Long-term outcome after liver transplantation

Safe pregnancy after liver transplantation: Evidence from a multicenter Italian collaborative study

BACKGROUND

Women who have undergone liver transplantation (LT) enjoy better health, and possibility of childbearing. However, maternal and graft risks, optimal immunosuppression, and fetal outcome is still to clarify.

AIM

Aim of the study was to assess outcomes of pregnancy after LT at national level.

METHODS

In 2019, under the auspices of the Permanent Transplant Committee of the Italian Association for the Study of the Liver, a multicenter survey including 14 Italian LT-centers was conducted aiming at evaluating the outcomes of recipients and newborns, and graft injury/function parameters during pregnancy in LT-recipients.

RESULTS

Sixty-two pregnancies occurred in 60 LT-recipients between 1990 and 2018. Median age at the time of pregnancy was 31-years and median time from transplantation to conception was 8-years. During pregnancy, 4 recipients experienced maternal complications with hospital admission. Live-birth-rate was 100%. Prematurity occurred in 25/62 newborns, and 8/62 newborns had low-birth-weight. Cyclosporine was used in 16 and Tacrolimus in 37 pregnancies, with no different maternal or newborn outcomes. Low-birth-weight was correlated to high values of AST, ALT and GGT.

CONCLUSION

Pregnancy after LT has good outcome; however, maternal complications and prematurity may occur. Compliance with the immunosuppression is fundamental to ensure the stability of graft function and prevent graft-deterioration.

Usage of Tacrolimus and Mycophenolic Acid During Conception, Pregnancy, and Lactation, and Its Implications for Therapeutic Drug Monitoring: A Systematic Critical Review

BACKGROUND

Conception, pregnancy, and lactation following solid organ transplantation require appropriate management. The most frequently used immunosuppressive drug combination after solid organ transplantation consists of tacrolimus (Tac) plus mycophenolic acid (MPA). Here, the effects of Tac and MPA on fertility, pregnancy, and lactation are systematically reviewed, and their implications for therapeutic drug monitoring (TDM) are discussed.

METHODS

A systematic literature search was performed (August 19, 2019) using Ovid MEDLINE, EMBASE, the Cochrane Central Register of controlled trials, Google Scholar, and Web of Science, and 102 studies were included. Another 60 were included from the reference list of the published articles.

RESULTS

As MPA is teratogenic, women who are trying to conceive are strongly recommended to switch from MPA to azathioprine. MPA treatment in men during conception seems to have no adverse effect on pregnancy outcomes. Nevertheless, in 2015, the drug label was updated with additional risk minimization measures in a pregnancy prevention program. Data on MPA pharmacokinetics during pregnancy and lactation are limited. Tac treatment during conception, pregnancy, and lactation seems to be safe in terms of the health of the mother, (unborn) child, and allograft. However, Tac may increase the risk of hypertension, preeclampsia, preterm birth, and low birth weight. Infants will ingest very small amounts of Tac via breast milk from mothers treated with Tac. However, no adverse outcomes have been reported in children exposed to Tac during lactation. During pregnancy, changes in Tac pharmacokinetics result in increased unbound to whole-blood Tac concentration ratio. To maintain Tac concentrations within the target range, increased Tac dose and intensified TDM may be required. However, it is unclear if dose adjustments during pregnancy are necessary, considering the higher concentration of (active) unbound Tac.

CONCLUSIONS

Tac treatment during conception, pregnancy and lactation seems to be relatively safe. Due to pharmacokinetic changes during pregnancy, a higher Tac dose might be indicated to maintain target concentrations. However, more evidence is needed to make recommendations on both Tac dose adjustments and alternative matrices than whole-blood for TDM of Tac during pregnancy. MPA treatment in men during conception seems to have no adverse effect on pregnancy outcomes, whereas MPA use in women during conception and pregnancy is strongly discouraged.

Oral immunotherapy tolerizes mice to enzyme replacement therapy for Morquio A syndrome

Immune response to therapeutic enzymes poses a detriment to patient safety and treatment outcome. Enzyme replacement therapy (ERT) is a standard therapeutic option for some types of mucopolysaccharidoses, including Morquio A syndrome caused by N-acetylgalactosamine-6-sulfate sulfatase (GALNS) deficiency. Current protocols tolerize patients using cytotoxic immunosuppressives, which can cause adverse effects. Here we show development of tolerance in Morquio A mice via oral delivery of peptide or GALNS for 10 days prior to ERT. Our results show that using an immunodominant peptide (I10) or the complete GALNS enzyme to orally induce tolerance to GALNS prior to ERT resulted in several improvements to ERT in mice: (a) decreased splenocyte proliferation after in vitro GALNS stimulation, (b) modulation of the cytokine secretion profile, (c) decrease in GALNS-specific IgG or IgE in plasma, (d) decreased GAG storage in liver, and (e) fewer circulating immune complexes in plasma. This model could be extrapolated to other lysosomal storage disorders in which immune response hinders ERT.

