Late histopathological findings in renal allografts with four immunosuppressive regimens

The histological changes in renal allografts are usually studied when graft function has already deteriorated. The early results of renal allografts have improved dramatically during the last two decades, but the half-life of renal cadaveric allografts has remained unchanged at approximately 7 years. The mechanism of chronic rejection, and how to prevent it, is not known. We studied the histology of renal allografts under four different immunosuppressive regimens 2 years after transplantation. The aim of this study was to investigate whether histopathological changes exist in the renal allografts with relatively good and stable graft function. We also investigated whether there were differences in allograft histology between four immunosuppressive treatment groups 2 years after transplantation.

Quality of life before and after liver transplantation: experiences with 7 patients with primary biliary cirrhosis in a 2-year follow-up

Seven patients with end-stage primary biliary cirrhosis were evaluated both before and 1 and 2 years after liver transplantation using a clinical psychiatric interview and the self-rating questionaire SCL-90. Neuropsychological tests were done before and 1 year after operation. Preoperatively, all patients had a poor general condition and overall quality of life. Flattening of emotions and reactions, regression, disturbances of verbal memory and cognitive function, and dependence on close relatives were observed. One year after transplantation, 6 patients had a much better overall quality of life, and with five patients it improved still further during the 2nd year, but only 2 patients felt that their life situation had fully stabilised. However, nearly all of them experienced phases of moderate or even severe depression or anxiety during those 2 years. On neuropsychological tests patients appeared to be near their normal level. The only patient who died during this follow-up (some months after transplantation) had in her life history a prominent sense of insecurity and mistrust. It seems to take more than a year for the majority of patients to give up the regressive mode of experience and turn to adult interests in life again, as well as psychologically experience the new liver as part of oneself.

Outcome following liver transplantation for primary sclerosing cholangitis in the Nordic countries

BACKGROUND

Primary sclerosing cholangitis (PSC) is the most common indication for liver transplantation in the Nordic countries. Because these patients are difficult to evaluate with regard to timing of liver transplantation, it is important to establish predictors of post-transplant survival.

METHODS

Data from two groups of patients receiving liver allografts during 1982-2001 were recorded: (a) PSC patients and (b) comparison patients. Outcome following transplantation has been recorded for all patients. Regression analyses have been performed for PSC patients to analyse predictors of patient and graft survival.

RESULTS

A total of 245 PSC and 618 comparison patients received a first liver allograft in the period 1982 until the end of the study. The overall 1-, 3- and 5-year patient survival rates were 82%, 77% and 75%, and 80%, 77% and 74% in the PSC group and comparison group, respectively. Survival following transplantation has increased with time in both the PSC and the comparison group. Recent year of transplantation, no previous hepatobiliary surgery and a lower MELD score were predictors of survival following transplantation for PSC patients. PSC patients had a higher rate of re-transplantations (13% versus 8%, P = 0.01). Predictors of re-transplantation in PSC patients were an episode of early rejection and vascular thrombosis.

CONCLUSION

In PSC patients, year of transplantation, previous hepatobiliary surgery and MELD score are predictors of survival following transplantation and these patients are more frequently in need of re-transplantation compared to the comparison group.

Experience with albumin dialysis in five patients with severe overdoses of paracetamol

Five patients in whom the serum paracetamol levels or the amount of ingested paracetamol was high enough to cause severe liver injury were treated with N-acetyl-cysteine (NAC) and a molecular absorbant recirculating system (MARS). MARS treatment was started as early as possible in order to prevent or retard the development of hepatocyte necrosis. Four of our five patients survived without liver transplantation, and one died due to brain oedema. The early commencement with NAC and MARS treatments in paracetamol intoxication might give enough time for the liver to regenerate and thus avoid liver transplantation.

