Glomerular injury in end-stage liver disease--role of circulating IgG and IgM immune complexes

The relationship of IgG- and IgM-bound circulating immune complexes and immune dysfunction to glomerular injury was evaluated in 15 children with end-stage liver disease (ESLD) awaiting liver transplantation. Compared with age-matched controls, children with ESLD had significantly (P < 0.01) increased serum IgG, IgA, and IgM levels, as well as IgG- and IgM-bound circulating immune complexes. Furthermore, they showed a significant (P < 0.05) depression of C3 and C4 levels compared with controls. Hematuria occurred in 66% of children with ESLD, and the urinary protein/creatinine ratio was also significantly (P < 0.01) increased compared with controls (4.65 +/- 2.56 vs. 0.16 +/- 0.04 mg/mg). Light microscopy of renal biopsy tissue obtained from 6 children with ESLD at the time of transplantation demonstrated mesangial proliferation and expansion with basement membrane splitting. This was associated with subendothelial deposits on electron-microscopic examination, compatible with a diagnosis of membranoproliferative glomerulonephritis. By immunofluorescence, deposition of IgG, IgA, and IgM occurred in various combinations with co-deposition of complement fragments. We conclude that membranoproliferative glomerulonephritis is a common finding in children with ESLD, probably due to entrapment of circulating IgG- and IgM-bound immune complexes.

An unusual case of choledochal cyst causing hepatic failure requiring orthotopic liver transplantation

The authors describe a case of orthotopic liver transplantation (OLT) in a patient with an infantile form of choledochal cyst that progressed to severe hepatic failure. Choledochal cyst must be included in the differential diagnosis of extrahepatic biliary obstruction in infants; it represents an additional reason to consider early exploratory laparotomy, both for diagnosis and to perform definitive excision. In the event that end-stage liver disease develops, OLT should be considered.

Hepatic retransplantation: University of Nebraska Medical Center experience

The lack of an artificial liver makes liver retransplantation a unique, life-saving procedure when all the other alternatives to save a failed graft have been exhausted. On the other hand, the shortage of donors in line with the increasing number of end-stage liver disease patients who are waiting in long recipient lists represents a dilemma and raises the question of most appropriate recipient selection. In this report, we retrospectively analyzed the results of 350 primary, 48 secondary, and 5 tertiary hepatic transplants performed between July 1985 and January 1990 at University of Nebraska Medical Center. The same immunosuppression protocol was used in each case and the maintenance immunosuppressive therapy consisted of a cyclosporine (CyA) and steroids. The overall survival rate of 80.5% at 1 year which was achieved in the primary grafting group was significantly better than the secondary grafting group (63.0%, p less than 0.05). However, this difference was not significant in pediatric patients and their rates were 73.8% and 71.6% in primary and secondary grafting groups, respectively. When the retransplanted patients were considered as deaths unless secondary grafting was performed, the overall patient survival rate of 69.7% in primary grafting group at 1 yr increased to 77.8% in the retransplanted group and this difference was significant (p less than 0.05). Blood loss and operating time were found to be lower in the retransplanted group. Furthermore, the decrease of the operating time in the retransplanted pediatric patients reached statistical significance (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative trial of oral clotrimazole and nystatin for oropharyngeal candidiasis prophylaxis in orthotopic liver transplant patients

A prospective randomized study was conducted to assess the effectiveness of clotrimazole troches and nystatin suspension to prevent oral candidiasis in immunosuppressed orthotopic liver transplant patients. Thirty-four patients received either clotrimazole troches, 10 mg, five times daily, or nystatin suspension, 500,000 units, four times daily. Prophylaxis was initiated after extubation after transplantation and continued throughout the hospitalization. One of 17 patients in each treatment group developed clinical and microscopic evidence of an oropharyngeal Candida infection. This gave an intragroup and an overall infection rate of 5.9%. It appears that either nystatin or clotrimazole may be used for candidiasis prophylaxis in orthotopic liver transplant patients.

