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Nano O, Ivanov S, Kapoor T. Vanishing Bile Duct Syndrome in a Patient With Recurrent Hodgkin Lymphoma. J Med Cases 2023; 14:162-168. [PMID: 37303969 PMCID: PMC10251707 DOI: 10.14740/jmc4073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/06/2023] [Indexed: 06/13/2023] Open
Abstract
Vanishing bile duct syndrome (VBDS) is an acquired syndrome characterized by clinical and laboratory signs of cholestasis with pathologic findings of interlobular bile duct paucity in liver biopsy specimens. VBDS can result from a variety of conditions including infections, autoimmune diseases, adverse drug reactions, and neoplastic processes. Hodgkin lymphoma (HL) is a rare cause of VBDS. The mechanism by which HL leads to VBDS remains unknown. Development of VBDS in patients with HL portends an extremely poor prognosis due to the risk of progression to fulminant hepatic failure. Treatment of the underlying lymphoma has been demonstrated to offer increased probability of recovery from VBDS. The decision to treat and choice of treatment of the underlying lymphoma is often complicated by the hepatic dysfunction characteristic of VBDS. We present the case of a patient who presented with dyspnea and jaundice in the context of recurrent HL and VBDS. We additionally review the literature on HL complicated by VBDS with specific focus on treatment paradigms for management of these patients.
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Affiliation(s)
- Olger Nano
- Department of Hematology and Oncology, Memorial Healthcare System, Hollywood, FL 33021, USA
- Department of Hematology and Oncology, Memorial Cancer Institute, Pembroke Pines, FL 33026, USA
| | - Stanislav Ivanov
- Department of Hematology and Oncology, Memorial Healthcare System, Hollywood, FL 33021, USA
- Department of Hematology and Oncology, Memorial Cancer Institute, Pembroke Pines, FL 33026, USA
| | - Tarun Kapoor
- Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
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2
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Doss KM, Kling CE, Heldman MR, Singh N, Wagener M, Rakita RM, Fisher CE, Limaye AP. Real-world effectiveness of preemptive therapy (PET) for cytomegalovirus (CMV) disease prevention in CMV high-risk donor seropositive/recipient seronegative (D+R-) liver transplant recipients (LTxR). Transpl Infect Dis 2023; 25:e14015. [PMID: 36734631 DOI: 10.1111/tid.14015] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/06/2022] [Accepted: 12/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite superiority of preemptive therapy (PET) compared to universal prophylaxis for prevention of cytomegalovirus (CMV) disease in the CAPSIL randomized trial among CMV D+R- liver transplant recipients (LTxRs), real-world effectiveness may be lower because of logistical concerns about feasibility of PET. METHODS We retrospectively assessed PET as standard clinical care at a single transplant center among 50 consecutive adult CMV D+R- LTxRs undergoing a first liver transplant between 4/4/2019 and 5/18/2021 and compared outcomes and adherence to those randomized to PET in the CAPSIL study (N = 100). The primary outcome was CMV disease and secondary outcomes were biopsy-confirmed acute allograft rejection, retransplant, invasive fungal infections, and death, all assessed by 1-year post-transplant. Exploratory outcomes included virologic parameters and measures of adherence to protocol-specified CMV qPCR monitoring. RESULTS Baseline characteristics were similar between groups. The cumulative incidence of CMV disease at 1-year post-transplant was 4/50 (8%) versus 9/100 (9%) in the real-world and CAPSIL cohorts, respectively, p = 1.0. The rate of breakthrough CMV disease during the 100-day PET period was low (2/50 [4%]) and similar to the PET cohort from the CAPSIL study (3/100 [3%]). All secondary and exploratory outcomes were not significantly different between the real-world and CAPSIL PET cohorts. CONCLUSIONS In this first reported study of real-world PET, the feasibility and effectiveness for CMV disease prevention and for other clinical outcomes in CMV D+R- LTxRs were similar to those reported with PET in a clinical trial. Additional studies to confirm feasibility and generalizability in other settings are warranted.
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Affiliation(s)
- Kathleen M Doss
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Catherine E Kling
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Madeleine R Heldman
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Nina Singh
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Robert M Rakita
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Cynthia E Fisher
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Ajit P Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
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3
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Khot R, Morgan MA, Nair RT, Ludwig DR, Arif-Tiwari H, Bhati CS, Itani M. Radiologic findings of biliary complications post liver transplantation. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:166-185. [PMID: 36289069 DOI: 10.1007/s00261-022-03714-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/08/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023]
Abstract
Liver transplantation is a potentially curative treatment for patients with acute liver failure, end-stage liver disease, and primary hepatic malignancy. Despite tremendous advancements in surgical techniques and immunosuppressive management, there remains a high rate of post-transplant complications, with one of the main complications being biliary complications. In addition to anastomotic leak and stricture, numerous additional biliary complications are encountered, including ischemic cholangiopathy due to the sole arterial supply of the bile ducts, recurrence of primary biliary disease, infections, biliary obstruction from stones, cast, or hemobilia, and less commonly cystic duct remnant mucocele, vanishing duct syndrome, duct discrepancy and kinking, post-transplant lymphoproliferative disorder, retained stent, and ampullary dysfunction. This article presents an overview of biliary anatomy and surgical techniques in liver transplantation, followed by a detailed review of post-transplant biliary complications with their corresponding imaging findings on multiple modalities with emphasis on magnetic resonance imaging and MR cholangiopancreatography.
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Affiliation(s)
- Rachita Khot
- Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.
| | - Matthew A Morgan
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Rashmi T Nair
- Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Daniel R Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO, 63110, USA
| | - Hina Arif-Tiwari
- Department of Medical Imaging, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Chandra S Bhati
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Malak Itani
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO, 63110, USA
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4
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Human cytomegalovirus: a survey of end-organ diseases and diagnostic challenges in solid organ transplant recipients. Curr Opin Organ Transplant 2022; 27:243-249. [PMID: 36354249 DOI: 10.1097/mot.0000000000000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE OF REVIEW Human cytomegalovirus (CMV) infection is one of the most important infectious complications in solid organ transplant (SOT) recipients, leading to significant morbidity and mortality. Therefore, early detection and prompt treatment are imperative to improve transplant outcomes. This article highlights the clinical characteristics of the most common CMV end-organ diseases in SOT recipients and their diagnostic modalities and challenges. RECENT FINDINGS CMV can cause a variety of end-organ diseases in SOT recipients. Although CMV nucleic acid amplification by polymerase chain reaction (PCR) is frequently employed to detect CMV reactivation or infection, its predictive value for various CMV end-organ diseases remains uncertain. Given the limitation of PCR or other noninvasive tests, confirmation of CMV end-organ disease may require tissue biopsy, which may not be feasible or available, or may cause untoward complications. SUMMARY The utility of PCR to diagnose CMV end-organ disease is limited. As CMV can infect any organ system(s), clinicians caring for SOT recipients need to maintain vigilance for any signs and symptoms of end-organ disease to allow early recognition and prompt treatment. Invasive procedures might be needed to confirm the diagnosis and minimize the empirical use of antiviral therapy that may have substantial drug toxicities.
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5
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Izzo P, Gallo G, Codacci Pisanelli M, D’Onghia G, Macci L, Gabriele R, Polistena A, Izzo L, Izzo S, Basso L. Vanishing Bile Duct Syndrome in an Adult Patient: Case Report and Review of the Literature. J Clin Med 2022; 11:3253. [PMID: 35743323 PMCID: PMC9225336 DOI: 10.3390/jcm11123253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/01/2022] [Accepted: 06/06/2022] [Indexed: 12/04/2022] Open
Abstract
Vanishing bile duct syndrome (VBDS) is a rare condition characterized by progressive loss, destruction, and disappearance of the intra-hepatic bile ducts, leading to cholestasis and ductopenia. The exact mechanism of development of VDBS has not been established yet. Diagnosis of VBDS mainly relies on clinical and disease related presentations, but liver biopsy is compulsory for diagnosis. Due to the low incidence reported in the literature, a standardized treatment of VDBS has not been established; hence, this rare condition must be managed at a tertiary liver referral center. Here, we report the management and treatment of VBDS of an 81-year-old woman without any history of exposure to antibiotics, neoplasms, etc.
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Affiliation(s)
- Paolo Izzo
- “Pietro Valdoni” Department of Surgery, Policlinico “Umberto I”, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (P.I.); (M.C.P.); (G.D.); (L.M.); (R.G.); (A.P.); (L.I.); (L.B.)
| | - Gaetano Gallo
- Department of Surgical Sciences, Policlinico “Umberto I”, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Massimo Codacci Pisanelli
- “Pietro Valdoni” Department of Surgery, Policlinico “Umberto I”, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (P.I.); (M.C.P.); (G.D.); (L.M.); (R.G.); (A.P.); (L.I.); (L.B.)
| | - Giuliano D’Onghia
- “Pietro Valdoni” Department of Surgery, Policlinico “Umberto I”, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (P.I.); (M.C.P.); (G.D.); (L.M.); (R.G.); (A.P.); (L.I.); (L.B.)
| | - Leonardo Macci
- “Pietro Valdoni” Department of Surgery, Policlinico “Umberto I”, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (P.I.); (M.C.P.); (G.D.); (L.M.); (R.G.); (A.P.); (L.I.); (L.B.)
| | - Raimondo Gabriele
- “Pietro Valdoni” Department of Surgery, Policlinico “Umberto I”, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (P.I.); (M.C.P.); (G.D.); (L.M.); (R.G.); (A.P.); (L.I.); (L.B.)
| | - Andrea Polistena
- “Pietro Valdoni” Department of Surgery, Policlinico “Umberto I”, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (P.I.); (M.C.P.); (G.D.); (L.M.); (R.G.); (A.P.); (L.I.); (L.B.)
| | - Luciano Izzo
- “Pietro Valdoni” Department of Surgery, Policlinico “Umberto I”, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (P.I.); (M.C.P.); (G.D.); (L.M.); (R.G.); (A.P.); (L.I.); (L.B.)
| | - Sara Izzo
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Plastic Surgery Unit, Università degli Studi della Campania “Luigi Vanvitelli”, Piazza Luigi Miraglia 1, 80138 Napoli, Italy;
| | - Luigi Basso
- “Pietro Valdoni” Department of Surgery, Policlinico “Umberto I”, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (P.I.); (M.C.P.); (G.D.); (L.M.); (R.G.); (A.P.); (L.I.); (L.B.)
