Anti-alpha-fetoprotein imaging is useful for staging hepatoblastoma

BACKGROUND

Liver transplantation (Tx) has become an alternative treatment of malignant childhood liver tumors, and the importance of careful pretransplantation evaluation has been emphasized. Anti-alpha-fetoprotein (AFP) imaging has been suggested for evaluation of adult patients with AFP-positive tumors.

METHODS

Antibody imaging utilizing Tc-99 m-labeled monoclonal anti-AFP Fab' fragments was used to demonstrate pathologic uptake in hepatoblastoma (HB).

RESULTS

Radical operation or liver Tx was not possible after four cycles of chemotherapy in a child with HB because of a single extrahepatic metastasis. Chemotherapy was continued, and reevaluation with anti-AFP imaging demonstrated a pathologic uptake only in the liver. Subsequently, a right liver lobe resection was performed. Along with a new rise in serum AFP, repeated anti-AFP imaging revealed active liver tumor but no metastases. A liver Tx was performed, and the child is well with a normal serum AFP level 18 months after the operation.

CONCLUSION

This is the first case of pediatric HB in which anti-AFP imaging has been successfully used for patient management.

Celiac disease in patients with severe liver disease: gluten-free diet may reverse hepatic failure

BACKGROUND & AIMS

Mild liver abnormalities are common in patients with celiac disease and usually resolve with a gluten-free diet. We investigated the occurrence of celiac disease in patients with severe liver failure.

METHODS

Four patients with untreated celiac disease and severe liver disease are described. Further, the occurrence of celiac disease was studied in 185 adults with previous liver transplantation using serum immunoglobulin A endomysial and tissue transglutaminase antibodies in screening.

RESULTS

Of the 4 patients with severe liver disease and celiac disease, 1 had congenital liver fibrosis, 1 had massive hepatic steatosis, and 2 had progressive hepatitis without apparent origin. Three were even remitted for consideration of liver transplantation. Hepatic dysfunction reversed in all cases when a gluten-free diet was adopted. In the transplantation group, 8 patients (4.3%) had celiac disease. Six cases were detected before the operation: 3 had primary biliary cirrhosis, 1 had autoimmune hepatitis, 1 had primary sclerosing cholangitis, and 1 had congenital liver fibrosis. Only 1 patient had maintained a long-term strict gluten-free diet. Screening found 2 cases of celiac disease, 1 with autoimmune hepatitis and 1 with secondary sclerosing cholangitis.

CONCLUSIONS

The possible presence of celiac disease should be investigated in patients with severe liver disease. Dietary treatment may prevent progression to hepatic failure, even in cases in which liver transplantation is considered.

Comparison of plasma polymerase chain reaction and pp65-antigenemia assay in the quantification of cytomegalovirus in liver and kidney transplant patients

BACKGROUND

Cytomegalovirus (CMV) is a significant problem in transplantation. The antiviral treatment is based on the clinical symptoms and the rapid laboratory diagnosis. Although polymerase chain reaction (PCR) methods have already been widely used, the clinical correlation of the findings is not clear.

OBJECTIVE

The objective of this study was to investigate the usefulness of a quantitative plasma PCR test and compare it with the pp65-antigenemia test in the detection of clinically significant CMV infections in liver and kidney transplant patients.

STUDY DESIGN

The clinical material consisted of 253 consecutive blood samples was tested using a quantitative polymerase chain reaction test, Cobas Amplicor CMV Monitor (Roche) and pp65 antigenemia assay. Plasma was used for PCR and leucocytes were used for the antigenemia test.

RESULTS

CMV was detected in 89 out of 253 blood samples by one or both methods. PCR detected 78 (range 274-165000 copies/ml) and pp65 antigenemia test 79 (range 1-1500 positive cells/50000) of the positive findings. The sensitivity and specificity of PCR test was 86 and 94%, respectively. The PCR detected all clinically significant CMV infections (>10 positive cells in pp65 test) and infections which required antiviral treatment. In addition, the correlation between the two tests was almost linear.

CONCLUSIONS

The quantitative PCR appears to be a suitable alternative to diagnose and monitor CMV infections in transplant patients.

HFE haemochromatosis gene mutations in liver transplant patients

BACKGROUND

The majority of patients with inherited haemochromatosis carry two mutant alleles of the recently discovered HFE gene. Individuals heterozygous for the HFE mutation could be predisposed to end-stage liver disease due to other causes.

METHODS

The frequencies of the HFE gene mutations C282Y and H63D were determined in DNA samples obtained from 189 liver transplant patients and 225 healthy Finnish blood donors.