7-T MRI of explanted liver and ex-vivo pancreatic specimens: prospective study protocol of radiological-pathological correlation feasibility (the EXLIPSE project)

The study focuses on radiological-pathological correlation between imaging of ex vivo samples obtained by a 7-T scanner and histological examination. The specimens will be derived from native explanted cirrhotic livers, liver grafts excluded from donation because of severe steatosis, and primary pancreatic tumours. Magnetic resonance imaging (MRI) examinations will be performed within 24 h from liver or pancreatic lesion surgical removal. The MRI protocol will include morphological sequences, quantitative T1, T2, and fat-, water-fraction maps with Cartesian k-space acquisition, and multiparametric methods based on a transient-state “MRI fingerprinting”. Finally, the specimen will be fixed by formalin. Qualitative imaging analysis will be performed by two independent blinded radiologists to assess image consistency score. Quantitative analysis will be performed by drawing regions of interest on different tissue zones to measure T1 and T2 relaxation times as well as fat- and water-fraction. The same tissue areas will be analysed by the pathologists. This study will provide the possibility to improve our knowledge about qualitative and quantitative abdominal imaging assessment at 7 T, by correlating imaging characteristics and the corresponding histological composition of ex vivo specimens, in order to identify imaging biomarkers. Trial registration: ClinicalTrials.gov: 13646. Registered 9 July 2019—retrospectively registered

Sinusoidal and pericellular fibrosis in adult post-transplant liver biopsies: association with hepatic stellate cell activation and patient outcome

Post-transplant sinusoidal fibrosis (SF) and pericellular fibrosis (PCF) have not been extensively investigated in adults. Fifty-two post-transplant liver biopsies from 28 consented patients (12 men, mean age 49, range 33–67 years) were studied. Tissue morphology, including an arbitrary summative fibrosis score was assessed in detail. Collagen proportionate area (CPA) and alpha-smooth muscle actin (α-SMA) immunostain were evaluated by digital image analysis (DIA). Anti-keratin 7, anti-C4d and anti-sonic hedgehog (Shh) immunostains were scored semi-quantitatively. SF was observed in 36/52 (69.2%) biopsies and most of these (20/36, 55.6%) had centrilobular fibrosis (CLF). PCF was seen in 7/52 (13.5%) biopsies exclusively in cases with CLF. CPA was significantly correlated with time since liver transplantation (p = 0.043), summative fibrosis score and its main components but not with α-SMA. α-SMA-positive area significantly correlated with the Banff rejection score (p = 0.022) and centrilobular inflammatory changes were more severe in cases with CLF (p = 0.003). Hepatocyte ballooning of cholestatic type was associated with PCF (p = 0.016) and Shh expression (p < 0.001). Sinusoidal fibrosis is a frequent occurrence in post-transplant adult livers, with predilection toward centrilobular areas. Graft age and oxidative stress may contribute to SF development, while hepatocyte ballooning may be implicated in PCF development. Hepatic stellate cell (HSC) activation is likely affected by centrilobular inflammation.

Systematic review: impact of liver transplantation on employment

Background

The majority of liver transplant recipients survive long term after the procedure.

Aim

To assess if this positive outcome is associated with improved employment post-transplant.

Methods

A systematic review of publications between 2001 and 2016 was performed. A standard procedure was used to search for suitable publications from two databases (PubMed and EMBASE). Duplicates were removed and abstracts screened by both authors for possible inclusion. Possible suitable publications were obtained and examined for the presence of pre- and post-employment information. Full articles that had this information were reviewed by standard methodology for assessment of bias.

Results

A total of 162 individual abstracts were screened. Thirty-five full papers were reviewed and 13 papers included in the detailed review. Risk of bias was considered high due to low response rates, poor assessment of prognostic and confounding factors and varying definitions of employment. Heterogeneous data precluded meta-analysis. Eight studies focused on return to work as a primary outcome and five on quality of life with employment as a secondary outcome. Follow-up varied between 2 and 13 years. Rates of employment fell in all studies assessed. Employment rates ranged from 26 to 80% pre-transplant and 18 to 44% post-transplant. The proportion of those categorized as ill-health retired was 24% greater after orthotopic liver transplantation.