Liver transplantation for primary sclerosing cholangitis in the Nordic countries: outcome after acceptance to the waiting list

Primary sclerosing cholangitis (PSC) is a common indication for liver transplantation, but evaluation of patients and timing of liver transplantation remain as major problems. Data from PSC and control patients listed for liver transplantation from 1990 through 2000 in the Nordic countries were recorded prospectively. Outcomes from the waiting list and after transplantation have been recorded for both groups. For PSC patients, regression analyses have been performed to analyze predictors of outcome. A total of 255 PSC and 610 control patients were accepted on the liver transplantation waiting list from 1990 to 2000. In the PSC group, 223 patients (87%) received a first liver allograft, and 32 patients (13%) died without transplantation. The corresponding figures for the control group were 89% and 10%. For PSC patients, the 5- and 10-year survival from the time of acceptance was 68% and 58%, respectively. A higher Model for End-Stage Liver Disease score and a shorter duration of PSC predicted death on the waiting list for PSC patients. PSC is a frequent indication for liver transplantation. In our material, serum bilirubin or Model for End-Stage Liver Disease score and PSC duration are predictors of outcome including survival of the waiting list.

Human herpesvirus-6 and acute liver failure

BACKGROUND

In patients with acute liver failure (ALF) of unknown cause, viral infections are believed to be involved. This study investigates the involvement of human herpesvirus-6 (HHV-6).

METHODS

Thirty-two patients with ALF who underwent transplantations during a 6-year period were studied for viruses in biopsies from their explanted livers. Non-A to non-E hepatitis (unknown) ALF was the reason for transplantation in 15 patients, and another 17 patients with a known disease from the same time period served as controls. The explanted livers were examined for hepatitis viruses and other possible viral agents. HHV-6 antigens were demonstrated in the livers and blood mononuclear cells by immunoperoxidase staining.

RESULTS

Of the 15 patients with ALF of unknown cause, 12 (80%) demonstrated HHV-6 antigens in the liver. Most of these patients (10/12) also demonstrated HHV-6 antigenemia. The predominant histologic finding of HHV-6 infection was moderate to severe portal lymphocytic infiltration. HHV-6 was found in 4 of 17 control patients, and cytomegalovirus was found in 2 of 17 control patients (in the blood and explanted liver). No other viruses were found in the livers of the patients with ALF.

CONCLUSIONS

HHV-6 was found in most explanted livers of patients with ALF of unknown cause. HHV-6 antigenemia was associated with HHV-6 antigens in the liver. Only a few control patients displayed HHV-6 in the liver. These observations indicate that HHV-6 may be one of the causes of ALF.

Magnetic resonance imaging of the liver: true fast imaging with steady state free precession sequence facilitates rapid and reliable distinction between hepatic hemangiomas and liver malignancies

OBJECTIVE

To assess the capability of the true fast imaging with steady state free precession (true FISP) sequence in the distinction between hemangiomas and malignant liver lesions.

METHODS

Sixty-eight patients with 45 hemangiomas and 51 liver malignancies were included in this study. A 1.5-T magnetic resonance system and a phased-array body coil were used. In addition to true FISP, breath-hold and fat-suppressed, T2-weighted, half-Fourier single-shot turbo spin echo (HASTE) and both unenhanced and gadolinium (Gd)-enhanced T1-weighted sequences were acquired. Two radiologists evaluated the magnetic resonance images independently in a blinded fashion. Interobserver variations with true FISP and HASTE were determined. Lesion contrast-to-noise ratios were calculated from true FISP images.

RESULTS

With true FISP, readers 1 and 2 made a correct distinction between hemangiomas and liver malignancies in 43 of 45 (96%) cases and 40 of 45 (89%) cases, respectively. The kappa value was 0.65. With HASTE, the success rates were 40 of 45 cases (89%) and 36 of 45 cases (80%), respectively, and the kappa value was 0.33. With a Gd-enhanced T1-weighted sequence, the correct classifications were 35 of 45 cases (78%) and 37 of 45 cases (82%), respectively. All hemangiomas appeared as bright and well-demarcated lesions on true FISP images. Malignant liver foci were heterogeneous with unsharp margins and nearly isointense relative to liver. The specificities of true FISP in lesion differentiation were 100% and 98% for readers 1 and 2, respectively. The mean contrast to noise ratio value of hemangiomas was 21.2 (standard deviation [SD] = 9.2), and that of malignant lesions was 4.9 (SD = 3.9). This difference was highly significant (P < 0.0001).