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Fasullo M, Patel M, Khanna L, Shah T. Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000778. [PMID: 35552193 PMCID: PMC9109012 DOI: 10.1136/bmjgast-2021-000778] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/21/2022] [Indexed: 12/29/2022] Open
Abstract
Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease. Long-term survival is excellent, yet LT recipients are at risk of significant complications. Biliary complications are an important source of morbidity after LT, with an estimated incidence of 5%-32%. Post-LT biliary complications include strictures (anastomotic and non-anastomotic), bile leaks, stones, and sphincter of Oddi dysfunction. Prompt recognition and management is critical as these complications are associated with mortality rates up to 20% and retransplantation rates up to 13%. This review aims to summarise our current understanding of risk factors, natural history, diagnostic testing, and treatment options for post-transplant biliary complications.
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Affiliation(s)
- Matthew Fasullo
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Milan Patel
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Lauren Khanna
- Gastroenterology, New York University Medical Center, New York, New York, USA
| | - Tilak Shah
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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Malik A, Thanekar U, Mourya R, Shivakumar P. Recent developments in etiology and disease modeling of biliary atresia: a narrative review. ACTA ACUST UNITED AC 2020; 3. [PMID: 33615212 PMCID: PMC7891552 DOI: 10.21037/dmr-20-97] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Biliary atresia (BA) is a rare but severe fibroinflammatory disease of the extrahepatic and the intrahepatic bile ducts. Without prompt interventions, BA has fatal outcomes and is the most common indicator for pediatric liver transplantation (LTx). While the mainstay of treatment involves surgically correcting the extrahepatic biliary obstruction via Kasai hepato-portoenterostomy (KHPE), activation of a multitude of biological pathways and yet-to-be-determined etiology in BA continue to foster liver inflammation, cirrhosis and need for LTx. However, important caveats still exist in our understandings of the biliary pathophysiology, the rapidity of liver fibrosis and progression to liver failure, largely due to limited knowledge of the triggers of biliary injury and the inability to accurately model human BA. Although inconclusive, a large body of existing literature points to a potential viral infection in the early peri- or postnatal period as triggers of epithelial injury that perpetuates the downstream biliary disease. Further confounding this issue, are the lack of in-vivo and in-vitro models to efficiently recapitulate the cardinal features of BA, primarily liver fibrosis. To overcome these barriers in BA research, new directions in recent years have enabled (I) identification of additional triggers of biliary injury linked mostly to environmental toxins, (II) development of models to investigate liver fibrogenesis, and (III) translational research using patient-derived organoids. Here, we discuss recent advances that undoubtedly will stimulate future efforts investigating these new and exciting avenues towards mechanistic and drug discovery efforts and disease-preventive measures. The implications of these emerging scientific investigations and disease modeling in severe fibrosing cholangiopathies like BA are enormous and contribute substantially in our understandings of this rare but deadly disease. These findings are also expected to facilitate expeditious identification of translationally targetable pathways and bring us one step closer in treating an infant with BA, a population highly vulnerable to life-long liver related complications.
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Affiliation(s)
- Astha Malik
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Unmesha Thanekar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Reena Mourya
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Pranavkumar Shivakumar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
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8
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Hung HC, Hsu PJ, Lee JC, Wang YC, Cheng CH, Wu TH, Wu TJ, Chou HS, Chan KM, Lee WC, Lee CF. Plasma cytomegalovirus DNA load predicts outcomes in liver transplant recipients. IMMUNITY INFLAMMATION AND DISEASE 2020; 9:134-143. [PMID: 33145985 PMCID: PMC7860522 DOI: 10.1002/iid3.371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022]
Abstract
Objective Cytomegalovirus (CMV) infection has a significant negative impact on liver transplant (LT) recipients. We aimed to evaluate the efficacy of real‐time DNA quantitative polymerase chain reaction (qPCR) in the early detection of CMV and predicting post‐transplant outcomes. Materials and Methods This was a retrospective study that enrolled a total of 49 adult LT recipients between December 2016 and October 2019. Serial CMV qPCR were tested weekly. We used operating characteristic curve analysis to quantify qPCR replication numbers to decide the optimal threshold to predict posttransplant complications and overall survival. Results The optimal cut‐off value of 180 copies/ml (=164 IU/ml) was determined. We had 40 patients in the low qPCR group (<180 copies/ml) and nine patients in the high qPCR group (≥180 copies/ml). Higher qPCR was associated with more severe CMV disease, early allograft dysfunction, major posttransplant complications, longer ICU stays, and lower 2‐year overall survival (OS; all p < .05). In the univariate logistic regression model, persistent DNAemia ≥ 4 weeks after anti‐CMV treatment, coexisted bacterial and/or fungal infection, and high CMV qPCR ≥ 180 copies/ml with p < .100. High CMV qPCR ≥ 180 copies/ml (p = .016; hazard ratio [HR] = 19.5; 95% confidence interval [CI] = 1.73–219.49) remained to be the only independent risk factors for major complication by the multivariate analysis. The overall 2‐year OS rates were 92.5% and 66.7% in the low and the high qPCR group, respectively (p = .030). Conclusion Our findings support evidence that qPCR is effective in detecting CMV infection provides an objective perspective in predicting posttransplant outcomes. High plasma CMV DNA load (defined as CMV qPCR ≥ 180 copies/ml or 164 IU/ml) not only indicates a hazard in developing major posttransplant complications but also associates with prolonged and refractory treatment courses.
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Affiliation(s)
- Hao-Chien Hung
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Po-Jung Hsu
- Department of General Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Jin-Chiao Lee
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan.,Chang-Gung University College of Medicine, Taoyuan City, Taiwan
| | - Yu-Chao Wang
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan.,Chang-Gung University College of Medicine, Taoyuan City, Taiwan
| | - Chih-Hsien Cheng
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan.,Chang-Gung University College of Medicine, Taoyuan City, Taiwan
| | - Tsung-Han Wu
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan.,Chang-Gung University College of Medicine, Taoyuan City, Taiwan
| | - Ting-Jung Wu
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan.,Chang-Gung University College of Medicine, Taoyuan City, Taiwan
| | - Hong-Shiue Chou
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan.,Chang-Gung University College of Medicine, Taoyuan City, Taiwan
| | - Kun-Ming Chan
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan.,Chang-Gung University College of Medicine, Taoyuan City, Taiwan
| | - Wei-Chen Lee
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan.,Chang-Gung University College of Medicine, Taoyuan City, Taiwan
| | - Chen-Fang Lee
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan.,Chang-Gung University College of Medicine, Taoyuan City, Taiwan
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9
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Lattanzi B, Ott P, Rasmussen A, Kudsk KR, Merli M, Villadsen GE. Ischemic Damage Represents the Main Risk Factor for Biliary Stricture After Liver Transplantation: A Follow-Up Study in a Danish Population. In Vivo 2019; 32:1623-1628. [PMID: 30348725 DOI: 10.21873/invivo.11423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Biliary complications (BC) are frequently observed following liver transplantation. The aim of the present retrospective study, conducted at an outpatients' tertiary care hospital, was to determine the incidence of biliary complications and risk factors associated with their development in liver transplantation (lT) patients. MATERIALS AND METHODS The medical records were reviewed for all patients who underwent liver transplantation at the Rigshospitalet, Copenhagen, Denmark, from 2000 to 2011 and were referred to the Aarhus University Hospital for follow-up. Patients who died within 3 months of surgery or had incomplete clinical information were excluded. All data for demographic characteristics and possible risk factors for development of biliary stricture were collected. Fifty-one patients were included. RESULTS The median age at transplantation was 40 (range=7-64) years, and 53% of patients were males. Biliary complications occurred in 18 patients (35%), the majority of whom developed strictures (12 patients, 24%). Univariate and multivariate analyses revealed that cytomegalovirus infection (p=0.008), hepatic artery obstruction (p=0.03) and hepatic artery graft abnormalities (p=0.03) were independent risk factors for the development of biliary strictures. CONCLUSION One-third of patients presented biliary complications after liver transplantation, among which biliary strictures were the most common. Cytomegalovirus infection, hepatic artery stenosis and anatomical abnormality of the graft's hepatic artery are independent risk factors for the development of biliary stricture.
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Affiliation(s)
- Barbara Lattanzi
- Department of Clinical Medicine, Umberto 1 Hospital, Rome, Italy
| | - Peter Ott
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Allan Rasmussen
- Department of Surgical Gastroenterology and Liver Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Karen Raben Kudsk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Manuela Merli
- Department of Clinical Medicine, Umberto 1 Hospital, Rome, Italy
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10
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Infections in Liver Transplantation. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7120017 DOI: 10.1007/978-1-4939-9034-4_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Liver transplantation has become an important treatment modality for patients with end-stage liver disease/cirrhosis, acute liver failure, and hepatocellular carcinoma. Although surgical techniques and immunosuppressive regimens for liver transplantation have improved significantly over the past 20 years, infectious complications continue to contribute to the morbidity and mortality in this patient population. The use of standardized screening protocols for both donors and recipients, coupled with targeted prophylaxis against specific pathogens, has helped to mitigate the risk of infection in liver transplant recipients. Patients with chronic liver disease and cirrhosis have immunological deficits that place them at increased risk for infection while awaiting liver transplantation. The patient undergoing liver transplantation is prone to develop healthcare-acquired infections due to multidrug-resistant organisms that could potentially affect patient outcomes after transplantation. The complex nature of liver transplant surgery that involves multiple vascular and hepatobiliary anastomoses further increases the risk of infection after liver transplantation. During the early post-transplantation period, healthcare-acquired bacterial and fungal infections are the most common types of infection encountered in liver transplant recipients. The period of maximal immunosuppression that occurs at 1–6 months after transplantation can be complicated by opportunistic infections due to both primary infection and reactivation of latent infection. Severe community-acquired infections can complicate the course of liver transplantation beyond 12 months after transplant surgery. This chapter provides an overview of liver transplantation including indications, donor-recipient selection criteria, surgical procedures, and immunosuppressive therapies. A focus on infections in patients with chronic liver disease/cirrhosis and an overview of the specific infectious complications in liver transplant recipients are presented.
