Jaundice after renal allotransplantation

Herpes simplex virus hepatitis: an analysis of the published literature and institutional cases

Hepatitis is a rare complication of herpes simplex virus (HSV), often leading to acute liver failure (ALF), liver transplantation (LT), and/or death. Our aim was to identify variables associated with either survival or progression (death/LT), based on an analysis of cases in the literature and our institution. A total of 137 cases (132 literature, 5 institutional) of HSV hepatitis were identified. The main features at clinical presentation were fever (98%), coagulopathy (84%), and encephalopathy (80%). Rash was seen in less than half of patients. Most cases (58%) were first diagnosed at autopsy and the diagnosis was suspected clinically prior to tissue confirmation in only 23%. Overall, 74% of cases progressed to death or LT, with 51% in acyclovir-treated patients as compared to 88% in the untreated subjects (P=0.03). Variables on presentation associated with death or need for LT compared to spontaneous survival: male gender, age>40 yr, immunocompromised state, ALT>5,000 U/L, platelet count<75x10(3)/L, coagulopathy, encephalopathy, and absence of antiviral therapy. In conclusion, HSV hepatitis has a high mortality and is often clinically unsuspected. Patients who are male, older, immunocompromised, and/or presenting with significant liver dysfunction are more likely to progress to death and should thus be evaluated for LT early. Based on the frequent delay in HSV diagnosis, low risk-benefit ratio, and significantly improved outcomes, empiric acyclovir therapy for patients presenting with ALF of unknown etiology is recommended until HSV hepatitis is excluded.

Herpes simplex virus hepatitis: expanding the spectrum of disease

We describe 2 transplant patients with herpes simplex virus (HSV) hepatitis who were minimally symptomatic throughout their illness. The spectrum of disease caused by HSV hepatitis is more variable than previously reported in this population. HSV hepatitis should be considered in immunocompromised hosts with elevated transaminases without evidence of fulminant hepatic necrosis.

Hepatitis C infection in potential recipients with normal liver biochemistry does not preclude renal transplantation

The hepatitis C virus (HCV) may be an important cause of chronic liver disease in renal transplant recipients. We investigated retrospectively the incidence and outcome of HCV infection in long-term renal transplant recipients and patients on hemodialysis. Stored, pretransplant sera of transplant recipients with normal liver biochemistry at surgery were tested for hepatitis C by a second-generation enzyme immunoassay. Hemodialysis patients were tested by a first-generation enzyme-linked immunosorbent assay (ELISA) against c100-3. We studied 252 renal transplant recipients and 58 hemodialysis patients followed for 65 +/- 10 months and 26 +/- 6 months, respectively. Fifteen percent (38/252) of the transplant recipients were HCV positive as were 3/58 (5%) of the hemodialysis patients. Overt liver disease occurred in 22/252 (8.7%) transplant recipients and none in the hemodialysis group. Thirty-six percent (8/22) of transplant recipients with overt liver disease were HCV positive. No HCV-positive patients died of liver failure. Of six biopsies in the HCV-positive transplant group, two had histological evidence of CAH. CAH was seen in six of eight biopsies in the HCV-negative transplants and two of these latter patients progressed to cirrhosis. No hemodialysis patients had clinical or histological evidence of chronic liver disease. Two HCV-negative transplant patients died of liver failure, while no deaths related to liver disease occurred in hemodialysis patients regardless of HCV status. We conclude that hepatitis C may cause chronic hepatitis in renal transplant patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Fatal herpes simplex hepatitis type 2 in a post-thymectomized adult

The authors report an unusual case of herpes simplex type 2 (HSV) hepatitis which presented as part of a systemic HSV infection accompanied by disseminated intravascular coagulation (DIC). The patient was a 49-year-old Japanese male who three months prior to admission underwent surgical resection of his thymus for an invasive thymoma. Postoperatively, he received a course of chemotherapy which included prednisone, cyclophosphamide, vincristine, and pinorubicin. After discharge from the hospital, he was put on a maintenance dosage of prednisone and cyclophosphamide. Two weeks prior to this admission, the patient developed rhinorrhea, chills and general fatigue. Routine follow-up laboratory tests revealed markedly elevated liver enzymes which led to his immediate hospitalization. The tentative diagnosis on admission was fulminant hepatitis with DIC. The patient's condition steadily worsened during his hospitalization and acyclovir was initiated on the 4th hospital day due to the possibility of HSV hepatitis. He died on the same day. Histopathology performed on the liver at autopsy revealed hepatic inclusion bodies of HSV with positive immunohistochemical detection of the HSV type 2 antigen. Our case is the first report of HSV hepatitis associated with the removal of the thymus secondary to thymoma. It supports previous observations of disseminated HSV infection being prevalent in those patients with disorders of cell mediated immunity.

