Transplantation for primary biliary cirrhosis: retrospective analysis of 400 patients in a single center

Orthotopic liver transplantation (OLT) is an effective treatment for patients with advanced primary biliary cirrhosis (PBC). We have conducted a retrospective analysis of 400 consecutive patients transplanted for PBC between 1983 and 1999. Mean follow-up was 56 months. The proportion of patients grafted for PBC fell progressively, from 35% in 1990 (n = 80) to 21% in 1999 (n = 111); comparison of patients grafted in the 2 decades showed that the median age increased from 53 to 56 years and the median serum bilirubin at transplantation fell from 270 micromol/L to 132 micromol/L. The overall actuarial patient and graft survival at 1, 5, and 10 years is 83%, 78%, and 67% and 82%, 75%, and 61%, respectively. The net gain in 5-year survival compared with predicted survival in the absence of transplantation fell from 37% (range, 82%-90%) to 16% (range, 91%-99%). Multiple organ failure (16.1%) and sepsis (9.6%) were the major causes of early deaths (<6 months). Recurrent PBC, diagnosed on allograft histology, was found in 68 (17%) patients, at a mean time of 36 months. We were unable to identify any pretransplantation donor or recipient factor, which identified those patients at risk of recurrence, although recurrence was much earlier and more frequently seen in patients receiving tacrolimus (P =.04). PBC remains a good indication for liver transplantation, with excellent survival rates. The age at transplantation increased although patients tended to be grafted earlier. Survival rates have increased although there is a reduction in the survival benefit. Recurrence may be common, but does not seem to affect medium-term graft survival.

A taste of honey

Infantile botulism classically presents with a triad of clinical features: Bulbar palsies (slow/absent pupil response) Alert Absent fever Other common features are: Constipation, ptosis and poor feeding The diagnosis is a clinical one, confirmed by EMG and by testing stool for the organism, C. botulinum, or its toxin. Parents should be advised not to dip pacifiers in honey. In future Botulinum Immune Globulin may be available and should be considered if further trials are published showing benefit. Nosocomial infections, such as RSV, are important and should be carefully avoided, particularly in patients recovering from botulism.

Is it Kawasaki disease?

Atypical cases of KD are common (up to 10% of the total) and the diagnosis should be considered without the full complement of diagnostic criteria. The risk of coronary dilation is high if IVIG is not given. Administration of IVIG is effective at preventing aneurysms, if given early. The high-risk groups for coronary artery disease are infants younger than 6 months of age and older children with very high platelet counts, high ESR and fever persisting for more than 2 weeks.

A retrospective review of paediatric lymph node tuberculosis in Port Moresby, Papua New Guinea

The study aimed to examine the perception that the relapse rate following standard short-course chemotherapy in children with lymph node tuberculosis is greater than in similarly treated children with pulmonary tuberculosis (TB). The treatment records, clinical data and results of investigations of 427 children treated for lymph node TB between 1989 and 1996 were analysed. The results and role of investigations are discussed. The relapse rate was compared with that of 892 children treated for pulmonary TB during the same period. The documented relapse rate for lymph node TB was 2.8% compared with 0.6% in pulmonary TB. This highly significant difference led to a prospective study of outcome of lymph node TB treatment in Port Moresby.

Normalised intrinsic mortality risk in liver transplantation: European Liver Transplant Registry study

BACKGROUND

No model exists for liver transplantation to estimate the mortality risk in a given patient, and no standard by which to assess performance in different centres. We investigated the intrinsic mortality risk in the absence of known mortality risk factors.

METHODS

We identified mortality risk factors and risk ratios quantified in data from the European Liver Transplant Registry (22,089 patients at 102 centres in 18 countries) registered from 1988 to 1997. To develop a model of the intrinsic risk and the risk ratios for specific factors, univariate and multivariate analyses were done separately for the overall population, for adults, and for children younger than 15 years, and the number of deaths were estimated. We validated the model by comparing mortality in patients without risk factors with the model-adjusted mortality in patients with risk factors.