CONCLUSION

Noninvasive, rapid, and reliable differentiation between hemangiomas and malignant liver lesions is possible by using the true FISP sequence.

Detection of CMV-DNA in peripheral blood leukocytes of liver transplant patients after ganciclovir treatment

Cytomegalovirus (CMV) infections are common after transplantation, but usually successfully treated with antivirals. In this study, the detection of CMV-DNA in peripheral blood leukocytes was monitored and compared with CMVpp65-antigenemia in liver transplant patients receiving ganciclovir treatment. Twenty adult liver transplant recipients were frequently monitored for CMV up to 6 months after transplantation. CMV infections were diagnosed by pp65-antigenemia and the same specimens were used for CMV-DNA in situ hybridization. Altogether 202 blood specimens were analyzed. During the first 6 months, 14/20 patients developed CMV antigenemia and 11 were treated with ganciclovir. In all patients, CMV-DNA was detected before antigenemia (mean 15 days earlier). All patients responded to ganciclovir and pp65-antigenemia disappeared. However, 8/11 demonstrated persistence of CMV-DNA for up to 6 months. Recurrences appeared in 6/11 patients. In conclusion, detection of CMV-DNA preceded pp65-antigenemia. Persistence of CMV-DNA demonstrates that the virus is not eliminated by ganciclovir and recurrences can be expected.

Quality control of the European Liver Transplant Registry: results of audit visits to the contributing centers

BACKGROUND

The number of registries is increasing, but few of them perform reliability audits by comparing the data contained in the database with data contained in hospital charts.

METHODS

The European Liver Transplant Registry (ELTR) cocoordinating committee appointed an independent team to check the reliability of data contained in ELTR. Centers were selected at random. Ten percent of each center's files were selected at random, and 25 items per file were checked during the site visits. The rates of completeness and inconsistencies and the agreement between ELTR and charts were established. We also assessed the correlation between the quality of data and the visited centers' activity.

RESULTS

Seven hundred thirty-four files from 21 centers have been audited between June 1998 and June 2001. The rate of ELTR completeness was 95%, and the rate of consistency between charts and ELTR was 98%. The agreement between the ELTR and charts review was very good for all conditions (kappa value < or =0.81). However, comparisons of rates between items indicated that specific items, mostly cause of death or graft failure and patient outcome, should be targeted for improvement. No significant correlation was found between the quality of data and the experience of visited centers. The mean (min-max) and median cost per audited file were EUR 60 (8-150) and EUR 44, respectively.

CONCLUSION

The results of audit visits indicate that ELTR data are reliable, and the scientific results of ELTR can be considered credible and representative of liver transplantation in Europe. The method could serve as a model for auditing a registry.

Activation of protein C during reperfusion in clinical liver transplantation

BACKGROUND

Activated protein C (APC) exhibits anticoagulant and antiinflammatory properties. We studied the kinetics and magnitude of protein C activation in clinical liver transplantation and the interaction of this activation with neutrophil and monocyte activation.

METHODS

In 10 patients undergoing liver transplantation, we measured plasma protein C and APC levels, neutrophil and monocyte CD11b and L-selectin expression, and leukocyte differential counts pre-, intra-, and postoperatively. Samples of blood entering and leaving the liver were obtained simultaneously to assess changes across the liver.