Diffuse biliary tract injury after orthotopic liver transplantation

An unusual type of diffuse biliary tract injury after liver transplantation that is characterized by multiple intrahepatic biliary strictures, ductal dilatations, fluid collections, or intrahepatic abscesses has been identified. Over a 5-year period, a total of 10 patients (2%) developed diffuse intrahepatic biliary injury with established vascular patency and no obvious source for their biliary tract pathology. All patients received livers preserved in University of Wisconsin solution with a mean preservation time of 16 hours. This biliary tract injury was associated with the presence of severe preservation injury and Roux limb biliary reconstruction. Of the 10 patients, 5 were treated nonoperatively with multiple stricture dilations and stent placements, 3 underwent retransplantation, 1 was treated operatively with hepaticojejunostomy, and 1 died of sepsis. This study suggests that this complication appears to be related to preservation injury and that the etiology may be ischemic in origin.

Surgical complications in solitary pancreas and combined pancreas-kidney transplantations

The benefits of pancreas transplantation (PT) must be weighed against the morbidity associated with the operative procedure and long-term immunosuppression. Over a 32-month period, we performed 73 PTs including 61 combined pancreas-kidney transplants (PKT) and 12 solitary PTs. In the PKT group, 25 reoperations were performed in 18 patients (29.5%) at a mean of 39 +/- 12 days after transplant. In the solitary PT group, 16 reoperations were performed in 8 recipients (66.7%, p = 0.03) at a mean of 87 +/- 12 days after PT (p < 0.01). In the PKT group, pancreas allograft survival was 93.4%. Vascular thrombosis resulted in the loss of two pancreas allografts. In the solitary PT group, pancreas allograft survival was 50% (p < 0.001), with 6 transplant pancreatectomies performed for either infectious (5) or vascular (1) complications. Surgical complications after PT are common (35.6% in this series), occur earlier in patients who undergo PKT, and are more frequent and morbid in patients undergoing solitary PT, especially after a previous kidney transplant. An aggressive surgical approach can lead to a high rate of pancreas allograft salvage without jeopardizing either the patient or the renal allograft.

Histologic changes in liver allograft biopsies associated with elevated whole blood and tissue cyclosporine concentrations

Cyclosporine is used in the postoperative management of rejection in liver allograft recipients. Despite its efficacy in the treatment of allograft rejection, the drug exhibits toxicity at elevated whole blood concentrations including nephrotoxicity with associated histologic changes, and evidence of hepatotoxicity as determined by liver function studies. To date, there have been few published reports describing histologic changes in liver biopsies from patients with elevated blood cyclosporine levels. In the present study, we retrospectively examined biopsies from 16 liver allograft recipients, seven patients with elevated whole blood cyclosporine levels (> 1000 ng/ml) and nine control patients who had whole blood cyclosporine levels in the therapeutic range (558 to 993 ng/ml). In each case, frozen liver biopsy tissue was available to measure tissue levels of cyclosporine and metabolites. The blood and tissue drug levels were then correlated with the histologic changes present in the biopsy specimens. Patients with increased cyclosporine levels displayed histologic changes consisting of hypertrophy of the bile ductal epithelium with cytoplasmic vacuoles and the presence of "foamy" material within the hepatic sinusoids that were either absent or occurred less frequently in the control group. The histologic changes correlated best with cyclosporine metabolite levels rather than tissue levels of native drug. When liver function studies were correlated with cyclosporine levels, only gamma glutamyl transpeptidase (GGT) demonstrated a significant positive correlation with the histologic changes.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of intrahepatic cholangiojejunostomy in liver transplant recipients after extensive destruction of the extrahepatic biliary system

BACKGROUND

Extensive destruction of the extrahepatic biliary system after liver transplantation can be a catastrophic event. We present our experience with the use of intrahepatic cholangiojejunostomy (IHCJ) in this setting.

