Unique histopathological features of graft biopsies with liver function abnormalities in living donor liver transplant patients receiving basiliximab induction therapy

Renal function status in liver transplant patients in the first month post-transplant is associated with progressive chronic kidney disease

AIM

Renal dysfunction is a common complication of liver transplantation (LT), related to hepatorenal syndrome with end-stage liver disease or calcineurin-inhibitor nephrotoxicity. Chronic kidney disease (CKD) is also a common problem in long-term survivors post-LT. This study was done to investigate the association between renal functional status soon after LT and the development of CKD.

METHODS

We retrospectively evaluated 63 patients who were aged 18 years or older, and underwent LT at Tohoku University Hospital. The estimated glomerular filtration rate (eGFR) was calculated by the Modification of Diet in Renal Disease study equation for Japan.

RESULTS

Before transplantation, 25 patients (39.7%) were diagnosed with CKD (eGFR, <60 mL/min per 1.73 m(2) ). The incidence of CKD was 22.4% (13/58) at 2 years, 23.2% (13/56) at 3 years and 22.7% (12/54) at 5 years. The patients with CKD at 2 years post-transplant were more likely to have a history of glomerulonephritis, and were significantly older at the time of LT, compared to those without CKD. Levels of eGFR of less than 60 mL/min per 1.73 m(2) in the first month post-transplant and a volume of intraoperative blood loss of more than 300 mL/kg were predictive factors for the development of CKD at 2 years post-transplant and thereafter.

CONCLUSION

We have shown that there is an improvement of renal function in the majority of patients after LT. Regardless of the presence of pre-existing CKD, both renal function status at the first month post-transplant and a volume of intraoperative blood loss were predictive factors for the development of CKD at 2 years post-transplant and thereafter.

Role of steroid minimization in the tacrolimus-based immunosuppressive regimen for liver transplant recipients: a systematic review and meta-analysis of prospective randomized controlled trials

To evaluate the efficacy and safety of early steroid withdrawal or steroid avoidance in the tacrolimus (Tac)-based immunosuppressive regimen for liver transplant recipients. According to the requirements of the Cochrane systematic review, a thorough literature search was performed in the PubMed/MEDLINE and Cochrane electronic databases between 1995 and 2011 using the key words "liver transplantation," "Tac," and "steroid free" or "steroid withdrawal," restricting articles to the English language. Data were processed for a meta-analysis by Stata 12 software. Altogether 17 prospective randomized controlled trials containing 1,980 transplanted patients were included in this study. The overall pooled RR estimates of 1-, 2-, 3-, and 5-year patient and graft survival rates were 0.985, 0.998, 0.995, and 1.100 (95 % CI 0.925-1.048, 0.934-1.067, 0.894-1.107, and 0.968-1.250, respectively), as well as 0.998, 0.993, 0.945, and 1.053, respectively (95 % CI 0.928-1.072, 0.902-1.092, 0.833-1.072, and 0.849-1.307, respectively). The other pooled RR estimates of acute rejection and chronic rejection rates for all enrolled studies were 1.077 and 0.311 (95 % CI 0.864-1.343 and 0.003-37.207). As for secondary predictors, the pooled RR estimates such as HCV recurrence, HCC recurrence, diabetes, hypertension, kidney dysfunction, bacterial infection, and CMV were 1.101, 1.403, 1.836, 1.607, 0.842, 1.096, and 2.280, respectively (95 % CI 0.964-1.257, 0.422-4.688, 1.294-2.606, 0.926-1.228, 0.693-1.022, 0.783-1.533, and 1.500-3.465, respectively). There were no differences between the steroid group and steroid-free group for all clinical observational indices except for the incidence of diabetes (p = 0.001) and CMV infection (p < 0.001). In summary, our study indicate that rapid discontinuation of steroid in the Tac-based immunosuppressive regimen may not lead to an increased risk of morbidity and rejection rate.

Induction immunosuppression in liver transplantation: a review

Antibody therapy for induction is seldom used in liver transplantation in the United States, but continues to be used in approximately 10% of patients. The most commonly used antibody at the current time is basiliximab (Simulect, Novartis) and is used in adults with renal dysfunction at the time of liver transplantation with the intention of delaying introduction of calcineurin-inhibitors. In children, the same antibody is commonly used in order to reduce rates of acute rejection. Most patients, adult and pediatric, are treated with initially higher levels of tacrolimus rather than antibody induction.

Review article: use of induction therapy in liver transplantation

Induction therapy is used relatively infrequently in liver transplantation, but developments in induction regimens and strategies for their use are prompting a re-examination of its benefits. Rabbit antithymocyte globulin (rATG) induces protracted, dose-dependent lymphocytopenia with preferential reconstitution of regulatory T-lymphocytes. Non-depleting interleukin-2 receptor antagonists (IL-2RA) act selectively on activated T-lymphocytes with a shorter duration of effect. IL-2RA induction with delayed and reduced calcineurin inhibitor (CNI) exposure appears to preserve efficacy, while more aggressive CNI minimisation has been attempted successfully using rATG. Steroid-free tacrolimus monotherapy with rATG or IL-2RA induction is effective if adequate tacrolimus exposure is maintained. Early concerns that addition of induction to a conventional maintenance regimen could lead to accelerated progression of hepatitis C disease, or to an increased risk of hepatocellular cancer recurrence, now appear unfounded using modern regimens. Similarly, with routine use of systemic prophylaxis, recent prospective and retrospective data have not shown a higher rate of infections overall, or cytomegalovirus infection specifically, using rATG or IL-2RA induction. Historical evidence that lymphocyte-depleting agents increased the risk of non-Hodgkin lymphoma has not been confirmed for rATG. Wider use of induction in liver transplantation is now merited, using individualized strategies to support reduced CNI exposure or steroid-free immunosuppression.