RESULTS

Protein C level was low preoperatively (65%, range 39%-141%) and remained low throughout surgery. Compared with the preoperative level (107%, range 78%-161%), APC level increased during liver reperfusion (471%, range 183%-917%, P=0.05). A transhepatic decrease in protein C level (-16%, range -45%-5%, P=0.007), but not in APC level, occurred during initial liver reperfusion. At the same time, neutrophil and monocyte activation took place in the liver.

CONCLUSIONS

Despite protein C deficiency, patients with liver insufficiency are able to maintain normal APC levels. During reperfusion, protein C consumption occurs in the liver without concomitant hepatic release of APC, indicating a shortage of APC in the reperfused liver. The process consuming protein C and APC may be related to the simultaneous ongoing neutrophil and monocyte activation within the liver graft, indicating a regulatory role for APC in inflammation.

Highly urgent liver transplantation: possible impact of donor-recipient ABO matching on the outcome after transplantation

BACKGROUND

Survival after liver transplantation for fulminant hepatic failure has been reported to be less favorable than survival for patients with chronic liver diseases.

METHODS

We have studied all patients (n=229) undergoing highly urgent liver transplantation from 1990 to 2001 in the Nordic countries. The impact of patient and donor characteristics, with emphasis on donor-recipient ABO matching (identical, compatible, incompatible), has been studied.

RESULTS

One-year and 3-year patient survival rates were 73% and 70% for the total period and 86% and 78% for the last 4-year period. Patients receiving an ABO-compatible liver allograft had significantly lower patient survival rates than those receiving an ABO-identical donor organ (1-year patient survival rates 66% of vs. 79%, P=0.03). Graft survival rates varied less (1-year graft survival rates of 64% vs. 74%, P=0.09). Patients receiving an ABO-incompatible liver allograft had patient survival rates of 70% at 1 year and 60% at 3 years but low graft survival rates (40% and 30% at 1 and 3 years). In a multiple regression analysis, significant independent predictors of poor patient survival were early year of transplantation, ABO-compatible donor, high donor age, and waiting time more than 3 days and less than 9 days.

CONCLUSION

Survival after highly urgent liver transplantation has improved and is comparable to that observed in patients receiving a liver allograft because of chronic liver disease. Patients receiving an ABO-identical donor organ had significantly higher patient survival rates compared with those receiving an ABO-compatible donor liver.

Polycystic liver disease is genetically heterogeneous: clinical and linkage studies in eight Finnish families

BACKGROUND/AIMS

Polycystic liver disease (PCLD), a dominantly inherited condition separate from polycystic kidney disease (PKD), has recently been found to be linked to a locus on chromosome 19p13.2-13.1 in two North American families. Our aim was to study whether there is clinical or genetic heterogeneity within PCLD families.

METHODS

We collected clinical data of eight Finnish PCLD families and performed both linkage analysis and an extended admixture test. We used genetic markers located on chromosome 19p13.2-13.1 and, in addition, on the three known PKD loci on chromosomes 4q21-q23 (PKD2), 6p21 (ARPKD) and 16p13.3-p13.12 (PKD1).

RESULTS

There were a total of 33 PCLD patients among which the severity of the disease varied greatly even within families. Seven patients had disabling symptoms requiring cyst decompression while ten patients were found only when the symptomless family members were studied by abdominal ultrasound. When genetic homogeneity was assumed, the PCLD locus on chromosome 19p13.2-13.1 was excluded but when genetic heterogeneity was allowed, five families out of seven showed linkage to that locus. All three PKD loci were excluded.

CONCLUSIONS

Most Finnish PCLD families are linked to chromosome 19p13.2-13.1 but there exists also a second PCLD locus yet to be found.

