have similar graft and patient survivals as patients undergoing transplantation for other causes. However, because of the possibility of recidivism after orthotopic liver transplantation there is still reluctance to transplant alcoholic patients. This study examined the association between pretransplant psychosocial variables and the risk of recidivism after orthotopic liver transplantation. At our institution, 43 patients received orthotopic liver transplantation for the referral diagnosis of alcoholic liver disease from February 1, 1988 to May 1, 1991. This represented 17% of all first transplants (43 of 257) performed during this period. Patients were interviewed before orthotopic liver transplantation by a single psychiatrist and responses to a defined set of questions were entered into a clinical database. All 43 patients diagnosed with alcoholic liver disease and a comparison group of patients transplanted for diagnoses other than alcoholic liver disease received a postoperative questionnaire regarding past and present alcohol use. Patients enrolled in the study all had at least 7 mo of follow-up, with the median follow-up being 21 mo. Eighty-six percent of alcoholic liver disease patients (37 of 43) and 86% of patients in the comparison group (37 of 43) of ALD patients agreed to participate in the study. Nineteen percent of alcoholic liver disease patients (7 of 37) and 24% of patients in the comparison group (9 of 37) admitted to having used alcohol after orthotopic liver transplantation, wtih 8% (3 of 37) and 11% (4 of 37) currently using alcohol, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Predicting recidivism after orthotopic liver transplantation for alcoholic liver disease

With appropriate selection criteria, patients with end-stage alcoholic liver disease who undergo orthotopic liver transplantation have similar graft and patient survivals as patients undergoing transplantation for other causes. However, because of the possibility of recidivism after orthotopic liver transplantation there is still reluctance to transplant alcoholic patients. This study examined the association between pretransplant psychosocial variables and the risk of recidivism after orthotopic liver transplantation. At our institution, 43 patients received orthotopic liver transplantation for the referral diagnosis of alcoholic liver disease from February 1, 1988 to May 1, 1991. This represented 17% of all first transplants (43 of 257) performed during this period. Patients were interviewed before orthotopic liver transplantation by a single psychiatrist and responses to a defined set of questions were entered into a clinical database. All 43 patients diagnosed with alcoholic liver disease and a comparison group of patients transplanted for diagnoses other than alcoholic liver disease received a postoperative questionnaire regarding past and present alcohol use. Patients enrolled in the study all had at least 7 mo of follow-up, with the median follow-up being 21 mo. Eighty-six percent of alcoholic liver disease patients (37 of 43) and 86% of patients in the comparison group (37 of 43) of ALD patients agreed to participate in the study. Nineteen percent of alcoholic liver disease patients (7 of 37) and 24% of patients in the comparison group (9 of 37) admitted to having used alcohol after orthotopic liver transplantation, wtih 8% (3 of 37) and 11% (4 of 37) currently using alcohol, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitation of hepatitis C virus RNA in liver transplant recipients

BACKGROUND/AIMS

Hepatitis C virus (HCV) infection is common in liver transplant recipients, yet the effects of immunosuppression on HCV RNA levels and the relationship of HCV RNA levels to hepatic damage have not been studied.

METHODS

To explore these issues, we measured HCV RNA in serum by polymerase chain reaction amplification and branched DNA assay from 100 HCV-infected patients undergoing liver transplantation.

RESULTS

Mean posttransplant levels were 16-fold higher than pretransplant values (7,935,000 and 496,000 Eq/mL, respectively; n = 65; P < 0.0001). Patients with high pretransplant levels had higher mean posttransplant levels than those with low pretransplant levels (17,119,000 and 6,504,000 Eq/mL, respectively; P = 0.064). Posttransplant levels were similar in patients with recurrent and acquired infection and were independent of time of sampling. Fifty percent of patients with HCV infection had normal liver biopsy specimens, and there was no strong relationship between level of viremia and degree of hepatic damage.

CONCLUSIONS

HCV RNA levels increase markedly following liver transplantation. The frequent finding of viremia in the absence of histological hepatitis suggests that a "carrier state" is common. Absence of allograft damage in some (despite high levels of viral RNA) suggests that in immunosuppressed patients, HCV infection may be tolerated without direct hepatic damage.

The increased efficacy and decreased nephrotoxicity of a cyclosporine liposome

A potential approach to avoid the complications of systemic immunosuppression is to deliver immunosuppressive agents locally to the site of the allograft. Liposomes are phospholipid particles that allow delivery of drugs preferentially to the reticuloendothelial system. Since the liver is a primary component of the RES, we hypothesized that liposome technology could be utilized to deliver immunosuppressive agents locally to a transplanted liver, thereby avoiding the complications of systemically delivered immunosuppression. We evaluated this hypothesis with a prototypic cyclosporine liposome in a rat model. Pharmacokinetic studies of this liposome indicated earlier clearance from the systemic circulation and increased hepatic uptake relative to the standard intravenous form of CsA. Decreased nephrotoxicity was also shown in an ischemic kidney model in the rat. The immunosuppressive efficacy of this liposome was also tested in a rat liver transplant model. There was a significant increase in survival compared with standard intravenous CsA when both drugs were administered at a dose of 1.75 mg/kg/day for seven days posttransplant (P < .05, CsA liposome-treated versus CsA/saline-treated). There were no demonstrable early toxic effects or late toxic effects observed with follow-up to 100 days. These data indicate that CsA liposomes have potential for use as an immunosuppressive agent with increased efficacy and decreased nephrotoxicity relative to the commercially available form of intravenous CsA. This improved therapeutic index of a locally targeted drug may lead to fewer complications attributed to systemic immunosuppression.

Prolongation of in vivo mouse islet allograft survival by modulation of MHC class I antigen

Major histocompatibility complex class I-deficient islets from beta-2 microglobulin-deficient mice have been shown to have prolonged in vivo islet allograft survival. Additionally in vitro studies using the mixed lymphocyte islet coculture system have demonstrated a reduction in cytotoxic T lymphocyte activity against alloislets that have been pretreated with an antibody directed against MHC class I antigen. The clinical applicability of these findings are examined in this study, which evaluates the ability of MHC class I blocking antibody to prevent the in vivo destruction of alloislets. Recipients of allogenic islet transplants treated with phosphate-buffered saline or control F(ab')2 fragments rejected the transplanted alloislets in median times of 11.5 days and 11 days, respectively. Recipient mice treated with a monoclonal antibody or F(ab')2 fragments specific to the donor MHC class I antigen had significant prolongation in allograft survival (median allograft survival for both groups was 21 days) when compared with mice treated with PBS or control F(ab')2 fragment. These results demonstrate that treating recipients of alloislets with donor-specific MHC class I monoclonal antibody or the respective F(ab')2 fragments prolongs islet allograft survival. This confirms the importance of MHC class I antigen in the rejection of pancreatic islet allografts and suggests that blocking different domains on the MHC class I molecule could be used therapeutically in the protection of allografts from the immune system.