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11
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Yadav SK, Saigal S, Choudhary NS, Saha S, Sah JK, Saraf N, Kumar N, Goja S, Rastogi A, Bhangui P, Soin AS. Cytomegalovirus infection in living donor liver transplant recipients significantly impacts the early post-transplant outcome: A single center experience. Transpl Infect Dis 2018; 20:e12905. [PMID: 29668120 DOI: 10.1111/tid.12905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 12/26/2017] [Accepted: 01/07/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is the most common viral infection in liver transplant recipients that influences the outcomes of liver transplantation. However, its impact on early outcomes following living donor liver transplantation (LDLT) is not fully defined in the Indian subcontinent. This study was done to assess the impact of CMV infection on early post-transplant outcomes in LDLT recipients. METHODS Out of 272 LDLTs performed from January 2012 to April 2013, 151 recipients underwent CMV viral load analysis in plasma within 90 days post LDLT based on clinical suspicion. Patients with CMV infection (n = 55) were compared with those without CMV infection (n = 96). RESULTS The median time interval of CMV infection from LDLT was 25 days (range 2-90 days). The mean age of study population was 48.92 years. About 116 (76.8%) of the patients were male. Hepatitis C virus (HCV) (39.1%)-related chronic liver disease (CLD) was most common indication for liver transplant. No statistically significant difference was observed in etiology of liver disease (P = .38), Chid-Turcotte-Pugh (CTP) (P = .41), and Model for End-stage Liver Disease (MELD) (P = .12) scores between the groups. Patients with CMV infection had significantly higher incidence of acute cellular rejection (16.1% vs 5.4%, P = .02); longer ICU stay (P = .01); and a higher overall 90-day mortality (24.2% vs 6.7%, P = .001). Bacteremia and fungemia were significantly more common in the CMV infection group. CONCLUSION Cytomegalovirus infection significantly influences the early post LDLT outcomes and contributes to increased overall mortality.
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Affiliation(s)
- Sanjay Kumar Yadav
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Narendra Singh Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Sujeet Saha
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Jayant Kumar Sah
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Naveen Kumar
- Department of Microbiology, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Sanjay Goja
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - A S Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
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12
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Zhao Z, Bao L, Yu X, Zhu C, Xu J, Wang Y, Yin M, Li Y, Li W. Acute vanishing bile duct syndrome after therapy with cephalosporin, metronidazole, and clotrimazole: A case report. Medicine (Baltimore) 2017; 96:e8009. [PMID: 28885366 PMCID: PMC6392967 DOI: 10.1097/md.0000000000008009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
RATIONALE Vanishing bile duct syndrome (VBDS) consists of a series of diseases characterized by the loss of >50% bile duct in portal areas. Many factors are associated with VBDS including infections, neoplasms, and drugs. Antibiotic is one of the most frequently reported causes of VBDS. PATIENT CONCERNS A 29-year-old female was admitted because of liver injury for over 3 months. Tests for viruses that can cause hepatitis and autoantibodies were all negative. She was prescribed with antibiotics approximately a week before liver injury while there was no history of alcohol consumption. DIAGNOSES Liver biopsy demonstrated a loss of intrahepatic bile duct in most of the portal tracts. INTERVENTIONS This patient was treated with ursodeoxycholic acid, polyene phosphatidylcholine, and bicyclol. Most importantly, the treatments in our hospital were proved by the ethics committee of Department of Infectious Disease, Anhui Provincial Hospital. OUTCOMES The symptoms were improved. She is still under treatment. LESSONS VBDS is rare but can be severe. A liver biopsy offers an important evidence for the diagnosis of VBDS, especially for those with a history of susceptible drugs taking.
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Affiliation(s)
- Zonghao Zhao
- Department of Infectious Disease, Third Liver Unit
| | - Lei Bao
- Department of Infectious Disease, Third Liver Unit
| | - Xiaolan Yu
- Department of Ear-Nose-Throat, Anhui Provincial Hospital, Anhui Medical University, Hefei
| | - Chuanlong Zhu
- Department of Infectious Disease, Jiangsu Provincial Hospital, Nanjing Medical University, Nanjing
| | - Jing Xu
- Department of Infectious Disease, Third Liver Unit
| | - Yu Wang
- Department of Infectious Disease, Third Liver Unit
| | - Ming Yin
- Department of Infectious Disease, Intensive Care Unit, Anhui Provincial Hospital, Anhui Medical University, Hefei, China
| | - Yi Li
- Department of Infectious Disease, Third Liver Unit
| | - Wenting Li
- Department of Infectious Disease, Third Liver Unit
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13
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Yadav SK, Saigal S, Choudhary NS, Saha S, Kumar N, Soin AS. Cytomegalovirus Infection in Liver Transplant Recipients: Current Approach to Diagnosis and Management. J Clin Exp Hepatol 2017; 7:144-151. [PMID: 28663679 PMCID: PMC5478971 DOI: 10.1016/j.jceh.2017.05.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/16/2017] [Indexed: 02/06/2023] Open
Abstract
Cytomegalovirus (CMV) infection is the most common viral infection in liver transplant recipients, affecting post-transplant patients and graft survival. Recent advances in diagnosis and management of CMV have led to marked reduction in incidence, severity, and its associated morbidity and mortality. CMV DNA assay is the most commonly used laboratory parameter to diagnose and monitor CMV infection. Current evidence suggests that both pre-emptive and universal prophylaxis approaches are equally justified in liver transplant recipients. Intravenous ganciclovir and oral valganciclovir are the most commonly used drugs for treatment of CMV disease. Most of the centre use valganciclovir prophylaxis for prevention of CMV disease in liver trasplant recipient. The aim of this article is to review the current standard of care for diagnosis and management of CMV disease in liver transplant recipients.
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Affiliation(s)
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine and Dept of Microbiology, Medanta The Medicity, Gurugram, India
| | | | | | - Navin Kumar
- Institute of Liver Transplantation and Regenerative Medicine and Dept of Microbiology, Medanta The Medicity, Gurugram, India
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14
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Verma A, Palaniswamy K, Cremonini G, Heaton N, Dhawan A. Late cytomegalovirus infection in children: High incidence of allograft rejection and hepatitis in donor negative and seropositive liver transplant recipients. Pediatr Transplant 2017; 21. [PMID: 28134467 DOI: 10.1111/petr.12879] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2016] [Indexed: 12/18/2022]
Abstract
The complications and outcome associated with late CMV infection and disease on the graft are poorly characterized in PLT recipients. We studied the overall incidence, risk factors, and outcome of late CMV infection and disease (infection 6 months after transplant) in 180 PLT recipients admitted between 2008 and 2011 at the King's College Hospital. Antiviral prophylaxis of intravenous ganciclovir was given only to the D+R- group starting at day 7 post-transplant. The remaining groups (D-R+, D+R+, and D-R-) received pre-emptive therapy when they have CMV viremia above cut-off value and treatment for symptomatic CMV infection. The overall incidence of late CMV infection and disease was 9.4% (19/180) and 14.5% (19/130) in D+R-, D-R+, D+R- groups. The D-R+ group had the highest incidence of hepatitis (37.5%) and significantly increased incidence of CMV disease, and single and multiple acute rejection episodes when compared to the D+R- group, which received prophylaxis. The late CMV infection and disease in pediatric LT recipients was comparable to adult LT recipients despite variable duration of antiviral prophylaxis. Our results show that D-R+ group had highest rate of hepatitis and rejection episodes, associated with high morbidity, and should be considered for antiviral prophylaxis.
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Affiliation(s)
- A Verma
- Institute of Liver Studies, King's College Hospital, London, UK
| | - K Palaniswamy
- Pediatric Liver, GI and Nutrition and Institute of Liver Studies, King's College Hospital, London, UK
| | - G Cremonini
- Pediatric Liver, GI and Nutrition and Institute of Liver Studies, King's College Hospital, London, UK
| | - N Heaton
- Institute of Liver Studies, King's College Hospital, London, UK
| | - A Dhawan
- Pediatric Liver, GI and Nutrition and Institute of Liver Studies, King's College Hospital, London, UK
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15
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Prevention and treatment of liver allograft antibody-mediated rejection and the role of the 'two-hit hypothesis'. Curr Opin Organ Transplant 2016; 21:209-18. [PMID: 26918881 DOI: 10.1097/mot.0000000000000275] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The review outlines the diagnosis, prevention strategies, and possible treatment options for acute and chronic antibody-mediated rejection (AMR). RECENT FINDINGS Although rare, severe acute AMR (aAMR) usually occurs in patients with high mean fluorescence intensity despite serial dilutions or high-titer preformed class I donor-specific alloantibodies (DSA). The diagnosis is suspected when allograft dysfunction occurs with DSA, diffuse C4d staining, and a microvascular injury, and may be aided by the aAMR score. However, the incidence of and treatment approach to combined T-cell-mediated rejection (TCMR) with DSA present and some but not all features of AMR is yet to be determined. Chronic liver allograft AMR is characterized by low-grade chronic inflammation and progressive fibrosis with DSA, the chronic AMR (cAMR) score may facilitate diagnosis. The 'two-hit' hypothesis, whereby a coexistent insult upregulates human leukocyte antigen class II target antigens on the microvascular endothelium, may explain why suboptimal donors with lower sensitization levels might suffer from acute AMR and those with chronic complications (e.g., recurrent original disease) might be more susceptible to chronic AMR. Although treatment algorithms are needed, prevention is preferable and at a minimum includes transfusion minimization, and medication adherence. SUMMARY Severe acute AMR is rare but diagnosable, and there is need to determine the incidence of and optimal therapy for less severe combined AMR and TCMR. Chronic AMR is likely more common and of significant relevance to long-term allograft survival improvement. The two-hit hypothesis may help to explain the rarity of both findings and shed insight onto future prevention and treatment strategies.
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16
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Chen F, Tu XL. Revaluation of vanishing bile duct syndrome. Shijie Huaren Xiaohua Zazhi 2016; 24:3445-3453. [DOI: 10.11569/wcjd.v24.i23.3445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Vanishing bile duct syndrome (VBDS) can result from multiple etiologies, including congenital and genetic diseases, ischemic causes, neoplastic disorders, infections, immune disorders, drugs, idiopathic adulthood ductopenia (IAD) and so on. Recently, lymphoma, HIV/AIDS and drugs were identified to be major etiologies in the reported cases, some of which presented complex clinical course and were contributed by more than one etiological factor. Hepatic biopsy must be done for the diagnosis of VBDS and immunohistochemical staining for cytokeratin 7 (CK7) and CK19 has contributed to the establishment of diagnosis of VBDS. VBDS can be usually treated with symptomatic and supportive therapy, etiological therapy, liver transplantation, ursodeoxycholic acid and immunosuppressive agents. Glucocorticoids can be tried to switch to mycophemolate mofeil or tacrolimus when their effects are poor or side effects are severe. Severe cases ought to receive multimodality therapy besides plasmapheresis.