FINDINGS

Overall 5-year and 8-year actuarial survival was 66% (95% CI 65-66) and 61% (60-62). 65% of deaths occurred within 6 months. Retransplantation, transplantation for cancer, acute liver failure, fewer than 20 split-liver grafts per year, and a centre workload of fewer than 25 transplants per year were the main risk factors of 12 identified factors. 1-year and 5-year death rates among adults with no risk factors were similar to model estimates (15 [13-16] vs 14% [13-15], and 22 (20-24) vs 23% [21-24]). Corresponding data for paediatric transplants were 9% (7-12) compared with 11% (9-12) and 13% (10-17) compared with 14% (11-16). The reduction of mortality risk in high-volume centres was even greater in patients without risk factors (48 vs 23%, p<0.001).

INTERPRETATION

The normalised intrinsic mortality risk can be combined with the relative risk ratios of known risk factors to better estimate the mortality risk of a given procedure in a given patient. Centres can assess performance by removing potential bias of donor and recipient selection.

Band 3 mutations, renal tubular acidosis and South-East Asian ovalocytosis in Malaysia and Papua New Guinea: loss of up to 95% band 3 transport in red cells

We describe three mutations of the red-cell anion exchangerband 3 (AE1, SLC4A1) gene associated with distalrenal tubular acidosis (dRTA) in families from Malaysia and Papua NewGuinea: Gly(701)-->Asp (G701D), Ala(858)-->Asp(A858D) and deletion of Val(850) (DeltaV850). The mutationsA858D and DeltaV850 are novel; all three mutations seem to berestricted to South-East Asian populations. South-East Asianovalocytosis (SAO), resulting from the band 3 deletion of residues400-408, occurred in many of the families but did not itselfresult in dRTA. Compound heterozygotes of each of the dRTA mutationswith SAO all had dRTA, evidence of haemolytic anaemia and abnormal red-cell properties. The A858D mutation showed dominant inheritance and therecessive DeltaV850 and G701D mutations showed a pseudo-dominantphenotype when the transport-inactive SAO allele was also present. Red-cell and Xenopus oocyte expression studies showed that theDeltaV850 and A858D mutant proteins have greatly decreased aniontransport when present as compound heterozygotes (DeltaV850/A858D,DeltaV850/SAO or A858D/SAO). Red cells with A858D/SAO had only 3% ofthe SO(4)(2-) efflux of normal cells, thelowest anion transport activity so far reported for human red cells. The results suggest dRTA might arise by a different mechanism for eachmutation. We confirm that the G701D mutant protein has an absoluterequirement for glycophorin A for movement to the cell surface. Wesuggest that the dominant A858D mutant protein is possibly mis-targetedto an inappropriate plasma membrane domain in the renal tubular cell,and that the recessive DeltaV850 mutation might give dRTA because ofits decreased anion transport activity.

Changing referral pattern of biliary injuries sustained during laparoscopic cholecystectomy

SUMMARY

More patients with less severe type biliary injury are being referred earlier to a specialist hepatobiliary unit. Most patients still have ineffective corrective surgery before transfer. Presented in part to the European Congress of the International Hepato-Pancreatico-Biliary Association in Budapest, Hungary, May 1999 and published in abstract form as Digestive Surgery 1999; 16(Suppl 1): 32.

Kangaroo care in Port Moresby, Papua New Guinea

Kangaroo care is a simple and highly practical method of care of the low birthweight newborn which has been shown in some studies to significantly improve survival. We describe the introduction of 'kangaroo care' to the special care nursery at Port Moresby General Hospital, discuss the problems encountered and attempt to assess its impact in a 1-year retrospective study, during which it was associated with a reduction in hypothermia and an increased rate of weight gain.

Immunosuppressive effect of combination schedules of brequinar with leflunomide or tacrolimus on rat cardiac allotransplantation

