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Mishra S, Taneja S. Algorithmic Approach to Deranged Liver Functions After Transplantation. J Clin Exp Hepatol 2024; 14:101317. [PMID: 38264576 PMCID: PMC10801315 DOI: 10.1016/j.jceh.2023.101317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 12/06/2023] [Indexed: 01/25/2024] Open
Abstract
Liver transplant (LT) recipients require close follow-up with regular monitoring of the liver function tests (LFTs). Evaluation of deranged LFT should be individualized depending upon the time since LT, peri-operative events, clinical course, and any complications. These derangements can range from mild and asymptomatic to severe and symptomatic elevations requiring expedited personalized assessment and management. Pattern of LFT derangement (hepatocellular, cholestatic, or mixed), donor-recipient risk factors, timing after LT (post-operative, 1-12 months, and >12 months since LT) along with clinical context and symptomatology are important considerations before proceeding with the initial evaluation. Compliance to immunosuppression and drug interactions should be ascertained along with local epidemiology of infections. Essential initial evaluation must include an ultrasound abdomen with Doppler to rule out any structural causes such as biliary or vascular complications apart from focussed laboratory evaluation. Early allograft dysfunction, ischemia reperfusion injury, small-for-size syndrome, biliary leaks, hepatic artery, and portal vein thrombosis are usual culprits in the early post-operative period whereas viral hepatitis (acute or reactivation), opportunistic infections, and recurrence of the primary disease are more frequent in the later period. Graft rejection, biliary strictures, sepsis, and drug induced liver injury remain possible etiologies at all times points after LT. Initial evaluation algorithm must be customized based on history, clinical examination, risk factors, and pattern and severity of deranged LFT. Allograft rejection is a diagnosis of exclusion and requires liver biopsy to confirm and assess severity. Empirical treatment of rejection sans liver biopsy is discouraged.
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Affiliation(s)
- Saurabh Mishra
- Department of Gastroenterology and Hepatology, Paras Health, Sector 22, Panchkula, Haryana 134109, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
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Poudel S, Gupta S, Saigal S. Basics and Art of Immunosuppression in Liver Transplantation. J Clin Exp Hepatol 2024; 14:101345. [PMID: 38450290 PMCID: PMC10912712 DOI: 10.1016/j.jceh.2024.101345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 01/09/2024] [Indexed: 03/08/2024] Open
Abstract
Liver transplantation is one of the most challenging areas in the medical field. Despite that, it has already been established as a standard treatment option, especially in decompensated cirrhosis and selected cases of hepatocellular carcinoma and acute liver failure. Complications due to graft rejection, including mortality and morbidity, have greatly improved over time due to better immunosuppressive agents and management protocols. Currently, immunosuppression in liver transplant patients makes use of the best possible combinations of effective agents to achieve optimal immunosuppression for long-term graft survival. Induction agents are no longer used routinely, and the aim is to provide minimal immunosuppression in the maintenance phase. Currently available immunosuppressive agents are mainly classified as biological and pharmacological agents. Though the protocols may vary among the centers and over time, the basics of effective use usually remain similar. Most protocols use the combination of multiple agents with different mechanisms of action to reduce the dose and minimize the side effects. Along with the improvement in operative and perioperative techniques, this art of immunosuppression has contributed to the recent progress made in the outcomes of liver transplants. In this review, we will discuss the various types of immunosuppressive agents currently in use, the different protocols of immunosuppression used, and the art of optimal use for achieving maximum immunosuppression without increasing toxicity. We will also discuss the practical aspects of various immunosuppression regimens, including drug monitoring, and briefly discuss the concepts of immunosuppression minimization and withdrawal.
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Affiliation(s)
- Shekhar Poudel
- Fellow Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Principal Director and Head, Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
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Raja K, Panackel C. Post Liver Transplant Renal Dysfunction-Evaluation, Management and Immunosuppressive Practice. J Clin Exp Hepatol 2024; 14:101306. [PMID: 38274509 PMCID: PMC10806298 DOI: 10.1016/j.jceh.2023.101306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 11/21/2023] [Indexed: 01/27/2024] Open
Abstract
Liver transplantation (LT) is an effective and lifesaving treatment for patients with end-stage liver disease and hepatocellular carcinoma. Significant improvement in intermediate and long-term survival has been possible due to advancements in immunosuppressive therapy, perioperative care, and surgical techniques. Despite these advances, metabolic complications, including diabetes mellitus, cardiovascular diseases, malignancies, and renal dysfunction, are challenging issues after LT. Acute kidney injury (AKI) and chronic kidney disease (CKD) after LT are common and result in significant morbidity and mortality. Early diagnosis of kidney injury after LT is challenging, and no technique has yet proven effective in prediction of renal dysfunction. The methods for assessing renal function range from formulas that predict glomerular filtration rate to non-invasive biomarkers. The universal adoption of the model for end-stage liver disease has a direct impact on the incidence of peri-transplant AKI and development of CKD in the long-term. Post-LT renal dysfunction is multifactorial and is usually a result of pre-transplantation comorbidities, occurrence of renal dysfunction on the waiting list, perioperative events, and post-transplant nephrotoxic immunosuppressive medication use. Early identification of patients at risk for renal dysfunction and adoption of preventive measures are crucial in the pre-transplant period. No data are currently available to suggest a surgical technique that reliably demonstrates renal protection. Nephroprotective strategies during LT follow accepted surgical practice guidelines, such as maintenance of intravascular volume and mean arterial pressure. The management of kidney disease following LT is challenging, as by the time the serum creatinine is significantly elevated, few interventions impact the course of progression. Early nephroprotective measures are strongly advised and they mostly center on delaying the administration of calcineurin inhibitors (CNIs) during the initial postoperative period, lowering CNI dosage and combining CNI with mycophenolate mofetil and everolimus. The reasons for renal failure following LT, the techniques used to diagnose it, and the therapies designed to preserve renal function both immediately and late after LT are all critically evaluated in this review.