Conclusions

Improved survival after liver transplantation was not reflected in a return to employment and retirement was common. Areas for further study include interventions to minimize physical deconditioning, depression associated with lower employment rates and type of work available after transplant.

A prospective cohort study on posttraumatic stress disorder in liver transplantation recipients before and after transplantation: Prevalence, symptom occurrence, and intrusive memories

OBJECTIVE

This study aimed at increasing the understanding of posttraumatic stress disorder (PTSD) in liver transplant patients by describing the course of PTSD, symptom occurrence, psychological co-morbidity, and the nature of re-experiencing symptoms.

METHODS

A prospective cohort study was performed among 95 liver transplant recipients from before transplantation up until one year post-transplantation. Respondents filled out a questionnaire regarding psychological functioning (PTSD, anxiety, and depression) before, and at 3, 6, and 12months post-transplantation. Both quantitative and qualitative methods were used to analyze the data.

RESULTS

Before transplantation, respectively 10.5% and 6.3% of the respondents were identified as possible cases of full or partial PTSD. In all cases, co-morbid conditions of anxiety and/or depression were present. After transplantation, no new onset of full PTSD was found. New onset of possible partial PTSD was found in six respondents. Arousal symptoms were the most frequently reported symptoms, but may not be distinctive for PTSD in transplant patients because of the overlap with disease- and treatment-related symptoms. Re-experiencing symptoms before transplantation were mostly related to waiting for a donor organ and the upcoming surgery; after transplantation this was related to aspects of the hospital stay.

CONCLUSIONS

In our group of liver transplant patients, PTSD symptomatology was more present before transplantation than after transplantation. Being diagnosed with a life-threatening disease seemed to be the main stressor. However, when a diagnosis of PTSD is suspected, assessment by a clinician is warranted because of the overlap with mood and anxiety disorders, and disease- and treatment-related symptoms.

Study of the Role of Transforming Growth Factor β-1 in Organ Damage Protection in Porcine Model of Brain Death

BACKGROUND

From the medical and ethical points of view, donation after brain death is a more acceptable organ source than that from a living donor because it has the advantage of providing multiple organs from a single donor source. Hence, it has become a more promising field of research which focuses on the protection of organs at brain death Here we investigated the role of transforming growth factor (TGF)-β1 in a porcine model of brain death.

METHODS

A porcine model of brain death was established by increasing the intracranial pressure (ICP) after which TGF-β1 was monitored by immunofluorescence at the following time points: before ICP was performed (t1), at brain death (t2), and at 3 (t3), 6 (t4), 9 (t5), and 18 (t6) hours after brain death. The data were analyzed using the fixed effect regression method and the correlation between the results was determined by Pearson analysis.

RESULTS

Our results showed that there was a significant increase in the levels of TGF-β1 (P < .05), urea (P < .01), creatinine (P < .01), and aspartate aminotransferase (AST; P < .01) during the 18-hour brain death process. There were negative correlations between TGF-β1 and urea, creatinine, alanine aminotransferase, AST, and total bilirubin. The negative correlations between TGF-β1 and creatinine and AST achieved statistical significance (P < .05).

CONCLUSIONS

These findings taken together confirm that significant damages are caused to the myocardial fiber cell and kidney glomerulus during brain death process, and that TGF-β1 is associated with the protection of these organs.

Outcomes of pregnancy following liver transplantation: The King's College Hospital experience

Reports of pregnancy in liver transplantation (LT) patients have largely favorable outcomes. Concerns remain with regards to maternal and graft risk, optimal immunosuppression (IS), and fetal outcomes. We review all post-LT pregnancies at our center with regard to the outcomes and safety for the patient, graft, and fetus. A total of 117 conceptions occurred in 79 patients. Median age at conception was 29 years. Maternal complications included graft loss (2%), acute cellular rejection (ACR; 15%), pre-eclampsia/eclampsia (15%), gestational diabetes (7%), and bacterial sepsis (5%). ACR was significantly more common in those women who conceived within 12 months of LT (P = 0.001). The live birth rate was 73%. Prematurity occurred in 26 (31%) neonates, and 24 (29%) neonates were of low or very low birth weight. IS choice (cyclosporine versus tacrolimus) had no significant effect on pregnancy outcomes and complications. No congenital abnormalities occurred, and only 1 child born at 24 weeks had delayed developmental milestones. In conclusion, pregnancy following LT has a favorable outcome in the majority, but severe maternal risks remain. Patients should be counseled with regard to the above information so informed decisions can be made, and pregnancy must be considered high risk with regular monitoring by transplant clinicians and specialist obstetricians.