Management and outcome of major bile duct injuries after laparoscopic cholecystectomy: from therapeutic endoscopy to liver transplantation

Laparoscopic cholecystectomy is associated with a higher rate of bile duct injuries than an open cholecystectomy. The annual incidence of bile duct injuries has remained almost constant and these injuries tend to be more serious, making demands on the method of repair. We wanted to report the management and outcome of major bile duct injuries after laparoscopic cholecystectomy in patients referred to a hepatobiliary and liver transplantation unit. Eighteen patients (14 women), with a median age of 53.5 years were referred to the liver surgery unit with a major bile duct injury after laparoscopic cholecystectomy. The injury was identified after a median of 3 days (range, 0 to 25 days) after operation and the median time interval to referral was 79 days (0 to 2270 days). Fourteen patients had undergone surgery before referral. By the time of referral, four patients had developed end-stage cirrhosis, necessitating liver transplantation. Three of them had undergone bilioenteric drainage operations at the referring institute. Of the remaining 14 patients, three were managed by therapeutic endoscopic procedures. Ten patients were managed with Roux-en-Y hepaticojejunostomy. One died of septic complications before the repair. A median time for hospitalization in our unit was 33 days (range, 10 to 164 days). At present, 16 patients are alive. One patient died of Kaposi's sarcoma 7 months after liver transplantation. A long interval between bile duct injury and referral was associated with the development of end-stage liver disease. Surgery of biliary lesions is demanding, and surgical experience with multidisciplinary approach, including therapeutic endoscopy and liver transplantation, is necessary for successful outcome.

Human herpesvirus-6 infection is associated with adhesion molecule induction and lymphocyte infiltration in liver allografts

BACKGROUND/AIMS

Human herpesvirus-6 (HHV-6) infection has been recently described in liver transplants. HHV-6 may infect the transplant and cause graft dysfunction. Some association between HHV-6 and rejection has also been recorded. We have now investigated the possible involvement of HHV-6 in the intragraft immunological processes, adhesion molecules induction and lymphocyte activation.

METHODS

HHV-6 was detected in liver biopsies of 19 patients transplanted in the period from 1996 to 2000. Patients with other infections or rejection were excluded from the study. Finally, 19 biopsies of eight allografts with pure HHV-6 infection were available. Adhesion molecules (ICAM-1, VCAM-1, ELAM-1) and their ligands (LFA-1, VLA-4, sLeX) and lymphoid activation markers (MHC class II, IL-2R) were demonstrated in liver biopsies by immunohistochemistry. Five biopsies from patients with normal graft function and without rejection or infection were used as controls for immune staining, and ten biopsies with acute rejection but without infection were used as positive controls.

RESULTS

Biopsy histology demonstrated mild to moderate lymphocyte infiltration associated with HHV-6 infection. HHV-6 significantly (P < or = 0.05) increased the vascular expression of ICAM-1 and VCAM-1, and the number of graft infiltrating lymphocytes positive for LFA-1, VLA-4 and class II antigens. A total of 3/8 grafts developed chronic rejection.

CONCLUSIONS

HHV-6 infection increased adhesion molecule expression and lymphocyte infiltration in liver allografts.

Fulminant hepatic failure: outcome after listing for highly urgent liver transplantation-12 years experience in the nordic countries

Fulminant hepatic failure is a common indication for liver transplantation. Outcomes of patients listed for a highly urgent liver transplantation have been studied, with special emphasis on etiology of the liver disease, clinical condition, and ABO blood type. Data have been collected from the Nordic Liver Transplantation Registry. All Nordic patients listed for a highly urgent primary liver transplantation during a 12-year period have been included. Of the 315 patients listed for a highly urgent liver transplantation, 229 (73%) received a first liver allograft, 50 patients (16%) died without transplantation, and 36 patients (11%) were permanently withdrawn and survived. In 43% of the patients, no definite etiology of the liver failure could be established. Paracetamol intoxication was the most frequent specific indication for listing. Patients with blood type A had no significant shorter waiting time (3.8 v 6.6 days; P =.1) but a higher rate of transplantation (82% v 66%, P =.006) as compared with blood type O patients. In a multivariate analysis, paracetamol intoxication remained the single independent predictor of an outcome without transplantation. In conclusion, a high transplantation rate was observed among patients listed for a highly urgent liver transplantation because of fulminant hepatic failure. Blood type O patients had a lower chance of receiving a liver allograft. Patients with paracetamol intoxication had both a higher mortality without transplantation and a higher withdrawal rate attributable to improved condition.