METHODS

From July 1985 through December 1991, 668 liver transplantations were performed in 583 patients. Seven patients required IHCJ. This technique involves creating an anastomosis between the jejunal mucosal and hepatic parenchyma/capsule with the use of a Roux-en-Y limb of bowel. There were four adults and three children. The clinical presentation included bile leak (n = 4), subhepatic abscess (n = 2), and intrahepatic abscess (n = 1). The probable cause of these events included hepatic arterial thrombosis (n = 4), occult bile leak (n = 2), and fungal cholangitis (n = 1).

RESULTS

After IHCJ, six of the seven patients are currently alive, with a mean follow-up of 28 months. The current liver function test results include a mean bilirubin of 0.7 mg/dl (range, 0.4 to 1.9 mg/dl), serum glutamic pyruvic transaminase of 69 units/L (range, 32 to 118 units/L), and gamma-glutamyltranspeptidase of 118 IU/L (range, 111 to 265 IU/L).

CONCLUSIONS

These results suggest that IHCJ is a safe and effective alternative to retransplantation in liver recipients with extensive destruction of the extrahepatic biliary system.

The spectrum of Pneumocystis carinii infection after liver transplantation in children

We report the experience with Pneumocystis carinii lung infections in the 109 children undergoing liver transplantation at our hospital between August, 1985 and May, 1989. PCP developed in 9 of the 86 patients (10%) surviving > or = 6 weeks after transplantation and not receiving P carinii chemoprophylaxis. Of the 59 patients undergoing BAL 2 or more weeks after transplantation there were 16 specimens from 14 patients (24%) positive for P carinii. These patients had a spectrum of illness ranging from asymptomatic to severe pneumonia requiring mechanical ventilation. The mean interval from first transplantation to bronchoalveolar lavage positive for P carinii was 24.9 weeks and the mean interval to first PCP was 28.0 weeks. The earliest and latest occurrences of PCP were 7 weeks and 73 weeks, respectively, after transplantation. There were no complications attributed to BAL.

The results of reduced-size liver transplantation, including split livers, in patients with end-stage liver disease

We initiated a policy of using RSLT in critically ill patients in June of 1988. Since that time we have performed 30 RSLTs in 29 patients, including 28 children and 1 adult. The mean age of the children was 27 months (range 1 month to 10 years) with 14 (52%) being 1 year of age or less. The mean weight was 11.3 kg (range 2-50 kg) with 20 being 10 kg or less. A total of 22 patients were in the intensive care unit at the time of RSLT including 9 who were intubated. Of the 30 RSLTs, 23 were performed as a primary transplant while 7 were retransplants. Indications for primary transplantation included biliary atresia (n = 11), fulminant hepatic failure (n = 5), neonatal hepatitis (n = 4) and others (n = 3). The RSLT was used in retransplantation for primary nonfunction (n = 2), hepatic artery thrombosis (n = 2), chronic rejection (n = 2), and herpetic hepatitis (n = 1). The size reductions included 18 left lobes, 7 left lateral segments, and 5 right lobes. This group includes the use of the split-liver technique, which was applied to 10 patients (5 livers). The median donor/recipient weight ratio for left lobe transplants was 2:1; left lateral segments was 7.3:1; and right lobes 1.6:1. One year actuarial patient and graft survivals were 68 and 65%, respectively, with a mean follow-up of 10.6 months. The number of children dying awaiting transplantation has been significantly reduced following the introduction of RSLD (3 of 115, 2.6% vs. 12 of 95, 13%; P less than 0.02).

A randomized prospective trial of acyclovir and immune globulin prophylaxis in liver transplant recipients receiving OKT3 therapy

The use of OKT3 therapy is a major risk factor for opportunistic infections in liver transplant recipients. In the last 2 years, we prospectively randomized 100 patients receiving OKT3 therapy into either a control group (n = 50) or a prophylaxis group (n = 50). Prophylaxis consisted of six doses of intravenous immune globulin over 4 weeks and oral acyclovir for 3 months after OKT3 therapy. The two groups were comparable with respect to demographic, immunologic, and clinical characteristics. The regimen of prophylaxis resulted in (1) a significant reduction in the incidence of herpetic and Epstein-Barr viral infections; (2) no change in the incidence of cytomegalovirus infections; (3) a significant decrease in the incidence of fungal infections; and (4) fewer deaths due to sepsis. The incidence of viral and fungal infections was higher after OKT3 induction than after rescue therapy. Our conclusion is that opportunistic infections are frequent after OKT3 therapy in hepatic allograft recipients. Treatment with intravenous immune globulin and oral acyclovir is safe and effective in preventing non-cytomegaloviral and fungal infections in this setting, thus conferring a survival advantage with fewer deaths due to sepsis.