Immune monitoring of immunosuppression withdrawal of liver transplant recipients

Several studies have shown that some liver transplant recipients may tolerate immunosuppression withdrawal. Mechanisms and biomarkers of tolerance are not well known.

METHODS

Twenty-four LT patients with immunosuppression side-effects underwent progressive immunosuppression withdrawal. Peripheral lymphocyte populations and secretion of cytokines were analyzed at baseline and during withdrawal until tolerance (n = 15) or rejection (n = 9), as well as 3 months after tolerance achievement or rejection resolution (as follow-up). Immunological markers were compared among groups.

RESULTS

The percentages of CD3+CD4+ cells progressively decreased in both groups. CD3+CD8+ cells gradually increased in tolerant patients. B lymphocytes gradually decreased in tolerant and initially in non-tolerant patients, reverting at rejection. Regulatory T cells progressively increased until rejection in non-tolerants, decreasing to basal levels after renewing immunosuppression; no significant changes were found in tolerant patients. The percentages and absolute counts of natural killer cells significantly increased in both groups, being more evident in tolerant patients. The secretion of several cytokines was higher in non-tolerant patients when rejection was diagnosed.

CONCLUSIONS

The greater increase of natural killer cells in tolerant patients suggests their potential role in the tolerance phenomenon.

CD4+CD25+Foxp3+ Treg cells and liver transplant tolerance

Several subgroups of regulatory T (Treg) cells play crucial roles in both induction and maintenance of immune tolerance to self-antigens and alloantigens. The most extensively and comprehensively studied regulatory T cell subgroup is CD4⁺CD25⁺Foxp3⁺ Treg cells. Numerous studies indicate that insufficiency or dysfunction of CD4⁺CD25⁺Foxp3⁺ Treg cells is responsible for the development of many autoimmune diseases and rejections after organ transplantation. Therefore, harnessing CD4⁺CD25⁺Foxp3⁺ Treg cells may provide a promising approach for inducing and maintaining liver transplant tolerance. In this review, we will focus on the history and classification of regulatory T cells, the mechanisms by which regulatory T cells induce transplant tolerance and their roles in liver transplant tolerance.

The effect of self-efficacy, depression and symptom distress on employment status and leisure activities of liver transplant recipients

AIM

To examine the effect of self-efficacy, subjective work ability, depression and symptom distress on and to provide a description of, the employment and leisure activities of liver transplant recipients.

BACKGROUND

Return to work and leisure activities have become an important aspect of life for liver transplant recipients worldwide. An investigation of the factors that influence the employment status and leisure activities has been recommended as a means to help transplant recipients restore their productivity.

DESIGN

This was a cross-sectional, descriptive and correlational study in 2010.

METHODS

A convenience sampling method was used. Data were collected using a set of questionnaires that were administered retrospectively. A total of 106 liver transplant patients were included in this study.

RESULTS

The post-transplantation employment rate was 45.2%. The positive predictors of employment were higher subjective work ability and higher symptom distress. Gender (female), monthly family income (<US $2,000), depression and unemployment pre-transplantation were negatively associated with employment status. Of the 106 patients, 62 (58.5%) were in the low-diversity group (score of less than 3) of leisure activities. Monthly family income of <US $2,000 was associated with a low diversity of participation in leisure activities.

CONCLUSION

Subjective work ability and symptom distress were positive predictors of employment, while depression was a negative predictor. Nurses in the transplant team should focus on increasing a sense of confidence, decreasing depressive symptoms and monitoring the severity of symptoms to improve the employment status of liver transplant recipients.

Outcome and development of symptoms after orthotopic liver transplantation for Wilson disease

BACKGROUND

Wilson disease (WD) is an autosomal recessive copper storage disease resulting in hepatic and neurologic dysfunction. Liver transplantation is an effective treatment for fulminant cases for patients with chronic liver disease. Reports on the outcome of neuropsychiatric symptoms after orthotopic liver transplantation (OLT) are limited.

AIM

To assess the course of neuropsychiatric and hepatic symptoms after liver transplantation for Wilson disease

METHODS

Nineteen patients with Wilson disease received liver transplantation and were followed prospectively from 2005 to 2010 for the development of hepatic, neurological and psychiatric symptoms.