RESULTS

5% of the 189 liver transplant recipients were heterozygotes and 0.5% homozygotes for the C282Y mutation, while 16% were heterozygotes and 0.5% homozygotes for the H63D mutation. These figures were not increased in comparison to controls, of whom 11% were C282Y heterozygotes, 16% H63D heterozygotes and 0.9% H63D homozygotes. Among recipients with acute non-A-E hepatitis (n = 31), the frequency of the H63D allele was higher than in controls (21% versus 9.1%, P < 0.01). Perls' stain for iron in explanted liver specimens was positive in 28% of recipients with alcoholic cirrhosis, 26% of patients with acute non-A-E hepatitis and 14% in the rest of the recipients. The HFE genotypes did not correlate with the iron status.

CONCLUSION

Individuals heterozygous for either the C282Y or H63D mutation of the HFE gene are not at increased risk of developing chronic end-stage liver disease. However, subjects heterozygous for the H63D mutation may have an increased risk to develop fulminant non-A-E hepatitis.

HHV-6 reactivation is often associated with CMV infection in liver transplant patients

Human herpesvirus 6 (HHV-6) infection has been recently reported in liver transplant patients. HHV-6 is closely related to cytomegalo-virus (CMV), and some interaction between the viruses has been suggested. In this study, the post-transplant HHV-6 antigenemia was investigated in relation to symptomatic CMV infections in adult liver transplant patients. CMV infections were diagnosed by the pp65 antigenemia test and by viral cultures. HHV-6 infections were demonstrated by the HHV-6 antigenemia test and by serology. Significant symptomatic CMV infection was diagnosed in 42 of 75 patients during the first 6 months after transplantation. All CMV infections were successfully treated with ganciclovir. Concurrent HHV-6 antigenemia was detected in 21 (50%) of 42 patients with CMV infection. All HHV-6 infections were reactivations. HHV-6 also responded to the antiviral treatment, but with less clear effect. In conclusion, HHV-6 reactivation is often associated with CMV infection in liver transplant patients. The results support the suggestion that CMV and HHV-6 may have interactions.

Liver transplantation in patients over 60 years of age

Liver transplantation was previously only offered to patients under 60 years of age. We have analyzed the outcome after acceptance on the waiting list and after liver transplantation of patients over 60 years old. A total of 150 patients over 60 years old were listed for a first liver transplantation during 1990-1998. The annual number increased throughout the period. Primary biliary cirrhosis, primary sclerosing cholangitis, and acute hepatic failure were the most frequent diagnoses. A total of 119 patients received a first liver allograft. The patient 1-year survival was 75% and 3-year survival 62%, which was not significantly lower (P = 0.21) than that of the younger patients. When correcting for year of transplantation, the survival was, however, moderately but significantly lower than among the younger patients. Survival among those > 65 years (n = 38) did not differ from that of patients 60-65 years of age (n = 81). We conclude that an increasing number of patients over 60 years old can be listed for liver transplantation and receive a liver allograft with highly satisfying results.

A simple method for predicting bone fractures in PBC patients after liver transplantation

We introduce a simple serum test to predict which patients will have bone problems after liver transplantation. The crosslinked part of collagen I (s-ICTP) was measured in 21 patients with primary biliary cirrhosis before transplantation. Those with postoperative fractures had increased pretransplant values of s-ICTP compared with those without fractures.

Improved outcome of renal transplantation in amyloidosis

We report our results in 96 patients with amyloidosis who received 105 cadaveric renal allografts. The graft survival of amyloidosis patients has improved with time and with improved immunosuppression. The graft survival of amyloidosis patients is comparable to the results in another systemic disease, i. e., diabetes, and only slightly inferior to those in primary renal disease, even though amyloidosis patients tolerate complications poorly and the patients are at high risk of dying during the first 3 months.

Relationship between renal histology and later graft outcome

We have created the chronic allograft damage index (CADI), which quantifies the early histopathological changes in renal allografts. In this study we showed that the CADI at 2 years after renal transplantation predicted the graft outcome 4 years later and that the CADI identified the risk group that proceeded to chronic rejection during subsequent years.

Biliary complications in 100 adult liver transplantations: a retrospective clinical study

Biliary complications were reviewed in 100 consecutive adult liver transplantations. Included in the study were 92 patients surviving for more than 1 month. In 86 transplantations biliobiliary anastomosis was performed with (n = 25) or without (n = 61) a T-tube. In six cases biliodigestive anastomosis (Roux-en-Y) was performed. Biliary stricture caused by hepatic arterial thrombosis was not included. Biliary complications were seen in 17 cases: seven anastomotic strictures, four T-tube-related leakages, four anastomotic leakages, one leakage of unknown origin and one late cholangitis. Nine were surgically treated (six strictures and three leakages). Patients with primary sclerosing cholangitis had the highest biliary complication rate (36%). Early anastomotic strictures were associated with a higher rate of major bacterial infections (P = 0.03) and CMV disease (P = 0.08) than those without biliary complications. Biliobiliary anastomosis with a T-tube was associated with more complications (28%) than anastomoses without a T-tube (13%). To date, total patient survival including all 100 transplantations was 71% (median follow-up 3.3 years). We conclude that biliary complications are rather common but they do not affect survival and can be treated. Biliary T-tubes can be omitted.