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Affiliation(s)
- Kaiser Raja
- Department of Gastroenterology and Hepatology, King's College Hospital London, Dubai, United Arab Emirates
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Choudhary NS, Dhampalwar S, Saraf N, Soin AS. Metabolic dysfunction-associated steatotic liver disease: Where does non-alcoholic fatty liver disease in liver transplant recipients fit in this new definition? J Hepatol 2024; 80:e77-e79. [PMID: 37717602 DOI: 10.1016/j.jhep.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/19/2023]
Affiliation(s)
- Narendra Singh Choudhary
- Institute of Liver Transplantation & Regenerative Medicine, Medanta- The Medicity, Gurugram, India.
| | - Swapnil Dhampalwar
- Institute of Liver Transplantation & Regenerative Medicine, Medanta- The Medicity, Gurugram, India
| | - Neeraj Saraf
- Institute of Liver Transplantation & Regenerative Medicine, Medanta- The Medicity, Gurugram, India
| | - Arvinder S Soin
- Institute of Liver Transplantation & Regenerative Medicine, Medanta- The Medicity, Gurugram, India
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Li H, Yu S, Liu H, Chen L, Liu H, Liu X, Shen C. Immunologic barriers in liver transplantation: a single-cell analysis of the role of mesenchymal stem cells. Front Immunol 2023; 14:1274982. [PMID: 38143768 PMCID: PMC10748593 DOI: 10.3389/fimmu.2023.1274982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/13/2023] [Indexed: 12/26/2023] Open
Abstract
Background This study aimed to analyze the biomarkers that may reliably indicate rejection or tolerance and the mechanism that underlie the induction and maintenance of liver transplantation (LT) tolerance related to immunosuppressant or mesenchymal stem cells (MSCs). Methods LT models of Lewis-Lewis and F344-Lewis rats were established. Lewis-Lewis rats model served as a control (Syn). F344-Lewis rats were treated with immunosuppressant alone (Allo+IS) or in combination with MSCs (Allo+IS+MSCs). Intrahepatic cell composition particularly immune cells was compared between the groups by single-cell sequencing. Analysis of subclusters, KEGG pathway analysis, and pseudotime trajectory analysis were performed to explore the potential immunoregulatory mechanisms of immunosuppressant alone or combined with MSCs. Results Immunosuppressants alone or combined with MSCs increases the liver tolerance, to a certain extent. Single-cell sequencing identified intrahepatic cell composition signature, including cell subpopulations of B cells, cholangiocytes, endothelial cells, erythrocytes, hepatic stellate cells, hepatocytes, mononuclear phagocytes, neutrophils, T cells, and plasmacytoid dendritic cells. Immunosuppressant particularly its combination with MSCs altered the landscape of intrahepatic cells in transplanted livers, as well as gene expression patterns in immune cells. MSCs may be included in the differentiation of T cells, classical monocytes, and non-classical monocytes. Conclusion These findings provided novel insights for better understanding the heterogeneity and biological functions of intrahepatic immune cells after LT treated by IS alone or in combination with MSCs. The identified markers of immune cells may serve as the immunotherapeutic targets for MSC treatment of liver transplant rejection.
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Affiliation(s)
- Haitao Li
- Department of Hepatopancreatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
| | - Saihua Yu
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, China
| | - Haiyan Liu
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, China
| | - Lihong Chen
- Department of Pathology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
| | - Hongzhi Liu
- Department of Hepatopancreatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
| | - Xingwen Liu
- Department of Nursing, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
| | - Conglong Shen
- Department of Hepatopancreatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
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Choudhary NS, Dhampalwar S, Saraf N, Bansal SB, Gadde A, Rastogi A, Bhangui P, Rana A, Rana A, Soin AS. The Renal Histological Correlates of Refractory Renal Dysfunction After Liver Transplantation. J Clin Exp Hepatol 2023; 13:586-591. [PMID: 37440946 PMCID: PMC10333932 DOI: 10.1016/j.jceh.2023.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/21/2023] [Indexed: 07/15/2023] Open
Abstract
Background Kidney dysfunction is common after liver transplantation (LT) and is often attributed to calcineurin inhibitors (CNIs). Very few studies have looked at histological causes. Material and methods The study is a retrospective analysis of histological findings and diagnosis in all patients who underwent a kidney biopsy after LT from 2010 to 2020. Data are shown as mean ± standard deviation or medians (25-75 interquartile range). Results The study cohort consisted of 26 patients (25 males, 1 female), aged 55 ± 7 years at the time of the kidney biopsy. Kidney biopsies were done at 27.5 (6.7-60.7) months after LT. At the time of the kidney biopsy, the median serum creatinine was 2.10 (1.50-2.86) mg/dl and proteinuria was 3.8 (1.8-5.9) gm/day. Twenty-four (92%) patients were on CNIs. The diagnoses on kidney biopsies were diabetic nephropathy (n = 7), focal segmental glomerulosclerosis (n = 4), CNI nephrotoxicity (n = 3), IgA nephropathy (n = 4), chronic glomerulonephritis (n = 3), hypertensive nephropathy (n = 1), membranous glomerulonephritis (n = 1), acute on chronic interstitial nephritis (n = 1), and C1q nephropathy (n = 1), and the sample was inadequate in one patient. A total of sixteen patients had progression of kidney disease. The kidney function remained stable/improved in 6 (23%) patients, follow-up data were not available for 4 patients. Fourteen (53.8%) patients (including one with CNI nephrotoxicity) required hemodialysis at 13.5 (5.7-29) months after the kidney biopsy. Conclusion Although the kidney biopsy diagnosed the cause of unexplained renal insufficiency in LT recipients, the majority of patients progressed to end-stage renal disease despite treatment modifications. The use of CNIs was an uncommon cause of renal impairment.