Histologic resolution of documented hemosiderosis in a renal transplant recipient. A case report

A 33-year-old cadaveric renal transplant recipient showed complete histologic resolution of hemosiderosis by liver biopsies obtained pre- and post-transplantation. Although there have been reports in the past of progression of hemosiderosis to hemochromatosis to severe liver failure in the renal transplant population, the correlation has never been clear. This is the first case report of complete resolution of hemosiderosis as documented histologically by liver biopsies in a cadaveric renal transplant recipient.

Renal transplantation is not contraindicated in asymptomatic carriers of hepatitis B surface antigen

Recent reports showing that the presence of positive tests for hepatitis B surface antigen (HBsAg) is associated with prohibitively high morbidity and mortality suggest that such patients should not be considered for kidney transplantation. The clinical outcome and serology including hepatitis B DNA assays of 11 patients who were HBsAg-positive at the time of transplantation, as well as the hepatic complications in all 200 kidney transplantations during the same period, were analyzed. In the 11 HBsAg-positive patients, no clinical or laboratory evidence suggesting deterioration in liver function over a mean follow-up period of 8.0 +/- 1.7 years was found. Of six patients with fatal or severe chronic liver disease, only one was HBsAg-positive at the time of transplantation and showed no deterioration over 9 years. Two immunosuppressed patients developed anti-HBs antibodies after acute hepatitis B infection. A review of the literature leads to the conclusion that previous reports of poor patient prognosis may represent patients who first showed HBsAg positivity after transplantation or who had preexisting HBsAg-related liver disease. The present findings suggest that asymptomatic patients with positive tests for HBsAg should not be excluded from kidney transplantation programs.

Liver disease in recipients of long-functioning renal allografts

After noting that hepatic failure was the leading cause of death in our transplant recipients whose renal allografts had functioned for more than five years, we reviewed retrospectively the post-transplant course of these patients to assess the long-term effect of liver disease in this population. Sufficient data was available to evaluate 184 of 217 long-term survivors (85%). Twenty-six patients (14%) experienced a doubling of SGOT and/or SGPT of greater than six months' duration and were defined as having chronic liver disease. The etiology of chronic liver disease was identified in 14 patients (54%), of whom 11 were HBsAg positive. Evidence of chronic hepatitis developed in only six of 26 patients (22%) during the first four years post transplant. Once enzyme abnormalities occurred, they were unremitting until death or end of the study in 73% of patients. Actuarial survival of patients with chronic liver disease was markedly decreased compared to long-surviving transplanted controls. Ten of the 12 deaths in patients with hepatocellular abnormalities were due to hepatic failure, of which eight occurred in the setting of extrahepatic sepsis. Chronic liver disease is a late complication of transplantation and is associated with significant mortality due to an increased susceptibility to overwhelming sepsis.

A case of fulminant herpes simplex hepatitis in an adult

The case presented documents HSV hepatitis in a 41 year old caucasian male with a history of prolonged steroid treatment and recent irradiation for brain tumor recurrence. The fulminant nature of the hepatitis, accompanied by gastric ulcer hemorrhage, lead to his death within 24 hours of symptomatic manifestation. The diagnosis of HSV hepatitis was made postmortem. The etiology of the hepatitis was established by light microscopic identification of Cowdry type A intranuclear inclusion bodies, electron microscopic identification of virus particles, and the immunohistochemical detection of herpes simplex virus antigens.

Status of renal transplantation. A clinical perspective

Although the survival of patients on chronic dialysis has improved in recent years, the quality and status of rehabilitation remains poor. Renal transplantation must be used to complement chronic dialysis in the management of these patients. Physicians should not be biased and commit their patients to one or the other form of long-term treatment.