Drug toxicity is one of the major problems in clinical immunosuppression. Combining two immunosuppressants in low or ineffective doses is an attractive strategy if it helps to reduce drug-related toxicity. We examined the immunosuppressive efficacy of brequinar (BQR) in combination with leflunomide (Lef) or tacrolimus (FK) in a heterotopic rat cardiac allotransplantation model. Abdominal heterotopic heart grafts (DA x LEW) were immunosuppressed from the time of transplantation and continued until the ninth posttransplant day (POD) in experiments examining prophylaxis of rejection treatment (PRT). In a separate series of experiments designed to test rescue treatment (RT), immunosuppression was begun on POD 4 and continued for 10 days; transplanted rats were sacrificed the following day intentionally. Cardiac rejection was monitored by palpation and documented by light microscopy. Immunosuppressive drugs (BQR 3 mg/kg and 12 mg/kg; BQR 3 mg/kg + Lef 5 mg/kg; BQR 3 mg/kg + FK 0.5 mg/kg) were given orally by gavage; thrice weekly according to the monotherapy or dual-therapy dosing protocol. Median survival time of the cardiac graft for controls (no treatment) was 5 days. BQR monotherapy 3 mg/kg (low dose) improved graft survival (P = 0.003); graft histology showed moderate acute rejection. BQR monotherapy 12 mg/kg (therapeutic dose) application in the PRT or RT treatment arms of the study design resulted in aortic-graft ruptures and clinical toxicity in each treatment arm due to overimmunosuppression; normal graft morphology was maintained. Successful rescue of rejecting grafts was histologically documented. Combining BQR with Lef or FK in the PRT protocol showed prolonged graft survival in both drug combination groups (median survival time, 14 days; P = 0.009 and 0.014, respectively). Using an identical combination protocol for RT, all grafts achieved a 14-day graft survival; cardiac histology showed reversible moderate acute rejection. BQR given in the presence of Lef or FK not only prevented acute rejection but intercepted it so long as it was administered; grafts were rejected within 4 days of stopping immunosuppression in the PRT study. These combinations using low or subtherapeutic doses may be important for controlling transplant rejection and rescuing ongoing graft rejection. The need for continuing treatment in this strongly allogeneic model is highlighted.

Percutaneous portal vein thrombolysis and endovascular stent for management of posttransplant portal venous conduit thrombosis

BACKGROUND

Thrombosis of a portal vein conduit after liver transplant is an uncommon clinical situation. Percutaneous thrombolytic therapy for this condition has not been widely described.

METHODS

We describe a case of thrombosis of a portal vein (PV) conduit subsequent to orthotopic liver transplantation that was successfully treated by percutaneous portal vein thrombolysis by using tissue plasminogen activator, angioplasty, and endovascular stent placement.

RESULTS

A satisfactory outcome was achieved with a patent portal vein, on ultrasound, at 8-month follow-up.

CONCLUSION

A percutaneous transhepatic approach to treatment of thrombosis of a portal vein conduit appears to be a promising technique to use to avoid surgery, with good medium-term results.

Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome

BACKGROUND

Portal vein thrombosis (PVT) has been seen as an obstacle to liver transplantation (LTx). Recent data suggest that favorable results may be achieved in this group of patients but only limited information from small size series is available. The present study was conducted in an effort to review the surgical options in patients with PVT and to assess the impact of PVT on LTx outcome. Risk factors for PVT and the value of screening tools are also analyzed.

METHODS

Adult LTx performed from 1987 through 1996 were reviewed. PVT was retrospectively graded according to the operative findings: grade 1: <50% PVT +/- minimal obstruction of the superior mesenteric vein (SMV); grade 2: grade 1 but >50% PVT; grade 3: complete PV and proximal SMV thrombosis; grade 4: complete PV and entire SMV thrombosis.

RESULTS

Of 779 LTx, 63 had operatively confirmed PVT (8.1%): 24 had grade 1, 23 grade 2, 6 grade 3, and 10 grade 4 PVT. Being male, treatment for portal hypertension, Child-Pugh class C, and alcoholic liver disease were associated with PVT. Sensitivity of ultrasound (US) in detecting PVT increased with PVT grade and was 100% in grades 3-4. In patients with US-diagnosed PVT, an angiogram was performed and ruled out a false positive US diagnosis in 13%. In contrast with US, angiograms differentiated grade 1 from grade 2, and grade 3 from grade 4 PVT. Grade 1 and 2 PVT were managed by low dissection and/or a thrombectomy; in grade 3 the distal SMV was directly used as an inflow vessel, usually through an interposition donor iliac vein; in grade 4 a splanchnic tributary was used or a thrombectomy was attempted. Transfusion requirements in PVT patients (10 U) were higher than in non-PVT patients (5 U) (P<0.01). In-hospital mortality for PVT patients was 30% versus 12.4% in controls (P<0.01). Patients with PVT had more postoperative complications, renal failure, primary nonfunction, and PV rethrombosis. The overall actuarial 5-year patient survival rate in PVT patients (65.6%) was lower than in controls (76.3%; P=0.04). Patients with grade 1 PVT, however, had a 5-year survival rate (86%) identical to that of controls, whereas patients with grades 2, 3, and 4 PVT had reduced survival rates. The 5-year patient survival rate improved from the 1st to the 2nd era in non-PVT patients (from 72% to 83%; P<0.01), in grade 1 PVT (from 53% to 100%; P<0.01), and in grades 2 to 4 PVT (from 38% to 62%; P=0.11).