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Affiliation(s)
- Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Swapnil Dhampalwar
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Shyam B. Bansal
- Institute of Nephrology, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Ashwini Gadde
- Institute of Nephrology, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Abhyuday Rana
- Institute of Nephrology, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Alka Rana
- Department of Pathology, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
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Jadaun SS, Agarwal S, Gupta S, Saigal S. Practice of Immunosuppression in Liver Transplant Programs in India: Results of a Survey. J Clin Exp Hepatol 2023; 13:377-379. [PMID: 36950483 PMCID: PMC10025585 DOI: 10.1016/j.jceh.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 11/05/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Shekhar S Jadaun
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Shaleen Agarwal
- Department of Liver Transplant and Gastro Intestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Department of Liver Transplant and Gastro Intestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
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Panackel C, Mathew JF, Fawas N M, Jacob M. Immunosuppressive Drugs in Liver Transplant: An Insight. J Clin Exp Hepatol 2022; 12:1557-1571. [PMID: 36340316 PMCID: PMC9630030 DOI: 10.1016/j.jceh.2022.06.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/16/2022] [Indexed: 12/12/2022] Open
Abstract
Liver transplantation (LT) is the standard of care for end-stage liver failure and hepatocellular carcinoma. Over the years, immunosuppression regimens have improved, resulting in enhanced graft and patient survival. At present, the side effects of immunosuppressive agents are a significant threat to post-LT quality of life and long-term outcome. The role of personalized immunosuppression is to reach a delicate balance between optimal immunosuppression and minimal side effects. Today, immunosuppression in LT is more of an art than a science. There are no validated markers for overimmunosuppression and underimmunosuppression, only a few drugs have therapeutic drug monitoring and immunosuppression regimens vary from center to center. The immunosuppressive agents are broadly classified into biological agents and pharmacological agents. Most regimens use multiple agents with different modes of action to reduce the dosage and minimize the toxicities. The calcineurin inhibitor (CNI)-related toxicities are reduced by antibody induction or using mTOR inhibitor/antimetabolites as CNI sparing or CNI minimization strategies. Post-liver transplant immunosuppression has an intensive phase in the first three months when alloreactivity is high, followed by a maintenance phase when immunosuppression minimization protocols are implemented. Over time some patients achieve "tolerance," defined as the successful stopping of immunosuppression with good graft function and no indication of rejection. Cell-based therapy using immune cells with tolerogenic potential is the future and may permit complete withdrawal of immunosuppressive agents.
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Key Words
- AMR, Antibody-mediated rejection
- APCs, Antigen-presenting cells
- ATG, Anti-thymocyte globulin
- CNI, Calcineurin inhibitors
- CsA, Cyclosporine A
- EVR, Everolimus
- IL-2R, Interleukin 2 Receptor
- LT, Liver transplantation
- MMF, Mycophenolate mofetil
- MPA, Mycophenolic acid
- SRL, Sirolimus
- TAC, Tacrolimus
- TCMR, T-cell-mediated rejection
- antimetabolites
- basiliximab
- calcineurin inhibitors
- cyclosporine
- everolimus
- immunosuppression
- liver transplantation
- mTORi, mammalian targets of rapamycin inhibitor
- mycophenolate mofetil
- tacrolimus
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Affiliation(s)
- Charles Panackel
- Aster Integrated Liver Care, Aster Medcity, Kochi, Kerala, 682027, India
| | - Joe F Mathew
- Aster Integrated Liver Care, Aster Medcity, Kochi, Kerala, 682027, India
| | - Mohamed Fawas N
- Aster Integrated Liver Care, Aster Medcity, Kochi, Kerala, 682027, India
| | - Mathew Jacob
- Aster Integrated Liver Care, Aster Medcity, Kochi, Kerala, 682027, India
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Choudhary NS, Saraf N, Dhampalwar S, Mishra S, Gautam D, Lipi L, Rastogi A, Bhangui P, Chaudhary RJ, Gupta A, Yadav K, Soin AS. Nonalcoholic Fatty Liver Disease in Living Donor Liver Transplant Recipients: A Histology-Based Study. J Clin Exp Hepatol 2022; 12:1328-1332. [PMID: 36157151 PMCID: PMC9500106 DOI: 10.1016/j.jceh.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022] Open
Abstract
Background Recurrent or de novo nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are common after liver transplantation (LT) and may be associated with rapid progression to fibrosis; however, there is limited data in this regard after living donor liver transplantation (LDLT). Material and methods This is a retrospective study at a high volume LDLT center of all liver biopsies performed in patients with post-transplant NAFLD diagnosed on ultrasound of the abdomen. Liver biopsy was indicated for raised transaminases and/or high liver stiffness on TE. The association between these prebiopsy parameters and inflammation and fibrosis on histology was analyzed. Data are shown as mean ± standard deviation or median (25-75 interquartile range). Results The study cohort consisted of 31 males and 3 females, aged 43 ± 10 years. The LT to liver biopsy interval was 44 (28-68) months. The prebiopsy AST and ALT were 71 (38-119) and 66 (50-156), respectively. The histology suggested no nonalcoholic steatohepatitis (NASH) in 7 (20%), borderline NASH in 15 (44%), and NASH in 12 (35%) patients. A total of 15 patients (44%) had stage 1 or stage 2 fibrosis. The proportion of patients having fibrosis was significantly higher in patients with NASH (83%) compared to patients with borderline NASH (33%) or no NASH (none had fibrosis, P = 0.001). Among 18 patients who underwent TE (on FibroScan), liver stiffness was significantly higher in patients with fibrosis [18.1 (9.7-22.5)] than in those without fibrosis [9.7 (4.0-12.7); P = 0.043]. Conclusion Over a third of the LDLT recipients with post-transplant NAFLD developed NASH, and nearly half, borderline NASH 3-5 years after transplant. Most with established NASH also had fibrosis on histology. Prevention of risk factors and early diagnosis is warranted in these patients.