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17
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A review of nationwide population study of organ transplantation in Taiwan. ACTA ACUST UNITED AC 2016; 54:70-4. [DOI: 10.1016/j.aat.2016.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/09/2016] [Accepted: 05/20/2016] [Indexed: 12/20/2022]
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18
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Kang G, Hong H, Lee I, Ahn K, Kim J, Choi D. Ganciclovir and Foscarnet Therapy of Cytomegalovirus-Associated Meningoencephalitis in a Hemodialysis Patient With Liver Transplantation: Case Report. Transplant Proc 2016; 48:1208-11. [DOI: 10.1016/j.transproceed.2016.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/11/2016] [Accepted: 01/21/2016] [Indexed: 10/21/2022]
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19
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Martin-Gandul C, Mueller NJ, Pascual M, Manuel O. The Impact of Infection on Chronic Allograft Dysfunction and Allograft Survival After Solid Organ Transplantation. Am J Transplant 2015; 15:3024-40. [PMID: 26474168 DOI: 10.1111/ajt.13486] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 07/14/2015] [Accepted: 08/06/2015] [Indexed: 01/25/2023]
Abstract
Infectious diseases after solid organ transplantation (SOT) are a significant cause of morbidity and reduced allograft and patient survival; however, the influence of infection on the development of chronic allograft dysfunction has not been completely delineated. Some viral infections appear to affect allograft function by both inducing direct tissue damage and immunologically related injury, including acute rejection. In particular, this has been observed for cytomegalovirus (CMV) infection in all SOT recipients and for BK virus infection in kidney transplant recipients, for community-acquired respiratory viruses in lung transplant recipients, and for hepatitis C virus in liver transplant recipients. The impact of bacterial and fungal infections is less clear, but bacterial urinary tract infections and respiratory tract colonization by Pseudomonas aeruginosa and Aspergillus spp appear to be correlated with higher rates of chronic allograft dysfunction in kidney and lung transplant recipients, respectively. Evidence supports the beneficial effects of the use of antiviral prophylaxis for CMV in improving allograft function and survival in SOT recipients. Nevertheless, there is still a need for prospective interventional trials assessing the potential effects of preventive and therapeutic strategies against bacterial and fungal infection for reducing or delaying the development of chronic allograft dysfunction.
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Affiliation(s)
- C Martin-Gandul
- Transplantation Center, University Hospital and University of Lausanne, Lausanne, Switzerland.,Infectious Diseases Service, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - N J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - M Pascual
- Transplantation Center, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - O Manuel
- Transplantation Center, University Hospital and University of Lausanne, Lausanne, Switzerland.,Infectious Diseases Service, University Hospital and University of Lausanne, Lausanne, Switzerland
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20
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Fernández-Simon A, Díaz-Gonzalez A, Thuluvath PJ, Cárdenas A. Endoscopic retrograde cholangiography for biliary anastomotic strictures after liver transplantation. Clin Liver Dis 2014; 18:913-26. [PMID: 25438291 DOI: 10.1016/j.cld.2014.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Biliary complications after liver transplantation (LT) are an important cause of morbidity and mortality. In most cases, an anastomosis of the bile duct is performed as a duct-to-duct reconstruction, which makes endoscopic therapy with endoscopic retrograde cholangiography (ERC) feasible. Biliary anastomotic strictures (AS) are the most common cause of biliary complications. The early detection of an AS, which can sometimes be challenging given that its clinical presentation is often subtle, is of key importance to obtain high treatment success. In this review, we focus on the management of AS after LT with a special emphasis on ERC.
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Affiliation(s)
- Alejandro Fernández-Simon
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona, Villarroel 170, Esc 3-2, Barcelona 08036, Spain
| | - Alvaro Díaz-Gonzalez
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona, Villarroel 170, Esc 3-2, Barcelona 08036, Spain
| | - Paul J Thuluvath
- Medical Director, Institute for Digestive Health & Liver Disease, Mercy Medical Center, 301 Street, Paul Place, Baltimore, MD 21202, USA
| | - Andrés Cárdenas
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona, Villarroel 170, Esc 3-2, Barcelona 08036, Spain.
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21
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O’Leary JG, Kaneku H, Demetris AJ, Marr JD, Shiller SM, Susskind BM, Tillery GW, Terasaki PI, Klintmalm GB. Antibody-mediated rejection as a contributor to previously unexplained early liver allograft loss. Liver Transpl 2014; 20:218-27. [PMID: 24382837 PMCID: PMC4623588 DOI: 10.1002/lt.23788] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 10/12/2013] [Accepted: 10/21/2013] [Indexed: 12/23/2022]
Abstract
We analyzed 60 patients with idiopathic early allograft loss (defined as death or retransplantation at <90 days) to determine the relative contribution of preformed donor-specific human leukocyte antigen alloantibodies (DSAs) to this endpoint, and we defined strict criteria for the diagnosis of antibody-mediated rejection (AMR) in liver allografts. The inclusion criteria encompassed the availability of a pretransplant serum sample and both postreperfusion and follow-up tissue specimens for a blinded, retrospective re-review of histology and complement component 4d (C4d) staining. AMR was diagnosed on the basis of the presence of all 4 of the following strict criteria: (1) DSAs in serum, (2) histopathological evidence of diffuse microvascular injury/microvasculitis consistent with antibody-mediated injury, (3) diffuse C4d staining in the portal microvasculature with or without staining in the sinusoids or central veins in at least 1 sample, and (4) the exclusion of other causes of a similar type of injury. Patients thought to be experiencing definite AMR on the basis of routine histopathology alone showed the highest levels of DSA sensitization. Forty percent of patients with pretransplant DSAs with a pattern of bead saturation after serial dilutions developed AMR. Another multiparous female developed what appeared to be a strong recall response, which resulted in combined AMR and acute cellular rejection (ACR) causing graft failure. A contribution of DSAs to allograft failure could not be excluded for 3 additional patients who received marginal grafts. In conclusion, liver allograft recipients with preformed DSAs with a high mean fluorescence intensity despite dilution seem to be at risk for clinically significant allograft injury and possibly for loss from AMR, often in combination with ACR.
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Affiliation(s)
- Jacqueline G. O’Leary
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas TX
| | - Hugo Kaneku
- University of California Los Angeles, Los Angeles, CA,Terasaki Foundation Laboratory, Los Angeles, CA
| | | | - John D. Marr
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas TX
| | | | - Brian M. Susskind
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas TX
| | - Glenn W. Tillery
- Department of Pathology, Baylor University Medical Center, Dallas, TX
| | - Paul I. Terasaki
- University of California Los Angeles, Los Angeles, CA,Terasaki Foundation Laboratory, Los Angeles, CA
| | - Göran B. Klintmalm
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas TX
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22
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O'Leary JG, Kaneku H, Jennings LW, Bañuelos N, Susskind BM, Terasaki PI, Klintmalm GB. Preformed class II donor-specific antibodies are associated with an increased risk of early rejection after liver transplantation. Liver Transpl 2013; 19:973-80. [PMID: 23780820 DOI: 10.1002/lt.23687] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 05/26/2013] [Indexed: 12/12/2022]
Abstract
Preformed donor-specific human leukocyte antigen antibodies (DSAs) are considered a contraindication to the transplantation of most solid organs other than the liver. Conflicting data currently exist on the importance of preformed DSAs in rejection and patient survival after liver transplantation (LT). To evaluate preformed DSAs in LT, we retrospectively analyzed prospectively collected samples from all adult recipients of primary LT without another organ from January 1, 2000 to May 31, 2009 with a pre-LT sample available (95.8% of the patients). Fourteen percent of the patients had preformed class I and/or II DSAs with a mean fluorescence intensity (MFI) ≥ 5000. Preformed class I DSAs with an MFI ≥ 5000 remained persistent in only 5% of patients and were not associated with rejection. Preformed class II DSAs with an MFI of 5000 to 10,000 remained persistent in 23% of patients, and this rate increased to 33% for patients whose MFI was ≥10,000 (P < 0.001). Preformed class II DSAs in multivariable Cox proportional hazards modeling were associated with an increased risk of early rejection [hazard ratio (HR) = 1.58; p = 0.004]. In addition, multivariate modeling showed that in comparison with no DSAs (MFI < 1000), preformed class I and/or II DSAs with an MFI ≥ 5000 were independently correlated with the risk of death (HR = 1.51; p = 0.02).
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Affiliation(s)
- Jacqueline G O'Leary
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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23
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Cytomegalovirus Infection in Liver Transplant Recipients. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2012. [DOI: 10.1097/ipc.0b013e31823c4817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Sanna C, Giordanino C, Giono I, Barletti C, Ferrari A, Recchia S, Reggio D, Repici A, Ricchiuti A, Salizzoni M, Baldi I, Ciccone G, Rizzetto M, Saracco G. Safety and efficacy of endoscopic retrograde cholangiopancreatography in patients with post-liver transplant biliary complications: results of a cohort study with long-term follow-up. Gut Liver 2011; 5:328-34. [PMID: 21927662 PMCID: PMC3166674 DOI: 10.5009/gnl.2011.5.3.328] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 02/08/2011] [Indexed: 12/19/2022] Open
Abstract
Background/Aims Endoscopic retrograde cholangiopancreatography (ERCP) is the standard approach for the management of biliary complications in liver transplant patients; however, its safety and efficacy have not been established in this setting. This study was performed to evaluate the safety and long-term efficacy of ERCP in transplant patients. Methods The case reports of 1,500 liver transplant patients were reviewed. Orthotopic liver transplantation (OLT) patients were matched 1:2 with non-OLT patients and followed-up for long-term outcome (median, 7.4 years). Results Of the 1,500 liver transplant patients, 94 (6.3%) underwent 150 ERCPs after OLT. Anastomotic strictures were present in 45 patients, biliary stones in 24, biliary leaks in 7, papillary stenosis in 2, and primary sclerosing cholangitis in 1. An ERCP success rate of 90.7% was achieved; biliary stenting led to resolution of the bile leak in 7/7 (100%) patients, and biliary stones were removed in 21/24 (87.5%) patients. In addition, 34 of 45 patients with anastomotic stricture underwent endoscopic dilation. We obtained complete resolution in 22/34 (64.7%) patients. OLT patients did not show a higher probability of complications (odds ratio [OR], 1.04), of pancreatitis (OR, 0.80) or of bleeding (OR, 1.34). Conclusions ERCP is safe and effective for the treatment of post-OLT biliary complications, has a low rate of pancreatitis and results in a durable effect.