Neurological recovery after liver transplantation: a prospective study of 22 patients

A group of 22 liver transplantation patients were examined pre- and postoperatively using clinical neurological, neurophysiological and neuroradiological methods. After the operation improvement was observed in neurological symptoms, and in neuropsychological and neurophysiological test results. Our study shows that liver recipients have a high prevalence of nervous system dysfunction and that successful transplantation is followed by significant improvement.

Good and impaired response to ganciclovir treatment of severe CMV infections in liver transplant recipients

In this study we investigated good and impaired clinical responses to ganciclovir treatment of severe CMV disease in 23 adult liver transplant patients. CMV episodes were diagnosed by direct immunodetection of CMV-specific antigens in blood leukocytes and by viral cultures. The patients were monitored weekly for CMV antigenemia during the antiviral treatment. Sixteen out of 23 patients recovered from CMV episodes with the standard ganciclovir therapy of 2 weeks. Seven patients demonstrated an impaired response to ganciclovir and had to be treated for longer than 2 weeks (29 +/- 9 days). The patients with an impaired response to ganciclovir also demonstrated higher CMV antigenemia levels compared to those with good a response, and all still had antigenemia after 2 weeks' therapy. Thus, most severe CMV infections in liver transplant patients subsided with ganciclovir treatment of 2 weeks, but impaired responses also occurred and patients had to be treated for several weeks with ganciclovir before they recovered from CMV.

Transdermal oestrogen therapy protects postmenopausal liver transplant women from osteoporosis. A 2-year follow-up study

BACKGROUND/AIMS

Hormone replacement therapy (HRT) prevents osteoporosis in postmenopausal women by inhibiting bone resorption, but the benefits of oestrogen therapy in liver transplant patients have not been studied.

METHODS

The effect of transdermal HRT was studied in 33 postmenopausal liver transplant women. The main outcome measure was the change in bone mineral density (BMD) which was measured annually for 2 years. The effect on bone turnover was studied by assessment of the serum aminoterminal propeptide of type I procollagen (PINP).

RESULTS

The mean lumbar BMD increased from 0.816 at baseline to 0.858 and to 0.878 g/cm2 (P < 0.001) after 1 and 2 years of therapy, respectively. The BMD of the femoral neck increased from 0.665 to 0.690 g/cm2 (P < 0.006). During the first and second years, the mean BMD of the lumbar spine increased by 5.3 and 1.2%, while that of the femoral neck increased by 3.3 and 1.2%. After 2 years of HRT, only one-fifth of the patients had osteoporosis, whereas over half of the women had osteoporosis at baseline. The median serum PINP decreased by 47% at 1 year and remained decreased at 2 years compared with baseline levels.

CONCLUSION

Transdermal HRT decreased the turnover rate of mineralized bone matrix. Transplant women responded with increased BMD, just like healthy postmenopausal women.

Diagnostic implications of human cytomegalovirus immediate early-1 and pp67 mRNA detection in whole-blood samples from liver transplant patients using nucleic acid sequence-based amplification

Nucleic acid sequence-based amplification (NASBA) was used for detection of the human cytomegalovirus (CMV) immediate early-1 (IE) and the late pp67 mRNA in 353 blood samples collected from 34 liver transplant patients. The diagnostic value of these assays was compared to that of the pp65 antigenemia assay. Overall, 95 and 42% of the antigenemia-positive samples were IE NASBA and pp67 NASBA positive, respectively. Although the results from pp67 NASBA and the antigenemia assay appeared to correspond poorly, a clear correlation was seen between pp67 NASBA-negative results and low numbers of pp65 antigen-positive cells. Twenty patients (59%) were treated with ganciclovir after the diagnosis of symptomatic CMV infection. Before initiation of the antiviral therapy, the antigenemia assay detected the onset of symptomatic infection in all patients, whereas 95 and 60% of these patients were IE NASBA and pp67 NASBA positive, respectively. Although the sensitivity of IE NASBA was very high, the positive predictive value (PPV) of this assay for the onset of a symptomatic infection was only 63%. The PPV of the antigenemia assay as well as pp67 NASBA was considerably higher (80 and 86%, respectively). Thus, the detection of IE mRNA using NASBA appears to be particularly useful as a marker for early initiation of antiviral therapy in patients at high risk for the development of a symptomatic infection. Also, IE NASBA was found to be more sensitive than the antigenemia assay for monitoring CMV infection during antiviral therapy. On the contrary, pp67 NASBA did not appear to have additional diagnostic value compared to the antigenemia assay.