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Affiliation(s)
- Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Swapnil Dhampalwar
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Saurabh Mishra
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Dheeraj Gautam
- Department of Pathology, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Lipika Lipi
- Department of Pathology, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Rohan J. Chaudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Ankur Gupta
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Kamal Yadav
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
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Zhang W, Cao D, Wang M, Wu Y, Gong J, Li J, Liu Y. XBP1s repression regulates Kupffer cell polarization leading to immune suppressive effects protecting liver allograft in rats. Int Immunopharmacol 2021; 91:107294. [PMID: 33395585 DOI: 10.1016/j.intimp.2020.107294] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/30/2020] [Accepted: 12/08/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Polarized kupffer cells (KCs) influence the immune response after liver transplantation. We report an undiscovered immune regulatory role of X-box binding protein 1 (XBP1) on immune function of kupffer cells (KCs). METHODS Acute rejection model using rats. RESULTS We found that suppression of XBP1s in lipopolysaccharide (LPS) -activated KCs could increase the expression of arginase-1 (Arg-1) and CD204 but also decrease the expression levels of MHC-II and CD40 and shift the phenotype markers of KCs toward M2 via the janus kinase (JAK) 3- Signal Transducer And Activator Of Transcription (STAT) 6 pathway, presenting an immunosuppressive function by enhancing anti-inflammatory cytokine secretion and accelerating apoptosis of activated T cells. XBP1s over-expression in KCs shift the phenotype markers on KCs towards M1 via the JAK1-STAT1 pathway and have shown a strong pro-inflammatory property. Down-regulation of XBP1s in KCs changed the phenotype and cytokine secretion profile towards M2 and markedly protected the function and structure of allograft liver, prolonging the recipient's survival compared with control and normal saline groups in rats. CONCLUSIONS Our findings reveal a novel regulatory mechanism of XBP1 in an induced immuno-suppressive state to protect rat's liver allograft via JAK-STAT mediated KCs polarization.
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Affiliation(s)
- Weikang Zhang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430022, China
| | - Ding Cao
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China.
| | - Menghao Wang
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China
| | - Yakun Wu
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China
| | - Jianping Gong
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China
| | - Jingzheng Li
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China
| | - Yiming Liu
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China.
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Choudhary NS, Saraf N, Saigal S, Soin AS. Long-term Management of the Adult Liver Transplantation Recipients. J Clin Exp Hepatol 2021; 11:239-253. [PMID: 33746450 PMCID: PMC7953009 DOI: 10.1016/j.jceh.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/14/2020] [Indexed: 12/12/2022] Open
Abstract
The survival of liver transplantation (LT) recipients has been improved remarkably in short-term. The major causes of mortality in long-term include nonimmunological causes such as cardiovascular, de novo malignancy, chronic kidney disease, and recurrence of primary disease. Rejection-related mortality is rare in the long-term after LT. We discuss nonrejection causes of long-term morbidity/mortality, risk factors, and management strategies in LT recipients. In addition, we discuss osteoporosis, contraception, and pregnancy in LT recipients.
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Key Words
- AIH, autoimmune hepatitis
- BMI, body mass index
- CKD, chronic kidney disease
- CNI, calcineurin inhibitors
- CVD, cardiovascular disease
- DDLT, deceased donor liver transplantation
- DM, diabetes mellitus
- DNM, de novo malignancy
- HCV, hepatitis C virus
- HR, hazard ratio
- IUCD, Intrauterine contraceptive devices
- LDLT, living donor liver transplantation
- LT, liver transplantation
- MDRD, Modification of Diet in Renal Disease
- MMF, mycophenolate
- MS, metabolic syndrome
- NAFLD, nonalcoholic fatty liver disease
- NASH, nonalcoholic steatohepatitis
- OR, odds ratio
- PBC, primary biliary cholangitis
- PSC, primary sclerosing cholangitis
- PTDM, posttransplantation diabetes mellitus
- PTMS, posttransplantation metabolic syndrome
- SVR, sustained virological response
- cardiovascular disease
- de novo malignancy
- eGFR, estimated glomerular filtration rate
- mTORi, Mammalian target of rapamycin inhibitors
- osteoporosis
- pregnancy
- recurrence
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Affiliation(s)
| | - Neeraj Saraf
- Address for correspondence: Dr Neeraj Saraf, Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity Hospital, Sector 38, Gurgaon, Delhi (NCR), India.
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Csikány N, Kiss Á, Déri M, Fekete F, Minus A, Tóth K, Temesvári M, Sárváry E, Bihari L, Gerlei Z, Kóbori L, Monostory K. Clinical significance of personalized tacrolimus dosing by adjusting to donor CYP3A-status in liver transplant recipients. Br J Clin Pharmacol 2020; 87:1790-1800. [PMID: 32986876 DOI: 10.1111/bcp.14566] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/02/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
Donor's CYP3A-status (CYP3A5 genotype and CYP3A4 expression) can provide prognostic information regarding tacrolimus-metabolizing capacity of the liver graft and initial tacrolimus dosing for therapeutic blood concentrations in liver transplants. The present work prospectively investigated whether CYP3A-status guided tacrolimus therapy has any potential clinical benefit for recipients in the early postoperative period. METHODS The contribution of preliminary assaying of donor CYP3A-status to the optimization of initial tacrolimus therapy and to the reduction of adverse events (acute rejection, infection, nephrotoxicity) was investigated in 112 liver transplant recipients (CYPtest group) comparing to 101 control patients on tacrolimus concentration guided therapy. RESULTS The time for achieving therapeutic tacrolimus concentration was significantly reduced, confirming potential benefit of initial tacrolimus therapy adjusted to donor's CYP3A-status over classical clinical practice of tacrolimus concentration guided treatment (4 vs 8 days, P < 0.0001). Acute rejection episodes (3.6 vs 23.8%, P < 0.0001) and tacrolimus induced nephrotoxicity (8 vs 27%, P = 0.0004) were less frequent in CYPtest group than in control patients, whereas occurrence of infectious disease was not influenced by tacrolimus dosing strategy (3.6 vs 5.9% in CYPtest and control groups, P > 0.05). Acute rejection was often accompanied with tacrolimus blood concentrations lower than 10 ng mL-1 (20/24 of control and 2/4 of CYPtest patients), while nephrotoxicity was associated with high tacrolimus concentrations (>20 ng mL-1 ) in the first week after transplantation (13/27 of control and 2/9 of CYPtest patients). CONCLUSION CYP3A-status guided therapy significantly improved the risk of misdosing induced early adverse effects (acute rejection, nephrotoxicity).