CONCLUSIONS

The value of US diagnosis in patients with PVT depends on the PVT grade, and false negative diagnoses occur only in incomplete forms of PVT (grades 1-2). The degree of PVT dictates the surgical strategy to be used, thrombectomy/low dissection in grade 1-2, mesoportal jump graft in grade 3, and a splanchnic tributary in grade 4. Taken altogether, PVT patients undergo more difficult surgery, have more postoperative complications, have higher in-hospital mortality rates, and have reduced 5-year survival rates. Analysis by PVT grade, however, reveals that grade 1 PVT patients do as well as controls; only grades 2 to 4 PVT patients have poorer outcomes. With increased experience, results of LTx in PVT patients have improved and, even in severe forms of PVT, a 5-year survival rate >60% can now be achieved.

Factors predicting perioperative cytokine response in patients undergoing liver transplantation

OBJECTIVES

An exaggerated production of proinflammatory cytokines during liver transplantation stimulates the inflammatory process within the graft, and eventually promotes liver failure. This study was conducted to evaluate factors predicting perioperative response of proinflammatory cytokines during liver transplantation.

DESIGN

Prospective, consecutive entry study of liver transplant candidates.

SETTING

University hospital.

PATIENTS

Thirty liver transplant recipients.

INTERVENTIONS

Arterial blood samples were obtained perioperatively.

MEASUREMENTS

Interleukin (IL)-1beta, IL-6, tumor necrosis factor-alpha were measured by ELISA. Endotoxin was determined by a chromogenic endotoxin-specific method.

MAIN RESULTS

The peak concentrations of IL-1beta and IL-6 in the patients with complications were significantly higher than those in the patients without complications. The peak concentration of IL-1beta was significantly correlated with the level of bilirubin at admission and the intraoperative blood product requirement. The peak concentration of IL-6 was significantly correlated with the admission bilirubin and the intraoperative blood product requirement. A multivariate regression model revealed that the serum bilirubin and the intraoperative blood product requirement were the independent factors that influenced the peak concentration of IL-1beta or IL-6. The severely jaundiced patients had a significantly higher plasma concentration of endotoxin at the end of the anhepatic phase. In addition, there was a tendency for these patients to have a higher postoperative peak concentration of endotoxin.

CONCLUSIONS

Serum level of bilirubin may be a potent preoperative factor influencing perioperative cytokine response in patients undergoing liver transplantation. An enhanced perioperative response of endotoxin seen in severely jaundiced patients suggests the clinical implication of endotoxin removal during the anhepatic phase in liver transplant surgery.

Outcome of neonatal care in Port Moresby, Papua New Guinea: a 19-year review

The effectiveness of changes in practice can only be determined by comparing outcome before and after their introduction. This report presents and discusses the neonatal statistics from Port Moresby General Hospital (PMGH) over the last 19 years and attempts to determine the effects of changes in practice introduced during the last year of the study period. Neonatal mortality rates have been very constant. However, the changes in practice--having all but the sickest babies nursed with their mothers and encouraging kangaroo care--together with strict adherence to breastfeeding policies, including the use of expressed breastmilk wherever possible, and the close involvement of the local breastfeeding support group in follow-up, appeared to have beneficial effects in reducing the length of stay and increasing the rate of weight gain in the very low birthweight babies.

Hyperekplexia: a rare differential of neonatal fits described in a developing country

Hyperekplexia is a rare condition in which there is an exaggerated startle response. We report how a case presented in Papua New Guinea (PNG) and was diagnosed with international support. This is the first reported case in PNG. It is an important diagnosis to make to prevent sudden death and inappropriate treatment. The case illustrates the benefit of having a link with an international specialist and we discuss the importance of communication between developing and industrialized countries.