RESULTS

Eight patients (all female) were transplanted for acute liver failure and eleven patients for chronic liver failure. Patient survival rates one and five yr after transplantation were 78% and 65%, respectively. Of the surviving patients, hepatic symptom scores improved in all patients and neurological symptom scores improved in all but one patient after OLT compared to the time of initial diagnosis and compared to pre-OLT status. Psychiatric symptoms showed moderate improvements.

CONCLUSION

Survival after OLT for Wilson disease with end-stage liver disease is excellent. Overall, neuropsychiatric symptoms improved after transplantation, substantiating arguments for widening of the indication for liver transplantation in symptomatic neurologic Wilson disease patients with stable liver function.

Trial of complete weaning from immunosuppression for liver transplant recipients: factors predictive of tolerance

Recipients of liver transplantation (LT) may develop immunological tolerance. Factors predictive of tolerance are not clearly understood. Transplant recipients with normal liver function tests and without active viral hepatitis or autoimmune disease who presented with side effects of immunosuppression or a high risk of de novo malignancies were selected to participate in this prospective study. Twenty-four patients fulfilled the inclusion criteria and, therefore, underwent a gradual reduction of immunosuppression. Tolerance was defined as normal liver function tests after immunosuppression withdrawal. Basal clinical and immunological characteristics, including lymphocyte counts and subpopulations (T, B, natural killer, CD4(+) , CD8(+) , and regulatory T cells) and the phytohemagglutinin stimulation index (SI), were compared for tolerant and nontolerant patients. Fifteen of the 24 patients (62.5%) were tolerant at a median of 14 months (interquartile range = 8.5-22.5 months) after complete immunosuppression withdrawal. Tolerant patients had a longer median interval between transplantation and inclusion in the study (156 for tolerant patients versus 71 months for nontolerant patients, P = 0.003) and a lower median SI (7.49 for tolerant patients versus 41.73 for nontolerant patients, P = 0.01). We identified 3 groups of patients with different probabilities of tolerance: in the first group (n = 7 for an interval > 10 years and an SI < 20), 100% reached tolerance; in the second group (n = 10 for an interval > 10 years and an SI > 20 or an interval < 10 years and an SI < 20), 60% reached tolerance; and in the third group (n = 7 for an interval < 10 years and an SI > 20), 29% reached tolerance. In conclusion, a high proportion of select LT recipients can reach tolerance over the long term. Two simple basal variables-the time from transplantation and the SI-may help to identify these patients.

Evolving frequency and outcomes of liver transplantation based on etiology of liver disease

BACKGROUND

In the background of availability of better treatments for specific liver diseases and listing of nonalcoholic steatohepatitis (NASH) as an etiology for liver transplantation (LT), data are unclear on the impact of disease etiology on the frequency of LT and liver posttransplantation outcomes.

METHODS

The United Network for Organ Sharing database (1994-2009) was queried for adults receiving first LT for primary biliary cirrhosis (PBC; n=3052), primary sclerosing cholangitis (PSC; n=3854), hepatitis C virus (HCV; n=15,147), alcoholic cirrhosis (AC; n=8940), HCV+alcohol (n=6066), NASH (n=1368), cryptogenic cirrhosis (CC; n=5856), hepatitis B virus (HBV; n=1816), and hepatocellular carcinoma (HCC; n=8588). Graft and patient survival were compared and Cox models were built to determine independent prediction of outcomes by disease etiology.

RESULTS

The frequency of LT increased for NASH, HCC, and HCV+alcohol, remained stable for AC, and decreased for PBC, PSC, HCV, CC, and HBV. The proportion of simultaneous liver-kidney transplants increased from approximately 3% in 2001 to 10% in 2009. Compared with PBC, 5-year graft and patient survival were (a) similar for PSC, NASH, and HBV (80-85%), (b) poorer for AC and CC (hazard ratio, 1-1.5), and (c) worst for HCV, HCV+alcohol, and HCC (hazard ratio, 1.5-2.4). Five-year outcomes for HCV-associated HCC were poorer compared with HCC due to other etiologies.

CONCLUSIONS

LT performed for NASH and HCC are increasing. Potent treatment options resulted in a decrease in number of transplants for HBV, HCV, and PBC. Better treatment modalities for HCV are expected to further reduce the number of LT for HCV. Excellent posttransplantation outcomes for NASH and AC are encouraging, resulting in wider acceptance of transplants for these etiologies.