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Affiliation(s)
- Nóra Csikány
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Ádám Kiss
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Máté Déri
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Ferenc Fekete
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Annamária Minus
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Katalin Tóth
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Manna Temesvári
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Enikő Sárváry
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - László Bihari
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Zsuzsa Gerlei
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - László Kóbori
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Katalin Monostory
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
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13
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Impact of immunosuppressive therapy on brain derived cytokines after liver transplantation. Transpl Immunol 2019; 58:101248. [PMID: 31669260 DOI: 10.1016/j.trim.2019.101248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/27/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND While acute neurotoxic side effects of calcineurin inhibitors (CNI) are well-known, data upon long-term effects on brain structure and function are sparse. We hypothesize that long-term CNI therapy affects the neuroimmune system, thereby, increasing the risk of neurodegeneration. Here, we measured the impact of CNI therapy on plasma levels of brain- and T cell-derived cytokines in a cohort of patients after liver transplantation (LT). METHODS Levels of T cell-mediated cytokines (e.g. Interferon-γ (IFN-γ)) and brain-derived cytokines (e.g. brain derived neurotrophic factor (BDNF), platelet derived growth factor (PDGF)) were measured by multiplex assays in plasma of 82 patients about 10 years after LT (17 with CNI free, 35 with CNI low dose, 30 with standard dose CNI immunosuppression) and 33 healthy controls. Data were related to psychometric test results and parameters of cerebral magnetic resonance imaging. RESULTS IFN-γ levels were significantly higher in the CNI free LT patient group (p=0.027) compared to healthy controls. BDNF levels were significantly lower in LT patients treated with CNI (CNI low: p<0.001; CNI standard: p=0.016) compared to controls. PDGF levels were significantly lower in the CNI low dose group (p=0.004) and for PDGF-AB/BB also in the CNI standard dose group (p=0.029) compared to controls. BDNF and PDGF negatively correlated with cognitive function and brain volume (p<0.05) in the CNI low dose group. CONCLUSION Our results imply that long-term treatment with CNI suppresses BDNF and PDGF expression, both crucial for neuronal signaling, cell survival and synaptic plasticity and thereby may lead to cognitive dysfunction and neurodegeneration.
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14
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McLean KA, Drake TM, Sgrò A, Camilleri-Brennan J, Knight SR, Ots R, Adair A, Wigmore SJ, Harrison EM. The effect of liver transplantation on patient-centred outcomes: a propensity-score matched analysis. Transpl Int 2019; 32:808-819. [PMID: 30793373 DOI: 10.1111/tri.13416] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/19/2018] [Accepted: 02/18/2019] [Indexed: 12/21/2022]
Abstract
It is unclear whether liver transplantation confers an increase in health-related quality of life (HR-QoL) across all dimensions of health. This study aimed to estimate the effect of liver transplantation on HR-QoL. Pre- and post-transplantation patients attending an outpatient clinic were invited to complete the condition-specific 'Short form of liver disease QOL' questionnaire. Mixed-effect linear regression and propensity-score matching (PSM) on pretransplantation characteristics were used to estimate the difference in overall HR-QoL associated with transplantation. Of 454/609 (74.5%) eligible patients who were included in the analysis, 102 (22.5%) patients fall under pretransplantation category, and 352 (77.5%) were under post-transplantation category. Overall HR-QoL post-transplantation significantly increased in patients without hepatocellular carcinoma (HCC) (β = 16.84, 95% CI: 13.33 to 20.35, P < 0.001), but not with HCC (β = 1.25, 95% CI: -5.09 to 7.60, P = 0.704). Donation after circulatory death (DCD) organ recipients had a significantly lower HR-QoL (β = -4.61, 95% CI: -8.95 to -0.24, P = 0.043). Following PSM, transplantation was associated with a significant increase in overall HR-QoL (average treatment effect: 6.3, 95% CI: 2.1-10.9). There is a significant improvement in HR-QoL attributable to transplantation in this cohort. Post-transplantation HR-QoL was affected by several factors, including HCC status and DCD transplantation, which has important implications for counselling prior to liver transplantation.
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Affiliation(s)
- Kenneth A McLean
- Scottish Liver Transplant Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Thomas M Drake
- Scottish Liver Transplant Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alessandro Sgrò
- Scottish Liver Transplant Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Julian Camilleri-Brennan
- Scottish Liver Transplant Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Stephen R Knight
- Scottish Liver Transplant Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Riinu Ots
- Scottish Liver Transplant Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Anya Adair
- Scottish Liver Transplant Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Stephen J Wigmore
- Scottish Liver Transplant Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ewen M Harrison
- Scottish Liver Transplant Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
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15
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Choudhary NS, Saigal S. Preventive Strategies for Nonalcoholic Fatty Liver Disease After Liver Transplantation. J Clin Exp Hepatol 2019; 9:619-624. [PMID: 31695252 PMCID: PMC6823688 DOI: 10.1016/j.jceh.2019.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/22/2019] [Indexed: 12/12/2022] Open
Abstract
Post-transplant nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH) is common and can be recurrent or de novo. The available data suggest that progression of fibrosis is accelerated in these patients compared to NASH in general population. The long-term data suggest more risk of metabolic syndrome and associated metabolic comorbidities and cardiovascular disease in these patients. The current review focuses on prevalence and prevention/treatment of post-transplant NAFLD or NASH.