Granzyme expression in fine-needle aspirates from liver allografts is increased during acute rejection

We investigated whether determination in fine-needle aspiration biopsy (FNAB) specimens of cells expressing granzymes (Grs) and Fas ligand would provide a reliable, easy, and quantitative measure of rejection activity in the transplanted liver. Retrospectively, 13 FNAB specimens obtained during clinical acute rejection, 10 FNAB specimens obtained during subclinical rejection, 12 FNAB specimens obtained during cytomegalovirus (CMV) infection, and 26 FNAB specimens obtained in the absence of rejection or infection were included on the study. Cytospin preparations of FNAB and peripheral-blood specimens were immunocytochemically stained for Fas-ligand and Gr, and increments in the liver were calculated by subtracting frequencies of positive cells in blood from those in FNAB specimens. Only sporadically Fas ligand-expressing, but many Gr-expressing, cells were detected in FNAB specimens. Increments in Gr-positive (Gr(+)) cells were significantly greater in FNAB specimens obtained during clinical rejection (median, 70 Gr(+) cells; range, 0 to 312 Gr(+) cells; P = .006) and tended to be greater in FNAB specimens obtained during subclinical rejection (median, 62 Gr(+) cells; range, 5 to 113 Gr(+) cells; P = .09) compared with those obtained in the absence of rejection (median, 16 Gr(+) cells; range, 0 to 103 Gr(+) cells). Increments obtained during clinical or subclinical rejection did not differ from those obtained during CMV infection (median, 27 Gr(+) cells; range, 6 to 212 Gr(+) cells). With the exclusion of specimens obtained during CMV infection, the sensitivity of Gr determination in FNAB specimens for the diagnosis of acute rejection (either clinical or subclinical) was 70%, and specificity, 69%. In FNAB specimens obtained during clinical and subclinical acute rejection episodes after liver transplantation, increased numbers of Gr-expressing cells were present; in the absence of CMV infection, their quantification provides a measure for rejection activity with moderate accuracy.

Magnesium depletion in chronic terminal liver cirrhosis

Serum ionized magnesium represents less than 1% of the total body magnesium. The most reliable method to evaluate magnesium status is the magnesium loading test: In magnesium depletion its uptake is increased (20-50%) and is about 6% in normal magnesium status. There are no studies on magnesium status in chronic cirrhotics who may be in depletion. We performed magnesium loading test in 10 chronic cirrhotics listed for liver transplantation and in six healthy control patients. Magnesium sulphate 30 mmol was infused and urine magnesium was determined over 24 h. Serum ionized magnesium increased similarly in all patients. The uptake of magnesium was 8 +/- 8% in control patients and 34 +/- 26% in cirrhotics (p < 0.01). Chronic terminal cirrhotics are magnesium depleted which should be taken into account in case of liver transplantation and also in other interventions. Spot sampled serum ionized magnesium revealed magnesium depletion poorly.

CMV infection is usually associated with concurrent HHV-6 and HHV-7 antigenemia in liver transplant patients