A selective approach to preexisting portal vein thrombosis in patients undergoing liver transplantation

Splanchnic venous inflow is considered mandatory to ensure graft survival after liver transplantation. Over a 68-month period, we performed 570 liver transplants in 495 patients. Portal vein thrombosis was present in 16 patients. At transplant, the extent of the occlusion included portal vein alone (n = 4), portal including confluence of the splenic and superior mesenteric veins (n = 8), portal, splenic, and distal superior mesenteric veins (n = 2), and the entire portal vein, splenic vein, and superior mesenteric vein (n = 2). The operative approach included thrombectomy alone (n = 5), anastomosis at the confluence of the splenic and superior mesenteric splenic veins (n = 8), and extra-anatomic venous reconstruction (n = 3). The mean operative blood loss was 22 +/- 22 units, and the mean operative time was 9.7 +/- 4.8 hours. The 1-year actuarial survival rate was 81%, with a mean follow-up of 12.5 months. In summary, with a selective approach and the use of innovative forms of splanchnic venous inflow, portal vein thrombosis is no longer a contraindication to liver transplantation.

Treatment of valproic acid-associated hepatic failure with orthotopic liver transplantation

OBJECTIVE

To report a case of valproic acid (VPA)-induced hepatotoxicity and to discuss the incidence rates, risk factors, possible etiologies, preventive measures, and treatment courses for this severe reaction.

DATA SOURCES

Case reports, review articles, and relevant laboratory studies identified by MEDLINE.

DATA EXTRACTION

Data were abstracted from pertinent published sources by one author and reviewed by the remaining authors.

DATA SYNTHESIS

The case of a 23-year-old woman with VPA-associated hepatic failure was successfully treated with orthotopic liver transplantation. Hepatic failure is a rare, often fatal, adverse effect of VPA. Most cases of VPA-associated hepatic failure have occurred within several months of initiation of therapy. Initial symptoms of presentation often include nausea and vomiting, lethargy, or loss of seizure control. Laboratory values to be monitored include serum concentrations of hepatic enzymes, and, in some patients, tests indicative of the liver's synthetic capabilities. The exact mechanism of VPA-associated hepatic failure has not been clearly established; however, it is postulated to involve the formation of toxic metabolites. Major risk factors include age less than two years and concomitant treatment with more than one anticonvulsant. Other significant risk factors include underlying metabolic or serious neurologic disorders.

CONCLUSIONS

Caution should be taken when initiating VPA therapy and clinicians should be familiar with the risk factors and clinical presentation of this reaction.

Syndrome of multiple bowel perforations in liver transplant recipients

In an analysis of surgical complications following 500 consecutive orthotopic liver transplants, we identified 12 patients who developed the syndrome of multiple bowel perforations that was not due to iatrogenic injury. All cases occurred in small children (mean weight: 9.0 kg), who represented 7% of the pediatric population. Each patient had a minimum of three perforations. The typical intraoperative findings were pin-point perforations in areas of normal-appearing bowel. With only one possible exception (a patient with cytomegalovirus enteritis), no specific etiology could be determined. Management was based on multiple exploratory laparotomies and individualized operative procedures. All patients are currently alive (mean follow-up: 34.9 months). The pathogenesis of the syndrome of multiple bowel perforations remains unclear but is possibly multifactorial or related to high doses of steroids. Aggressive surgical management with semiopen treatment of peritonitis and frequent explorations has afforded excellent results.