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Affiliation(s)
| | - Sanjiv Saigal
- Address for correspondence: Sanjiv Saigal, Director, Hepatology & Liver Transplant, Medanta Institute of Digestive & Hepatobiliary Sciences &Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, PIN 122001, India.
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16
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Choudhary NS, Saigal S, Sonavane A, Prakash AK, Pandey A, Saraf N, Soin AS. A Case of Sirolimus-Induced Interstitial Lung Disease After Liver Transplantation. J Clin Exp Hepatol 2019; 9:539-540. [PMID: 31516270 PMCID: PMC6728530 DOI: 10.1016/j.jceh.2018.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 09/26/2018] [Indexed: 12/12/2022] Open
Abstract
Mammalian target of rapamycin inhibitors (mTORis) are immunosuppression agents that are commonly used in solid organ transplantation. Available mTORis include sirolimus and everolimus. Interstitial lung disease (ILD) is an uncommon side effect of mTORis in liver transplantation. A high index of suspicion is needed, and timely intervention can reverse the disease. We present a case of sirolimus-induced ILD that improved after discontinuation of sirolimus.
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Affiliation(s)
- Narendra S. Choudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjiv Saigal
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India,Address for correspondence: Sanjiv Saigal, Director – Hepatology, Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Medanta The Medicity Hospital, Sector 38, Gurgaon, Delhi (NCR), India. Tel.: +919811552928.
| | - Amey Sonavane
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Ashish K. Prakash
- Department of Respiratory Medicine and Sleep Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Arvind Pandey
- Department of Radiodiagnosis, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Neeraj Saraf
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Arvinder S. Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
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17
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Choudhary NS, Saraf N, Saigal S, Gautam D, Rastogi A, Goja S, Bhangui P, Srinivasan T, Yadav SK, Soin A. Revisiting chronic rejection following living donor liver transplantation in the tacrolimus era: A single center experience. Clin Transplant 2018; 32. [DOI: 10.1111/ctr.13161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2017] [Indexed: 01/02/2023]
Affiliation(s)
- Narendra Singh Choudhary
- Institute of Liver Transplantation and Regenerative Medicine; Medanta, The Medicity; Gurgaon India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine; Medanta, The Medicity; Gurgaon India
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine; Medanta, The Medicity; Gurgaon India
| | - Dheeraj Gautam
- Department of Histopathology; Medanta, The Medicity; Gurgaon India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine; Medanta, The Medicity; Gurgaon India
| | - Sanjay Goja
- Institute of Liver Transplantation and Regenerative Medicine; Medanta, The Medicity; Gurgaon India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine; Medanta, The Medicity; Gurgaon India
| | - Thiagrajan Srinivasan
- Institute of Liver Transplantation and Regenerative Medicine; Medanta, The Medicity; Gurgaon India
| | - Sanjay Kumar Yadav
- Institute of Liver Transplantation and Regenerative Medicine; Medanta, The Medicity; Gurgaon India
| | - Arvinder Soin
- Institute of Liver Transplantation and Regenerative Medicine; Medanta, The Medicity; Gurgaon India
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18
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Choudhary NS, Saigal S, Bansal RK, Saraf N, Gautam D, Soin AS. Acute and Chronic Rejection After Liver Transplantation: What A Clinician Needs to Know. J Clin Exp Hepatol 2017; 7:358-366. [PMID: 29234201 PMCID: PMC5715482 DOI: 10.1016/j.jceh.2017.10.003] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 10/30/2017] [Indexed: 02/07/2023] Open
Abstract
While antibody mediated hyper-acute vasculitic rejection is rare in liver transplant recipients, acute and chronic rejection have clinical significance. The liver allograft behaves differently to other solid organ transplants as acute rejection generally does not impair graft survival and chronic rejection (CR) is uncommon. The incidence of acute and chronic rejection has declined in current era due to improved immunosuppressive regimens. Acute rejection generally improves with steroid boluses and steroid resistant rejection is uncommon. CR may improve with escalation of immunosuppression or may result in irreversible loss of graft function leading to retransplantation or death. The current review discusses diagnosis and management of acute and chronic liver allograft rejection.
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Affiliation(s)
- Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India,Address for correspondence: Sanjiv Saigal, Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Sector 38, Gurgaon, Haryana 122001, India. Tel.: +91 9811552928.Sanjiv Saigal, Institute of Liver Transplantation and Regenerative Medicine, Medanta The MedicitySector 38GurgaonHaryana122001India
| | - Rinkesh K. Bansal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India
| | - Dheeraj Gautam
- Department of Pathology, Medanta The Medicity, Gurugram, India
| | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India
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19
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Song JY, Du GS, Xiao L, Chen W, Suo LL, Gao Y, Feng LK, Shi BY. Individualized Immunosuppressive Protocol of Liver Transplant Recipient Should be Made Based on Splenic Function Status. Chin Med J (Engl) 2017; 129:1340-6. [PMID: 27231173 PMCID: PMC4894046 DOI: 10.4103/0366-6999.182828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Lymphocyte subsets play important roles in rejection in liver transplant recipients, and the effect of splenic function on these roles remains unknown. The aim of this study was to explore the feasibility to adjust immunosuppressive agents based on splenic function status through detecting the lymphocyte subsets in liver transplantBeijing recipients. METHODS The lymphocyte subsets of 49 liver transplant recipients were assessed in the 309th Hospital of Chinese People's Liberation Army between June 2014 and August 2015. The patients were divided into splenectomy group (n = 9), normal splenic function group (n = 24), and hypersplenism group (n = 16). The percentages and counts of CD4+ T, CD8+ T, natural killer (NK) cell, B-cell, regulatory B-cell (Breg), and regulatory T-cell (Treg) were detected by flow cytometer. In addition, the immunosuppressive agents, histories of rejection and infection, and postoperative time of the patients were compared among the three groups. RESULTS There was no significant difference of clinical characteristics among the three groups. The percentage of CD19+CD24+CD38+ Breg was significantly higher in hypersplenism group than normal splenic function group and splenectomy group (3.29 ± 0.97% vs. 2.12 ± 1.08% and 1.90 ± 0.99%, P = 0.001). The same result was found in CD4+CD25+FoxP3+ Treg percentage (0.97 ± 0.39% vs. 0.54 ± 0.31% and 0.56 ± 0.28%, P = 0.001). The counts of CD8+ T-cell, CD4+ T-cell, and NK cell were significantly lower in hypersplenism group than normal splenic function group (254.25 ± 149.08 vs. 476.96 ± 225.52, P= 0.002; 301.69 ± 154.39 vs. 532.50 ± 194.42, P= 0.000; and 88.56 ± 63.15 vs. 188.33 ± 134.51, P = 0.048). Moreover, the counts of CD4+ T-cell and NK cell were significantly lower in hypersplenism group than splenectomy group (301.69 ± 154.39 vs. 491.89 ± 132.31, P= 0.033; and 88.56 ± 63.15 vs. 226.00 ± 168.85, P = 0.032). CONCLUSION Splenic function status might affect the immunity of liver transplant recipients, that should be considered when we make immunosuppressive protocols.