Outcome of liver retransplantation in children

Irreversible liver graft failure is a life-threatening complication. We reviewed the first 200 pediatric liver transplantations in Birmingham. Forty-one children developed primary graft failure, 9 of whom developed secondary graft failure. The main indications for graft failure were primary nonfunction (PRNF; 8 patients), vascular complications (VASC; 23 patients), and chronic rejection (CHRE; 19 patients). Thirty-two children underwent retransplantation (ReTx) (21 children received reduced grafts; 11 children, whole hepatic grafts). Patient survival was significantly worse for retransplant recipients compared with children receiving a single graft (63% v 76. 5% actuarial patient survival at 1 year; P <.05). Primary graft 1-year actuarial survival was 74% in first grafts compared with 47% for regrafts (P <.05), but improved with time. The graft 1-year survival rate was 55% for whole grafts and 45% for reduced and/or split grafts in the first 100 grafts compared with 83% and 66% in the second 100 grafts, respectively (P <.01). Emergency ReTx within a month of transplantation was associated with more complications and a worse outcome (1-year survival rate, 37%) compared with patients who underwent ReTx later (1-year survival rate, 72%; P <. 01). The incidence of primary graft failure decreased from 33% in the first 100 grafts to 16% in the second 100 grafts (P <.01), as did the incidence of PRNF, which decreased from 8% to 0% (P <.05). Although the rates of graft failure from VASC decreased from 15% to 8% (P =.2) and CHRE decreased from 11% to 8% (P =.6), neither reached statistical significance. The improved results overall are because of advances in surgical techniques, intensive care management, and graft preservation and refinements in immunosuppression. We conclude that ReTx for a child with primary graft failure is justified.

Poor outcome in patients with diabetes mellitus undergoing liver transplantation

BACKGROUND

Relatively few studies have examined the influence of pretransplant diabetes on survival after an orthotopic liver transplant (OLT), and those published to date show only minor increases in infection rates among diabetics and no increase in mortality.

METHODS

We examined the effect of diabetes mellitus on survival after OLT. 1005 adults underwent OLT between 1982 and May 1997. Seventy-eight patients with pretransplant diabetes mellitus (7.8% of all OLT, 38 insulin treated, 25 tablet treated, 15 diet controlled) were identified and compared with controls matched for age, sex, and date of first transplant and also with all nondiabetic adult liver recipients undergoing OLT during the same period.

RESULTS

In patients undergoing OLT survival was worse in diabetics than in the comparison group (P=0.002) and vs. all adult nondiabetics undergoing (n=927) (P=0.004); in diabetics with alcoholic liver disease (ALD) vs. all nondiabetics with alcoholic liver disease (P= <0.0001); and in insulin-treated compared with non-insulin-treated diabetics (P=0.05). Multivariate analysis showed type of diabetes (P=0.001) and ALD (P=0.024) to be the most significant independent variables adversely affecting survival. Survival in diabetics undergoing OLT could be further stratified according to whether diabetics were insulin treated.

CONCLUSIONS

Poorer outcome in the diabetics undergoing OLT, particularly in those with ALD, suggests the need for a more detailed pre-OLT assessment of these patients, particularly those with insulin and tablet controlled diabetes.

Serum hepatocyte growth factor as an index of extensive catabolism of patients awaiting liver transplantation

BACKGROUND

Whole body catabolism as the result of intrahepatic metabolic derangement is common in liver transplant candidates. However, individual nutritional assessment parameters lack sensitivity and specificity in determining energy status of these patients. Recently, serum hepatocyte growth factor (HGF) has been shown to reflect the recovery of hepatic energy metabolism after liver transplantation.

AIMS

The relation between preoperative levels of serum HGF and metabolic variables was investigated to clarify the clinical value of measuring HGF in evaluations of the catabolism.

PATIENTS/METHODS

Blood samples were obtained from 30 liver transplant recipients, and biopsy specimens were taken from each recipient's rectus muscle and the explanted liver. Preoperative serum concentration of HGF was determined. Whole body energy metabolism was assessed by measuring glycogen contents of biopsy specimens and plasma or serum levels of glucose, insulin, total ketone bodies, total carnitine, and amino acids.

RESULTS

Serum HGF concentration was elevated in 22 of 30 patients and correlated with the Child-Pugh score. It showed a negative association with muscle glycogen content, and a positive correlation with serum levels of glucose, total carnitine, and total ketone bodies. Patients with elevated serum HGF concentrations had higher preoperative plasma levels of aromatic amino acids and branched chain amino acids, associated with lower branched chain to aromatic amino acid ratios.

CONCLUSIONS

The elevated serum concentration of HGF in liver transplant candidates reflected inhibition of peripheral glucose storage, enhanced lipid oxidation, and increased peripheral release of branched chain amino acids, and thus extensive energy catabolism.