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Affiliation(s)
- Claudia Sanna
- Department of Gastroenterology, University of Turin, Molinette Hospital, Turin, Italy
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25
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Musat A, Agni R, Wai P, Pirsch J, Lorentzen D, Powell A, Leverson G, Bellingham J, Fernandez L, Foley D, Mezrich J, D'Alessandro A, Lucey M. The significance of donor-specific HLA antibodies in rejection and ductopenia development in ABO compatible liver transplantation. Am J Transplant 2011; 11:500-10. [PMID: 21342448 PMCID: PMC3357120 DOI: 10.1111/j.1600-6143.2010.03414.x] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The role of humoral alloreactivity in ABO-compatible liver transplantation remains unclear. To understand the significance of donor-specific HLA alloantibodies (DSA) in liver rejection, we applied the currently used strategy for detection of antibody-mediated rejection of other solid allografts. For this purpose we reviewed the data on 43 recipients of ABO identical/compatible donor livers who had indication liver biopsy stained for complement element C4d and contemporaneous circulating DSA determination. Seventeen (40%) patients had significant circulating DSA in association with diffuse portal C4d deposition (DSA+/diffuse C4d+). These DSA+/diffuse C4d+ subjects had higher frequency of acute cellular rejection (ACR) 15/17 versus 13/26 (88% vs. 50%), p = 0.02, and steroid resistant rejection 7/17 versus 5/26 (41% vs. 19%), p = 0.03. Based on detection of the combination DSA+/diffuse C4d+, 53.6% of cases of ACR had evidence of concurrent humoral alloreactivity. Six of the 10 patients with ductopenic rejection had circulating DSA and diffuse portal C4d, three of whom (2 early and 1 late posttransplantation) developed unrelenting cholestasis, necessitating specific antibody-depleting therapy to salvage the allografts. Thus, in ABO-compatible liver transplantation humoral alloreactivity mediated by antibodies against donor HLA molecules appears to be frequently intertwined with cellular mechanisms of rejection, and to play a role in ductopenia development.
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Affiliation(s)
- A.I. Musat
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,Corresponding author: Alexandru I. Musat,
| | - R.M. Agni
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - P.Y. Wai
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - J.D. Pirsch
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - D.F. Lorentzen
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - A. Powell
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - G.E. Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - J.M. Bellingham
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - L.A. Fernandez
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - D.P. Foley
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - J.D. Mezrich
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - A.M. D'Alessandro
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - M.R. Lucey
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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26
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Akamatsu N, Sugawara Y, Hashimoto D. Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: a systematic review of the incidence, risk factors and outcome. Transpl Int 2010; 24:379-92. [PMID: 21143651 DOI: 10.1111/j.1432-2277.2010.01202.x] [Citation(s) in RCA: 224] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biliary reconstruction remains common in postoperative complications after liver transplantation. A systematic search was conducted on the PubMed database and 61 studies of retrospective or prospective institutional data were eligible for this review. The study comprised a total of 14,359 liver transplantations. The overall incidence of biliary stricture was 13%; 12% among deceased donor liver transplantation (DDLT) patients and 19% among living donor liver transplantation (LDLT) recipients. The overall incidence of biliary leakage was 8.2%, 7.8% among DDLT patients and 9.5% among LDLT recipients. An endoscopic strategy is the first choice for biliary complications; 83% of patients with biliary stricture were treated by endoscopic modalities with a success rate of 57% and 38% of patients with leakage were indicated for endoscopic biliary drainage. T-tube placement was not performed in 82% of duct-to-duct reconstruction. The incidence of biliary stricture was 10% with a T-tube and 13% without a T-tube and the incidence of leakage was 5% with a T-tube and 6% without a T-tube. A preceding bile leak and LDLT procedure are accepted risk factors for anastomotic stricture. Biliary complications remain common, which requires further investigation and the refinement of reconstruction techniques and management strategies.
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Affiliation(s)
- Nobuhisa Akamatsu
- Department of Hepato-biliary-pancreatic Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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27
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Lee SO, Razonable RR. Current concepts on cytomegalovirus infection after liver transplantation. World J Hepatol 2010; 2:325-36. [PMID: 21161017 PMCID: PMC2998977 DOI: 10.4254/wjh.v2.i9.325] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Revised: 09/03/2010] [Accepted: 09/10/2010] [Indexed: 02/06/2023] Open
Abstract
Cytomegalovirus (CMV) is the most common viral pathogen that negatively impacts on the outcome of liver transplantation. CMV cause febrile illness often accompanied by bone marrow suppression, and in some cases, invades tissues including the transplanted allograft. In addition, CMV has been significantly associated with an increased predisposition to allograft rejection, accelerated hepatitis C recurrence, and other opportunistic infections, as well as reduced overall patient and allograft survival. To negate the adverse effects of CMV on outcome, its prevention, whether through antiviral prophylaxis or preemptive therapy, is regarded as an essential component to the medical management of liver transplant patients. Two recent guidelines have suggested that antiviral prophylaxis or preemptive therapy are similarly effective in preventing CMV disease in modest-risk CMV-seropositive liver transplant recipients, while antiviral prophylaxis is the preferred strategy over preemptive therapy for the prevention of CMV disease in high-risk recipients [CMV-seronegative recipients of liver allografts from CMV-seropositive donors (D+/R-)]. However, antiviral prophylaxis has only delayed the onset of CMV disease in many CMV D+/R- liver transplant recipients, and at least in one study, such occurrence of late-onset primary CMV disease was significantly associated with increased mortality after liver transplantation. Therefore, optimized strategies for prevention are needed, and aggressive treatment of CMV infection and disease should be pursued. The standard treatment of CMV disease consists of intravenous ganciclovir or oral valganciclovir, and if feasible, one should also reduce the degree of immunosuppression. In one recent controlled clinical trial, valganciclovir was found to be as effective and safe as intravenous ganciclovir for the treatment of mild to moderate CMV disease in solid organ (including liver) transplant recipients. In this article, the authors review the current state and the future perspectives of prevention and treatment of CMV disease after liver transplantation.
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Affiliation(s)
- Sang-Oh Lee
- Sang-Oh Lee, Division of Infectious Diseases, College of Medicine, Mayo Clinic, Rochester, MN 55905, United States
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Nemes B, Sótonyi P, Lotz G, Heratizadeh A, Gelley F, Doege C, Hubay M, Schaff Z, Nashan B. Localization of apoptosis proteins and lymphocyte subsets in chronic rejection of human liver allograft. Interv Med Appl Sci 2010. [DOI: 10.1556/imas.2.2010.2.6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
In chronic liver rejection lymphocyte mediated processes lead to chronic inflammation, necrosis and repair mechanisms. The aim of the present study was to investigate the expression of apoptosis related proteins (FAS/APO-1, FAS-L, Bcl-2, Bax, TNF-α, and INF-γ). ApopTag reaction and immunohistochemistry were performed on liver samples of chronically rejected allografts and compared with normal donor livers. In chronic rejection, apoptosis was detected in pericentral hepatocytes and in the biliary epithelium. Bcl-2 was strongly expressed on lymphocytes around the bile ducts, but not on the biliary epithelium itself. Bax, FAS, TNF-α and INF-γ were present in pericentral areas. T-cells showed up around bile ducts, whereas macrophages around pericentral areas. In pericentral areas apoptosis seems to be fostered through TNF-α and INF-γ and by the lack of Bcl-2. Based on these results both downregulation and upregulation of apoptotic proteins can be observed in chronic liver allograft rejection: FAS is upregulated in biliary epithelium and zone 2, protein levels of FASL remain unchanged, BAX is upregulated in zone 3, BCL2 is downregulated in both biliary epithelium and zone 1 and both TNFa and IFN are upregulated in zone 3. Our results suggest that the balance between pro- and antiapoptotic patterns was shifted to the proapoptotic side, mainly in the centrilobular area of the hepatic lobule, and in the bile ducts. According to these findings in chronic rejection the predictive sites of apoptosis are the biliary epithelium and the pericentral areas.
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Affiliation(s)
- Balázs Nemes
- 1 Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - P. Sótonyi
- 2 Department of Cardiovascular Surgery, Semmelweis University, Városmajor u. 68, H-1122, Budapest, Hungary
| | - G. Lotz
- 3 2nd Department of Pathology, Semmelweis University, Üllői u. 93, H-1091, Budapest, Hungary
| | - A. Heratizadeh
- 4 Department of Dermatology, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - F. Gelley
- 1 Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - C. Doege
- 5 Department of Pediatric, Department of Neonatology, Ruptrecht-Karls University, Im Neuerheimer Feld 150, D-69120, Heidelberg, Germany
| | - M. Hubay
- 6 Department of Forensic Medicine, Semmelweis University, Üllői u. 93, H-1091, Budapest, Hungary
| | - Zs. Schaff
- 3 2nd Department of Pathology, Semmelweis University, Üllői u. 93, H-1091, Budapest, Hungary
| | - B. Nashan
- 7 Department of Surgery, Microbiology and Immunology, Dalhousie University, 1278 Tower Road Halifax, VG Site 65–202, Nova Scotia, B3H 2Y9, Canada
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Biliary reconstruction using a side-to-side choledochocholedochostomy with or without T-tube in deceased donor liver transplantation: a prospective randomized trial. Ann Surg 2009; 250:766-71. [PMID: 19809299 DOI: 10.1097/sla.0b013e3181bd920a] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The biliary anastomosis is still one of the major causes for morbidity after orthotopic liver transplantation. The optimal method of reconstruction remains controversial. The aim of the study was to assess biliary complications after liver transplantation using a choledochocholedochostomy with or without a temporary T-tube. BACKGROUND DATA Several reports have suggested that biliary reconstruction without T-tube is a safer method with a lower rate of biliary complications compared with T-tube insertion. METHODS A total of 194 recipients of deceased donor liver grafts were randomized. In group 1 the biliary reconstruction was performed by side-to-side choledochocholedochostomy with (n = 99) and in group 2 (n = 95) without a T-tube. The T-tube was removed after 6 weeks. RESULTS The overall biliary complication rate was significantly increased in group 2 (P < 0.0005). Biliary leaks occurred in 5 patients in group 1 and in 9 patients in group 2 (5.05% vs. 9.47%; P = 0.2756 ns). Anastomotic strictures of the bile duct were seen in 7 patients in group 1 and in 8 patients in group 2 (7.07% vs. 8.42%; P = 0.7923 ns). Two of the patients in group 1 and 5 patients in group 2 developed an ischemic type biliary lesion (2.02% vs. 5.26%; P = 0.2716 ns). The rate of reoperations was comparable in both groups. The rate of invasive interventions was higher in the group without T-tubes (9% vs. 18%, P = ns), as was the rate of cholangitis (5% vs. 11%. P = ns) and pancreatitis (4% vs. 14%, P = 0.0218). No complications after removal of the T-tube were observed. CONCLUSION This study is a large prospective randomized trial to assess biliary complications that occur following liver transplantation, after anatomizing the bile duct with or without T-tubes. A significant increased rate of complications in the group without T-tube insertion was observed. In summary, our results indicate that the usage of T-tubes is safe and an excellent tool for the quality control of biliary anastomoses.