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Affiliation(s)
- Ji-Yong Song
- Department of Education, Chinese People's Liberation Army Medical School, Beijing 100853, China
| | - Guo-Sheng Du
- Department of Hepatobiliary, Organ Transplant Institute, The 309th Hospital of Chinese People's Liberation Army, Beijing 100091, China
| | - Li Xiao
- Department of Hepatobiliary, Organ Transplant Institute, The 309th Hospital of Chinese People's Liberation Army, Beijing 100091, China
| | - Wen Chen
- Department of Hepatobiliary, Organ Transplant Institute, The 309th Hospital of Chinese People's Liberation Army, Beijing 100091, China
| | - Long-Long Suo
- Department of Hepatobiliary, Organ Transplant Institute, The 309th Hospital of Chinese People's Liberation Army, Beijing 100091, China
| | - Yu Gao
- Department of Hepatobiliary, Organ Transplant Institute, The 309th Hospital of Chinese People's Liberation Army, Beijing 100091, China
| | - Li-Kui Feng
- Department of Hepatobiliary, Organ Transplant Institute, The 309th Hospital of Chinese People's Liberation Army, Beijing 100091, China
| | - Bing-Yi Shi
- Department of Education, Chinese People's Liberation Army Medical School, Beijing 100853, China
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20
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Breil T, Wenning D, Teufel U, Hoffmann GF, Ries M. An Assessment of Publication Status of Pediatric Liver Transplantation Studies. PLoS One 2016; 11:e0168251. [PMID: 27992485 PMCID: PMC5167264 DOI: 10.1371/journal.pone.0168251] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 11/28/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Pediatric liver transplantation is a highly specialized, challenging field. Selective reporting may introduce bias into evidence based clinical decision making, but the precise extent of unpublished data in pediatric liver transplantation is unknown today. We therefore assessed the public availability of completed clinical trials in pediatric liver transplantation. METHODS We determined the proportion of published and unpublished pre-registered, completed pediatric liver transplantation studies on ClinicalTrials.gov. The major trial and literature databases, i.e., clinicaltrials.gov, Pubmed, and Google Scholar were searched for publications. In addition, principal investigators or sponsors were contacted directly. STROBE criteria were applied for the descriptive analysis. RESULTS Out of N = 33 studies focusing on pediatric liver transplantation registered as completed until March 2014 on clinicaltrials.gov, N = 19 (58%) studies were published until February 2015, whereas N = 14 (42%) studies remained unpublished. The unpublished trials contain data from N = 2105 (35%) patients out of a total population of N = 6044 study participants. Median time-to-publication, i.e., the period from completion of the trial until public availability of the data was 23 IQR 10 to 28 months. Most pertinent key questions in pediatric liver transplantation, i.e., surgical procedures, immunosuppression, concomitant infections, and graft rejection were addressed in 48% of studies (N = 16/33), half of which were published. CONCLUSION Half of the clinical trials in pediatric liver transplantation focused on key questions such as surgical procedures, immunosuppression, concomitant infections, and graft rejection. There is still a considerable amount of unpublished studies results in pediatric liver transplantation. Time from study completion to publication was almost twice as long as the 12 months mandatory FDAAA-timeline with a trend towards acceleration over time. The data should serve as a baseline for future progress in the field. More stringent publication of completed trials and focused multicenter research should be encouraged.
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Affiliation(s)
- Thomas Breil
- Pediatric Gastroenterology and Hepatology, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Daniel Wenning
- Pediatric Gastroenterology and Hepatology, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulrike Teufel
- Pediatric Gastroenterology and Hepatology, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Georg F. Hoffmann
- Pediatric Gastroenterology and Hepatology, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
- Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Ries
- Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
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21
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Li M, Zhao Y, Humar A, Tevar AD, Hughes C, Venkataramanan R. Pharmacokinetics of drugs in adult living donor liver transplant patients: regulatory factors and observations based on studies in animals and humans. Expert Opin Drug Metab Toxicol 2016; 12:231-43. [PMID: 26809188 DOI: 10.1517/17425255.2016.1139575] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Limited information is available on the pharmacokinetics of drugs in the donors and recipients following adult living donor liver transplantation (LDLT). Given that both the donors and recipients receive multiple drug therapies, it is important to assess the pharmacokinetics of drugs used in these patients. AREAS COVERED Pathophysiological changes that occur post-surgery and regulatory factors that may influence pharmacokinetics of drugs, especially hepatic drug metabolism and transport in both LDLT donors and the recipients are discussed. Pharmacokinetic data in animals with partial hepatectomy are presented. Clinical pharmacokinetic data of certain drugs in LDLT recipients are further reviewed. EXPERT OPINION It takes up to six months for the liver volume to return to normal after LDLT surgery. In the LDLT recipients, drug exposure generally is higher with lower clearance during early period post-transplant; lower initial dosages of immunosuppressants are used than deceased donor liver transplant recipients during the first six months post-transplantation. In animals, the activities of hepatic drug metabolizing enzymes and transporters are known to be altered differentially during liver regeneration. Future studies on the actual hepatic function with reference to drug metabolism, drug transport, and biliary secretion in both LDLT donors and recipients are required.