Human herpesvirus 6 and 7 (HHV-6, HHV-7) have been recently reported in liver transplant patients. HHV-6 may cause fever, neurological disorders and hepatitis. The clinical significance of HHV-7 is less clear. HHV-6 and -7 are closely related to cytomegalovirus (CMV), and interactions between the viruses have also been suggested. In this study, we investigated the post transplant HHV-6 and -7 antigenemia was in relation to symptomatic CMV disease after liver transplantation. Consecutive 34 adult liver allograft recipients transplanted during 1999-2000 were included in the study. CMV infections were diagnosed by the frequent monitoring of pp65-antigenemia and by viral cultures. HHV-6 and -7 were demonstrated, by using immunoperoxidase staining and monoclonal antibodies against the virus specific antigens, in the mononuclear cells from the same blood specimens which were obtained for CMV pp65 monitoring. Altogether 322 blood specimens were analyzed. CMV disease was diagnosed in 12 (35%) patients during the first 3 months (first pp65 positive specimen mean 25 days, range 8-61 days) after transplantation. Concurrent HHV-6 antigenemia was detected in 10/12 (mean 14 days, range 6-22 days) and HHV-7 antigenemia in 9/12 patients (mean 25 days, range 10-89 days) after transplantation. HHV-6 usually appeared slightly before CMV. All CMV infections were successfully treated with ganciclovir and the CMV-antigenemia subsided. HHV-6 and -7 antigenemia also responded to the antiviral treatment, but more slowly than CMV. In conclusion, CMV infection was usually associated with HHV-6 and -7 antigenemia in liver transplant patients. The results support the suggestion that CMV, HHV-6 and -7 may have interactions. The clinical symptoms of CMV infection, may also be linked with HHV-6 or -7.

Monitoring of viral load by quantitative plasma PCR during active cytomegalovirus infection of individual liver transplant patients

A quantitative PCR test, the Cobas Amplicor CMV Monitor, was used for the monitoring of viral load in the peripheral blood of 27 individual liver transplant patients and correlated with cytomegalovirus (CMV) pp65 antigenemia. Altogether, 243 specimens were analyzed. During the first 3 months, 20 patients showed PCR positivity which correlated with pp65 antigenemia. Of those, 13 patients developed symptomatic CMV infection 27 to 52 days after transplantation, with a significantly higher peak viral load in PCR and in pp65 assay compared with the seven asymptomatic infections (median 10,200 versus 2,240 copies/ml, P < 0.05, and median 100 versus 30 pp65-positive cells/50,000 leukocytes, P < 0.01). Five were primary infections of D+/R- cases (donor CMV seropositive and recipient seronegative) and demonstrated, except in one case, a high peak viral load (>10,000 copies/ml; range, 10,200 to 21,600 copies, and > or =50 positive cells, range, 50 to 800 cells). The peak viral loads of the six D+/R+ patients with symptomatic infection varied widely (range, 2,290 to 126,000 copies and 50 to 300 positive cells). Two D-/R+ patients developed symptomatic infection with a lower viral load (range, 1,120 to 6,510 copies and 25 to 100 positive cells). All symptomatic infections were successfully treated with ganciclovir. The asymptomatic infections all in D+/R+ patients with low copy numbers (<5,500 copies) were monitored until CMV disappeared. One of the seven PCR-negative patients had one sample with low antigenemia, but the subsequent specimens were all negative. The time-related correlation of the two methods was also good. In summary, quantitative PCR could equally well be used as the CMV pp65 assay for the monitoring of viral load in individual transplant patients.

The use of fine-needle aspiration biopsy in detection of acute rejection in children after liver transplantation

Diagnosis of acute rejection after liver transplantation is based mainly on clinical signs and the liver core biopsy findings. In this study we retrospectively analyzed our data on the routine use of fine-needle aspiration biopsy (FNAB) after 63 pediatric liver transplantations. A total of 824 FNABs was taken during the postoperative hospitalization, with a mean of 13 biopsies per patient. Forty-nine acute rejection episodes were diagnosed and treated after 39 transplantations (62%). The FNAB analysis detected rejections often before clinical signs. At the time of rejection diagnosis, fever was present in 38% of the patients, and serum bilirubin and alanine aminotransferase were elevated in only 19% and 13%, respectively. The rejections responded well to oral methylprednisolone, and lymphoglobulins were needed in only two episodes (4%). The results indicate that FNAB is a safe and sensitive method for the diagnosis and follow up of acute cellular rejection in pediatric liver recipients.