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Longerich T, Flechtenmacher C, Schirmacher P. [Quality and quantity in hepatopathology. Diagnostic and clinically relevant grading for non-tumourous liver diseases]. DER PATHOLOGE 2009; 29:15-26. [PMID: 18210114 DOI: 10.1007/s00292-007-0963-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article describes the grading and staging systems used in the clinical context for non-neoplastic liver diseases (chronic and autoimmune hepatitis, fatty liver and steatohepatitis, medicinal toxic liver damage, iron storage disease and gall duct diseases). Fibrotic parenchymal alterations can also be assessed as well as livers planned for transplantation, with respect to possible rejection reactions. The basis for the histopathological diagnostic procedure is the liver biopsy. The consistent and correct use of the histological scores is obligatory in the diagnostic assessment of non-neoplastic liver diseases. Different scores are available for the various liver diseases. These are qualitative and quantitative scores based on empiricism and the practical relevance has been effectively proven. Grading describes the inflammatory activity and staging the extent of fibrosis or structural disorders up to liver cirrhosis. In many instances staging is the histopathological criteria for the prognosis assessment and is, therefore, decisive for therapy indications and therapy initiation.
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Affiliation(s)
- T Longerich
- Pathologisches Institut der Universität Heidelberg, Im Neuenheimer Feld 220, 69120, Heidelberg
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31
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Abstract
Secondary sclerosing cholangitis (SSC) is a chronic cholestatic biliary disease, characterized by inflammation, obliterative fibrosis of the bile ducts, stricture formation and progressive destruction of the biliary tree that leads to biliary cirrhosis. SSC is thought to develop as a consequence of known injuries or secondary to pathological processes of the biliary tree. The most frequently described causes of SSC are longstanding biliary obstruction, surgical trauma to the bile duct and ischemic injury to the biliary tree in liver allografts. SSC may also follow intra-arterial chemotherapy. Sclerosing cholangitis in critically ill patients is a largely unrecognized new form of SSC, and is associated with rapid progression to liver cirrhosis. The mechanisms leading to cholangiopathy in critically ill patients are widely unknown; however, the available clinical data indicate that ischemic injury to the intrahepatic biliary tree may be one of the earliest events in the development of this severe form of sclerosing cholangitis. Therapeutic options for most forms of SSC are limited, and patients with SSC who do not undergo transplantation have significantly reduced survival compared with patients with primary sclerosing cholangitis. Sclerosing cholangitis in critically ill patients, in particular, is associated with rapid disease progression and poor outcome.
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Affiliation(s)
- Petra Ruemmele
- Department of Internal Medicine I, University of Regensburg, Germany.
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Razonable RR. Cytomegalovirus infection after liver transplantation: Current concepts and challenges. World J Gastroenterol 2008; 14:4849-60. [PMID: 18756591 PMCID: PMC2739936 DOI: 10.3748/wjg.14.4849] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Cytomegalovirus (CMV) is a common viral pathogen that influences the outcome of liver transplantation. In addition to the direct effects of CMV syndrome and tissue-invasive diseases, CMV is associated with an increased predisposition to acute and chronic allograft rejection, accelerated hepatitis C recurrence, and other opportunistic infections, as well as reduced overall patient and allograft survival. Risk factors for CMV disease are often interrelated, and include CMV D+/R- serostatus, acute rejection, female gender, age, use of high-dose mycophenolate mofetil and prednisone, and the overall state of immunity. In addition to the role of CMV-specific CD4+ and CD8+ T lymphocytes, there are data to suggest that functionality of the innate immune system contributes to CMV disease pathogenesis. In one study, liver transplant recipients with a specific polymorphism in innate immune molecules known as Toll-like receptors were more likely to develop higher levels of CMV replication and clinical disease. Because of the direct and indirect adverse effects of CMV disease, its prevention, whether through antiviral prophylaxis or preemptive therapy, is an essential component in improving the outcome of liver transplantation. In the majority of transplant centers, antiviral prophylaxis is the preferred strategy over preemptive therapy for the prevention of CMV disease in CMV-seronegative recipients of liver allografts from CMV-seropositive donors (D+/R-). However, the major drawback of antiviral prophylaxis is the occurrence of delayed-onset primary CMV disease. In several prospective and retrospective studies, the incidence of delayed-onset primary CMV disease ranged from 16% to 47% of CMV D+/R- liver transplant recipients. Current data suggests that delayed-onset CMV disease is associated with increased mortality after liver transplantation. Therefore, optimized strategies for prevention and novel drugs with unique modes of action are needed. Currently, a randomized controlled clinical trial is being performed comparing the efficacy and safety of maribavir, a novel benzimidazole riboside, and oral ganciclovir as prophylaxis against primary CMV disease in liver transplant recipients. The treatment of CMV disease consists mainly of intravenous (IV) ganciclovir, and if feasible, a reduction in the degree of immunosuppression. A recent controlled clinical trial demonstrated that valganciclovir is as effective and safe as IV ganciclovir for the treatment of CMV disease in solid organ (including liver) transplant recipients. In this article, the author reviews the current state and the future perspectives of prevention and treatment of CMV disease after liver transplantation.
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Nemes B, Zádori G, Hartmann E, Németh A, Fehérvári I, Görög D, Máthé Z, Dávid A, Jakab K, Sárváry E, Piros L, Tóth S, Fazakas J, Gerlei Z, Járay J, Doros A. Biliary complications following orthotopic liver transplantation. The Hungarian experience. Orv Hetil 2008; 149:963-73. [DOI: 10.1556/oh.2008.28363] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A szerzők összefoglalják a magyar májátültetési program epeúti szövődményeinek jellemzőit. Feltárják az epeúti szövődmények előfordulási gyakoriságát. Elemzik az epeúti szövődmények típusait és azok megoszlását, valamint hatásukat a beteg-, illetve graftvesztésre. Elemzik az irodalomban már ismert rizikófaktorokat a hazai betegpopulációban. Ismertetik az epeúti szövődmények kezelési lehetőségeit. Retrospektív vizsgálat során a betegeket két csoportba osztották aszerint, hogy a májátültetés után kialakult-e epeúti szövődmény, vagy nem, majd a két csoportot összehasonlították számos vizsgált paraméter, valamint a túlélések szempontjából. Az epeúti szövődményes betegeket tovább csoportosították annak alapján, hogy a szövődmény a májátültetés után három hónapon belül vagy később alakult ki. Ezt a két csoportot szintén összehasonlították a fentebb említett kontrollcsoporttal. Egyvariációs összehasonlítások esetén a folytonos adatokat a populáció homogenitásának vizsgálata után (Levene-teszt) kétmintás
t
-próbával, illetve Mann–Whitney-féle U-teszttel, a kategorikus adatokat χ
2
-próbával, illetve Kaplan–Meier-analízissel vizsgálták. A túlélést Kaplan–Meier-metodikával vizsgálták. Az eredményeket valamennyi statisztikai próbánál akkor tekintették szignifikánsnak, ha a
p
< 0,05 volt.
Eredmények:
Epeúti szövődmény a betegek 26%-ában jelent meg, 290 vizsgált beteg közül 76 esetben. A leggyakoribb a szűkület (18%), majd az epecsorgás (9%), a necrosis (6%), végül az ischaemiás típusú epeúti károsodás (3%). Epeúti szövődmények esetén az 5 éves kumulatív túlélés rosszabb (55%), mint ezek hiányában (66%), és a retranszplantációk aránya is magasabb (15%) volt. A leggyakoribb kezelési típusok: intervenciós radiológiai (69%), sebészi (17%), ERCP (14%).
Következtetések:
Az epeúti szövődmények aránya megfelel a nemzetközi közléseknek, 2002 óta arányuk csökkent. Epeúti szövődmények kialakulásának rizikófaktorai: cholangitis, az arteria hepatica thrombosisa és stenosisa, magas bevitt intraoperatív volumen, valamint az akut rejectio. Korai epeúti szövődmények gyakran társultak a beültetett májgraft kezdeti gyenge működésével (ún. „initial poor function”). A korai epeúti szövődmények felelősek a túlélés csökkenéséért, a késői szövődmények inkább az életminőséget rontják. Az epeúti szövődményes betegeket döntően intervenciós radiológiai módszerekkel kezelték.
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Affiliation(s)
- Balázs Nemes
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Gergely Zádori
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Erika Hartmann
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Andrea Németh
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Imre Fehérvári
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Dénes Görög
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Zoltán Máthé
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Andrea Dávid
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Katalin Jakab
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Enikő Sárváry
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - László Piros
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Szabolcs Tóth
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - János Fazakas
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Zsuzsa Gerlei
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Jenő Járay
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Attila Doros
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
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Jue TL, Imperial JC. Management of post-liver-transplant biliary strictures: a work in progress. Gastrointest Endosc 2008; 67:886-9. [PMID: 18440379 DOI: 10.1016/j.gie.2008.01.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Accepted: 01/05/2008] [Indexed: 12/29/2022]
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Abstract
Perhaps no condition associated with chronic cholestasis is less understood than vanishing bile duct syndrome, a term that refers loosely to the group of acquired disorders associated with progressive destruction and disappearance of the intrahepatic bile ducts and, ultimately, cholestasis. Although the array of insults resulting in poor bile flow is vast, most adult patients who have chronic cholestasis have either primary biliary cirrhosis (or primary sclerosing cholangitis; in some cases, however, a cause cannot be identified. This article reviews the multiple causes, postulated pathophysiology, clinical features, and treatment options for this syndrome.