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Affiliation(s)
- Mi Li
- a Department of Pharmaceutical Sciences, School of Pharmacy , University of Pittsburgh , Pittsburgh , PA , USA.,b School of Medicine , Tsinghua University , Beijing , China
| | - Yang Zhao
- a Department of Pharmaceutical Sciences, School of Pharmacy , University of Pittsburgh , Pittsburgh , PA , USA.,c Office of Pharmaceutical Quality , Center for Drug Evaluation and Research, US Food and Drug Administration , Silver Spring , MD , USA
| | - Abhinav Humar
- d Department of Surgery, School of Medicine , Thomas Starzl Transplantation Institute , Pittsburgh , PA , USA
| | - Amit D Tevar
- d Department of Surgery, School of Medicine , Thomas Starzl Transplantation Institute , Pittsburgh , PA , USA
| | - Christopher Hughes
- d Department of Surgery, School of Medicine , Thomas Starzl Transplantation Institute , Pittsburgh , PA , USA
| | - Raman Venkataramanan
- a Department of Pharmaceutical Sciences, School of Pharmacy , University of Pittsburgh , Pittsburgh , PA , USA.,d Department of Surgery, School of Medicine , Thomas Starzl Transplantation Institute , Pittsburgh , PA , USA.,e Magee Womens Research Institute , Pittsburgh , PA , USA.,f Department of Pathology , School of Medicine, University of Pittsburgh , Pittsburgh , PA , USA
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22
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Monostory K, Tóth K, Kiss Á, Háfra E, Csikány N, Paulik J, Sárváry E, Kóbori L. Personalizing initial calcineurin inhibitor dosing by adjusting to donor CYP3A-status in liver transplant patients. Br J Clin Pharmacol 2015; 80:1429-37. [PMID: 26271661 DOI: 10.1111/bcp.12747] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/10/2015] [Accepted: 08/11/2015] [Indexed: 12/14/2022] Open
Abstract
AIMS Inter-individual variability in dose requirements of calcineurin inhibitors (CNI) has been linked to genetic polymorphisms of CYP3A enzymes. CYP3A5*3, CYP3A4*1B and CYP3A4*22 alleles of liver grafts may explain about one third of the inter-individual differences in pharmacokinetics of ciclosporin and tacrolimus in recipients. However, non-genetic factors, influencing CYP3A expression, can contribute to the variability of CYP3A function due to phenoconversion. The present study evaluated the association between CYP3A4 expression combined with CYP3A5 genotype of donor livers and recipients' CNI therapy after transplantation. METHODS The contribution of donors' CYP3A5 genotype and CYP3A4 expression to the blood concentrations and dose requirements of CNIs was evaluated in 131 liver transplant recipients. RESULTS The recipients with grafts from normal CYP3A4 expresser donors carrying CYP3A5*3/*3 required CNI maintenance doses more or less similar to the bodyweight-controlled starting doses (9.1 mg kg(-1) of ciclosporin and 0.1 mg kg(-1) of tacrolimus). The patients transplanted with grafts from low CYP3A4 expressers required substantial reduction (by about 50%, 4.2 mg kg(-1) of ciclosporin, 0.047 mg kg(-1) of tacrolimus, P < 0.001), while the recipients with grafts from high expressers or with grafts carrying at least one copy of the functional CYP3A5*1 allele required an increase (by about 50% [12.8-13.8 mg kg(-1)] for ciclosporin and 100% [0.21 mg kg(-1) ] for tacrolimus, P < 0.001) of the initial CNI dose for achieving target blood concentrations. CONCLUSIONS Donor livers' CYP3A-status, taking both CYP3A5 allelic variations and CYP3A4 expression into account, can better identify the risk of CNI over- or underexposure, and may contribute to the avoidance of misdosing-induced graft injury in the early post-operative period.
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Affiliation(s)
- Katalin Monostory
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Magyar Tudósok 2, H-1117, Budapest
| | - Katalin Tóth
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Magyar Tudósok 2, H-1117, Budapest
| | - Ádám Kiss
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Magyar Tudósok 2, H-1117, Budapest
| | - Edit Háfra
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Magyar Tudósok 2, H-1117, Budapest
| | - Nóra Csikány
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Magyar Tudósok 2, H-1117, Budapest
| | - József Paulik
- Nucleotest Bio Ltd., Tündérliget 3/2, H-1038, Budapest
| | - Enikő Sárváry
- Department of Transplantation and Surgery, Semmelweis University, Baross 23, H-1082, Budapest, Hungary
| | - László Kóbori
- Department of Transplantation and Surgery, Semmelweis University, Baross 23, H-1082, Budapest, Hungary
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Agrawal S, Dhiman RK. Hepatobiliary quiz-8 (2013). J Clin Exp Hepatol 2013; 3:357-61. [PMID: 25755526 PMCID: PMC4216931 DOI: 10.1016/j.jceh.2013.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Radha K. Dhiman
- Address for correspondence: Radha K. Dhiman, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Agrawal S, Dhiman RK. Hepatobiliary quiz-7 (2013). J Clin Exp Hepatol 2013; 3:267-71. [PMID: 25755512 PMCID: PMC3940107 DOI: 10.1016/j.jceh.2013.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Swastik Agrawal
- Address for correspondence: Radha K. Dhiman, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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