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Affiliation(s)
- Nancy S Reau
- Center for Liver Diseases, Section of Gastroenterology, Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland, MC7120, Chicago, IL 60637, USA.
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Londoño MC, Balderramo D, Cárdenas A. Management of biliary complications after orthotopic liver transplantation: The role of endoscopy. World J Gastroenterol 2008; 14:493-7. [PMID: 18203278 PMCID: PMC2681137 DOI: 10.3748/wjg.14.493] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Biliary complications are significant causes of morbidity and mortality after orthotopic liver transplantation (OLT). The estimated incidence of biliary complications after OLT ranges between 10%-25%, however, these numbers continue to decline due to improvement in surgical techniques. The most common biliary complications are strictures (both anastomotic and non-anastomotic) and bile leaks. Most of these problems can be appropriately managed with endoscopic retrograde cholangiography (ERC). Other complications such as bile duct stones, bile casts, sphincter of Oddi dysfunction, and hemobilia, are less frequent and also can be managed with ERC. This article will review the risk factors, diagnosis, and endoscopic management of the most common biliary complications after OLT.
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Harada K, Nakanuma Y. Molecular mechanisms of cholangiopathy in primary biliary cirrhosis. Med Mol Morphol 2006; 39:55-61. [PMID: 16821141 DOI: 10.1007/s00795-006-0321-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2006] [Accepted: 04/20/2006] [Indexed: 12/16/2022]
Abstract
Primary biliary cirrhosis (PBC) is histologically characterized by chronic nonsuppurative destructive cholangitis (CNSDC) and the progressive loss of intrahepatic small bile ducts. Cellular immune mechanisms involving T-cell reaction are thought to be significantly involved in the formation of CNSDC and bile duct loss. In inflamed portal tracts of PBC, CD4+ T cells of Th1 type expressing IFN-gamma or CXCR3 are aggregated and more commonly detected around injured bile ducts than Th2-type CD4+ T cells expressing IL-4 or CCR4, indicating that Th1-dominant cellular immunity plays a more-prominent role in recruitment of memory T-cell subsets in PBC and may be responsible for the progressive bile duct damage. Biliary epithelial apoptosis is demonstrated to be a major pathogenic process of bile duct loss in PBC. In CNSDC, several biliary apoptotic cells, an aberrant expression of Fas antigen (proapoptotic molecule) and decreased expression of bcl-2 and mcl-1 (antiapoptotic molecules) are found, although interlobular bile ducts express bcl-2 and mcl-2 but lack Fas. In addition, the upregulation of WAF1 and p53 related to biliary apoptosis is found in biliary epithelial cells of PBC, which may be due to cell senescence in response to genotoxic damage such as oxidative stress. Several steps and mechanisms during induction and progression of cholangitis and biliary apoptosis followed by bile duct loss are now being proposed in PBC, but future analysis of an etiopathogenesis to explain the characteristic histopathogenesis of PBC is required.
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Affiliation(s)
- Kenichi Harada
- Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa, 920-8640, Japan.
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Buis CI, Hoekstra H, Verdonk RC, Porte RJ. Causes and consequences of ischemic-type biliary lesions after liver transplantation. ACTA ACUST UNITED AC 2006; 13:517-24. [PMID: 17139425 DOI: 10.1007/s00534-005-1080-2] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Accepted: 11/25/2005] [Indexed: 02/06/2023]
Abstract
Biliary complications are a major source of morbidity, graft loss, and even mortality after liver transplantation. The most troublesome are the so-called ischemic-type biliary lesions (ITBL), with an incidence varying between 5% and 15%. ITBL is a radiological diagnosis, characterized by intrahepatic strictures and dilatations on a cholangiogram, in the absence of hepatic artery thrombosis. Several risk factors for ITBL have been identified, strongly suggesting a multifactorial origin. The main categories of risk factors for ITBL include ischemia-related injury; immunologically induced injury; and cytotoxic injury, induced by bile salts. However, in many cases no specific risk factor can be identified. Ischemia-related injury comprises prolonged ischemic times and disturbance in blood flow through the peribiliary vascular plexus. Immunological injury is assumed to be a risk factor based on the relationship of ITBL with ABO incompatibility, polymorphism in genes coding for chemokines, and pre-existing immunologically mediated diseases such as primary sclerosing cholangitis and autoimmune hepatitis. The clinical presentation of patients with ITBL is often not specific; symptoms may include fever, abdominal complaints, and increased cholestasis on liver function tests. Diagnosis is made by imaging studies of the bile ducts. Treatment starts with relieving the symptoms of cholestasis and dilatation by endoscopic retrograde cholangiopancreaticography (ERCP) or percutaneous transhepatic cholangiodrainage (PTCD), followed by stenting if possible. Eventually up to 50% of the patients with ITBL will require a retransplantation or may die. In selected patients, a retransplantation can be avoided or delayed by resection of the extra-hepatic bile ducts and construction of a hepaticojejunostomy. More research on the pathogenesis of ITBL is needed before more specific preventive or therapeutic strategies can be developed.
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Affiliation(s)
- Carlijn I Buis
- Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Pascher A, Neuhaus P. Biliary complications after deceased-donor orthotopic liver transplantation. ACTA ACUST UNITED AC 2006; 13:487-96. [PMID: 17139421 DOI: 10.1007/s00534-005-1083-z] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Accepted: 11/25/2005] [Indexed: 12/29/2022]
Abstract
A wide range of potential biliary complications can occur after orthotopic liver transplantation (OLT). The most common biliary complications are bile leaks, anastomotic and intrahepatic strictures, stones, and ampullary dyfunction, which may occur in up to 20%-40% of OLT recipients. Leaks predominate in the early posttransplant period; stricture formation typically develops gradually over time. However, with the advent of new techniques, such as split-liver, reduced-size, and living-donor liver transplantation, the spectrum of biliary complications has changed. Risk factors for biliary complications comprise technical failure; T-tube or stent-related complications; hepatic artery thrombosis; bleeding; ischemia/reperfusion injury; and other immunological, nonimmunological, and infectious complications. Noninvasive diagnostic methods have been established and treatment modalities have been modified towards a primarily nonoperative, endoscopy-based strategy. Besides, the management of biliary complications after OLT requires a multidisciplinary approach, in which interventional and endoscopic treatment options have to be weighed up against surgical treatment options. The etiology and spectrum of bile duct complications, their diagnosis, and their treatment will be reviewed in this article.
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Affiliation(s)
- Andreas Pascher
- Department of General, Visceral, and Transplantation Surgery, Charité, Campus Virchow, Universitaetsmedizin Berlin, Augustenburgerplatz 1, 13353 Berlin, Germany
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41
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Abstract
1. Recurrent primary sclerosing cholangitis (PSC) is extremely difficult, if not impossible, to distinguish from other causes of biliary strictures or sclerosing cholangitis in allografts using needle biopsy evaluation alone. Technical problems with biliary reconstruction, long cold ischemic times, non-heart beating donors, ABO blood group incompatibility, antibody-mediated rejection, and small-for-size syndrome in reduced-size or living donor livers can also cause similar manifestations in a peripheral core biopsy. 2. Some difficulties in distinguishing between sclerosing cholangitis and chronic rejection (CR) arise because: a) at risk populations are similar; b) both can cause "cholestatic" elevation of liver injury tests; and c) both can lead to intrahepatic cholestasis and small bile duct loss. 3. Etiopathogenesis and pathology of CR and sclerosing cholangitis have some overlapping features, but show distinct differences that result in significantly different and discriminating pathologic manifestations. 4. Clues in the clinical history, evaluation of serial biopsies, and histopathology can be used to distinguish with confidence between sclerosing cholangitis and CR. 5. Potential discriminating features include liver size and gross appearance, and histopathology findings in the arterial tree, hilar lymph nodes, large and small bile ducts, interface zone, lobular, and perivenular regions.
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Affiliation(s)
- Anthony Jake Demetris
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA.
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42
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Abstract
Liver transplantation has become the accepted standard of care in the treatment of a child with a failing liver. Advances in the management of critical care and immunosuppression along with the development of innovative operative procedures have improved outcome such that 5-year survival rates of 80% to 90% are expected following liver transplantation. Organ allocation schemes have evolved in an effort to better stratify recipient risk thereby more appropriately distributing deceased donor grafts. A persistent shortage of appropriate donors continues to contribute to patient mortality. The consequences of long-term immunosuppression have become increasingly apparent such that health care providers need to be aware of the side effects of chronic immunosuppression. New strategies need to be defined to minimize the need of continuous immunosuppression. The continued success of pediatric liver transplantation will require multi-disciplinary health care teams comprised of general pediatricians, pediatric hepatologists, transplant surgeons, and transplant coordinators who focus on the complex needs of the transplant recipient.
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Affiliation(s)
- Gregory M Tiao
- Department of Pediatric Surgery, Pediatric Liver Care Center, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 45229, USA.
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43
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Abstract
In the past two decades, pediatric liver transplantation has become the state-of-the-art operation with anticipated success and limited mortality. The future success of pediatric liver transplantation will require thoughtful solutions to the delicate balance of risk to donors and recipients, the complex needs of the acute postoperative patient, and the long-term challenges of chronic immunosuppression in these previously unsalvageable patients.
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Affiliation(s)
- Greg Tiao
- Department of Pediatric Surgery, Pediatric Liver Care Center, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue Cincinnati, OH 45229, USA
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44
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Abstract
Complications involving the biliary tract after orthotopic liver transplantation (OLT) have been a common problem since the early beginning of this technique. Biliary complications have been reported to occur at a relatively constant rate of approximately 10-15% of all deceased donor full size OLTs. There is a wide range of potential biliary complications which can occur after OLT. Their incidence varies according to the type of graft, type of donor, and the type of biliary anastomosis performed. The spectrum of biliary complications has changed over the past decade because of the establishment of split liver, reduced-size, and living donor liver transplantation. Apart from technical developments, novel diagnostic methods have been introduced and evaluated in OLT, the most prominent being magnetic resonance imaging (MRI). Treatment modalities have also changed over the past years towards a primarily nonoperative, endoscopy-based strategy, leaving the surgical intervention for lesions which otherwise are not curable. The management of biliary complications after OLT requires a multidisciplinary approach. Conservative, interventional, and endoscopic treatment options have to be weighed up against surgical re-intervention. In the following the spectrum of specific bile duct complications after OLT and their treatment options will be reviewed.
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Affiliation(s)
- Andreas Pascher
- Department of General, Visceral, and Transplantation Surgery, Universitätsmedizin Berlin, Berlin, Germany.
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45
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Nakamura N, Nishida S, Neff GR, Vaidya A, Levi DM, Kato T, Ruiz P, Tzakis AG, Madariaga JR. Intrahepatic biliary strictures without hepatic artery thrombosis after liver transplantation: an analysis of 1,113 liver transplantations at a single center. Transplantation 2005; 79:427-32. [PMID: 15729168 DOI: 10.1097/01.tp.0000152800.19986.9e] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Intrahepatic biliary strictures (IHBS) without hepatic artery thrombosis (HAT) is a serious complication and known to increase the risk of graft failure after liver transplantation. This manuscript describes the incidence, risk factors, clinical pictures, management, and outcomes. METHODS Between 1994 and 2002, 1,113 liver transplantations were performed in 974 adult patients. Data was retrospectively analyzed in terms of incidence, risk factors, clinical pictures (type of strictures), management (radiologic, surgical management), and outcomes. RESULTS Sixteen (1.4%) grafts had IHBS without HAT. Specific risk factors were not identified from donors or recipients. However, ischemic factors from the donors were suspected from non-heart-beating donors (n=1) and cardiac-arrest donors (n=2). Three types of IHBS were identified: (1) diffuse type (n=7), (2) bilateral proximal type (n=7), and (3) unilateral type (n=2). Overall success rate of radiologic interventions was 31.3% (5/16). Of the 11 patients who did not improve, 6 died: diffuse type (3/7, 42.9%), bilateral type (3/7, 42.9%), and unilateral (0/2, 0%). Three patients had retransplantation, and two patients are waiting retransplantation. The majority of the IHBS were diffuse or bilateral (14/16, 87.5%), and rate of the graft failure was high (10/14, 71.4 %). Overall graft survival of IHBS was lower than that without IHBS (P=0.025). CONCLUSIONS The majority of the IHBS without HAT were of a diffuse or bilateral proximal type. Patients with diffuse or bilateral proximal type have a low success rate from radiologic intervention and may benefit from early retransplantation.
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Affiliation(s)
- Noboru Nakamura
- Division of Transplantation, Department of Surgery, University of Miami, 1801 NW 9th Avenue, Miami, FL 33136, USA
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46
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Lotz G, Simon S, Patonai A, Sótonyi P, Nemes B, Sergi C, Glasz T, Füle T, Nashan B, Schaff Z. DETECTION OF CHLAMYDIA PNEUMONIAE IN LIVER TRANSPLANT PATIENTS WITH CHRONIC ALLOGRAFT REJECTION. Transplantation 2004; 77:1522-8. [PMID: 15239615 DOI: 10.1097/01.tp.0000120945.54057.16] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chlamydia pneumoniae is one of the possible pathogenetic factors of atherosclerotic processes. Foam cell arteriopathy is a generally accepted pathologic feature of chronic liver allograft rejection and has several similarities to the early lesions of atherosclerosis. The aim of the authors' study was to show any existing correlation between the occurrence of Chlamydia pneumoniae and the presence of foam cell arteriopathy in transplanted livers with chronic rejection. METHODS Ten liver samples from patients with chronic liver rejection including foam cell arteriopathy and 10 liver samples from healthy individuals were analyzed for the presence of Chlamydia pneumoniae by specific immunohistochemistry and polymerase chain reaction (PCR). Liver samples from two transplant patients with chronic liver rejection without any evidence of foam cell arteriopathy and nine patients with acute liver allograft rejection were also investigated by PCR. RESULTS In all 10 rejected liver samples, Chlamydia pneumoniae was detected by PCR, whereas only one of the healthy control samples and one of the samples with acute rejection were found to be positive. Immunohistochemistry showed similar results. The positive signals of Chlamydia pneumoniae were localized mainly in the hepatocytes, sinusoidal and perisinusoidal cells, and the cells of portal tracts, whereas most of the altered hepatic arteries showed no or very weak positivity. CONCLUSIONS The results strongly suggest an association between the occurrence of Chlamydia pneumoniae and the presence of foam cell arteriopathy in transplanted livers.
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Affiliation(s)
- Gábor Lotz
- 2nd Institute of Pathology, Semmelweis University, Ullõi str. 93, Budapest H-1091, Hungary
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47
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Jain D, Robert ME, Navarro V, Friedman AL, Crawford JM. Total fibrous obliteration of main portal vein and portal foam cell venopathy in chronic hepatic allograft rejection. Arch Pathol Lab Med 2004; 128:64-7. [PMID: 14692809 DOI: 10.5858/2004-128-64-tfoomp] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Chronic hepatic allograft rejection is characterized by arteriopathy and bile duct loss. Pathology of the portal vein or its branches is not considered to play a major role in chronic rejection. OBJECTIVE A recent case of chronic rejection with total fibrous obliteration of the portal vein at the hilum and graft loss prompted us to retrospectively analyze cases of failed allografts for portal vein changes. DESIGN Six cases of failed hepatic allograft recorded in our files from 1994 to 1998 were selected for the study. For comparison, 4 cases of hepatitis C cirrhosis were included. Clinical features, including arteriograms or Doppler studies, were reviewed whenever available. Sections taken from the hilum and random parenchyma stained with routine hematoxylin-eosin, elastic van Gieson, and Masson trichrome were examined by 3 experienced liver pathologists in a randomized, blinded fashion. RESULTS Significant hepatic artery occlusion with foam cell change and bile duct loss was seen in all cases of chronic rejection (3/3), but not in the other cases. Foam cell change in the portal vein at the hilum (3/3) and occasionally into the distal branches (2/3) with variable occlusion of the lumen was seen only in cases of chronic hepatic allograft rejection. Mild luminal narrowing was observed in all the cases of cirrhosis (4/4) as a result of phlebosclerosis, most likely representing a change secondary to portal hypertension. Total obliteration of the portal vein at the hilum was seen in the index case (case 1) only. CONCLUSION Portal venopathy can be a significant finding in chronic hepatic allograft rejection and may contribute to graft dysfunction or failure. Two-vessel disease must be considered in cases of chronic hepatic allograft rejection, and pathologists should thoroughly examine the hilum in explanted hepatic allografts.
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Affiliation(s)
- Dhanpat Jain
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06520-8023, USA.
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48
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Maguire D, Rela M, Heaton ND. Biliary complications after orthotopic liver transplantation. Transplant Rev (Orlando) 2002. [DOI: 10.1053/trte.2002.1296481] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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49
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Neil DAH, Hubscher SG. Histologic and biochemical changes during the evolution of chronic rejection of liver allografts. Hepatology 2002; 35:639-51. [PMID: 11870379 DOI: 10.1053/jhep.2002.31726] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Criteria for histologic diagnosis of chronic rejection (CR) are based on changes seen late in the disease process that are likely to be irreversible and unresponsive to treatment. Changes occurring during the evolution of CR are less clearly defined. The serial biopsy specimens, failed allografts, and biochemical profiles of 28 patients who underwent retransplantation for CR were examined with the aim of identifying histologic and biochemical features that were present during the early stages of CR. For each case, a point of acute deterioration in liver function tests (LFTs) was identified ("start time" [ST]) that subsequently progressed to graft failure. Biopsy specimens before, at the time of ("start biopsy" [SB]), and after the ST were assessed histologically, and findings were correlated with the biochemical changes. CR resulted from acute rejection (AR) that did not resolve. Centrilobular necroinflammation (CLNI) associated with an elevated aspartate transaminase (AST) level and portal tract features of AR were present at the start. Portal AR features resolved, CLNI persisted, AST level remained elevated, and bilirubin and alkaline phosphatase levels progressively increased throughout the evolution of CR. Portal tracts also showed a loss of small arterial and bile duct branches, with arterial loss occurring early and bile duct loss as a later progressive lesion. Foam cell arteriopathy was rarely seen in needle biopsy specimens. In conclusion, findings from this study may help identify patients at risk of progressing to graft loss from CR at a stage when the disease process is potentially reversible and amenable to treatment.
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Affiliation(s)
- Desley A H Neil
- Department of Pathology, Medical School, University of Birmingham, Edgbaston, Birmingham, United Kingdom B15 2TT.
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50
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Sebagh M, Blakolmer K, Falissard B, Roche B, Emile JF, Bismuth H, Samuel D, Reynès M. Accuracy of bile duct changes for the diagnosis of chronic liver allograft rejection: reliability of the 1999 Banff schema. Hepatology 2002; 35:117-25. [PMID: 11786967 DOI: 10.1053/jhep.2002.30085] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Chronic rejection (CR) after liver transplantation is thought to be a dynamic and potentially reversible process. The Banff working group has developed recommendations for its histopathologic staging. The 1999 Banff classification of CR (i.e., bile duct dystrophy >50% and/or bile duct loss >20%) was applied to: 1) biopsies from patients retransplanted for CR (N = 19) and pathologies other than CR (N = 21) to evaluate its specificity and sensitivity, especially of the early stage lesions of CR; and 2) biopsies from nonretransplanted patients (N = 21) to evaluate the evolution of CR lesions. Atypical forms of CR were also described. Including an early stage into the definition of CR has resulted in a much higher sensitivity for its diagnosis, as compared with the former classification (i.e., bile duct loss >50%) (89% vs. 33%; P =.0001), while keeping an acceptable specificity (74% vs. 100%; P =.03). In 55% of the nonretransplanted patients, CR lesions were reversible. No histologic feature reliably predicted CR outcome. Transient lobular hepatitis, unrelated to viral infection, and veno-occlusive disease were seen significantly more often in the CR group (P =.04 and P =.03, respectively). We conclude that the application of the 1999 Banff classification is superior to the previous classification for the diagnosis of CR. However, limited information can be drawn regarding the outcome of CR based on histology alone. Transient lobular hepatitis, unrelated to viral infection and veno-occlusive disease, may be an unusual expression of CR.
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Affiliation(s)
- Mylène Sebagh
- Service d'Anatomie Pathologique, Centre Hépato-biliaire, and Unité de Santé Publique, Hôpital Paul Brousse, Villejuif, France.
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