Clinical significance of post kidney transplant de novo DSA in otherwise stable grafts

The impact of post-transplant diabetes mellitus on liver transplant outcomes

BACKGROUND

Post-transplant diabetes mellitus (PTDM) is common after liver transplantation (LT). Yet, how PTDM relates to graft outcomes and survival needs elucidation as more individuals are transplanted for nonalcoholic fatty liver disease (NAFLD).

METHODS

This single-center, retrospective study of adult LT recipients (2003-2016) identified PTDM incidence and associations with graft steatosis, rejection, and post-LT patient survival. Multivariable analysis investigated predictors of PTDM. Kaplan-Meier curves depicted patient survival 5 years post-LT.

RESULTS

Among 415 adult LT recipients, 23% had pre-LT DM and 13% were transplanted for NAFLD. PTDM incidence was 34.7%, 46.9%, and 56.2% and overall survival was 90%, 80.9%, and 71.7% at 1, 3, and 5 years, respectively. Over a third of non-NAFLD patients developed PTDM. Half of PTDM cases developed by 6 months and 75% by 12 months. The PTDM group had more rejection episodes compared to no PTDM (31.9% vs 21.8%, P = 0.055), with trends toward worse patient survival 5 years post-LT (log-rank test P = 0.254). Age was the only significant predictor of PTDM.

CONCLUSIONS

Post-transplant diabetes mellitus occurs rapidly in the post-LT period and is a significant problem for both NAFLD and non-NAFLD LT recipients. Age is a significant risk factor for PTDM. Outcomes trended toward increased rejection and worse survival among PTDM individuals, suggesting the benefit of early strategies targeting glucose control.

AISF position paper on liver transplantation and pregnancy: Women in Hepatology Group, Italian Association for the Study of the Liver (AISF)

After the first successful pregnancy in a liver transplant recipient in 1978, much evidence has accumulated on the course, outcomes and management strategies of pregnancy following liver transplantation. Generally, liver transplantation restores sexual function and fertility as early as a few months after transplant. Considering that one third of all liver transplant recipients are women, that approximately one-third of them are of reproductive age (18-49 years), and that 15% of female liver transplant recipients are paediatric patients who have a >70% probability of reaching reproductive age, the issue of pregnancy after liver transplantation is rather relevant, and obstetricians, paediatricians, and transplant hepatologists ever more frequently encounter such patients. Pregnancy outcomes for both the mother and infant in liver transplant recipients are generally good, but there is an increased incidence of preterm delivery, hypertension/preeclampsia, foetal growth restriction, and gestational diabetes, which, by definition, render pregnancy in liver transplant recipients a high-risk one. In contrast, the risk of congenital anomalies and the live birth rate are comparable to those of the general population. Currently there are still no robust guidelines on the management of pregnancies after liver transplantation. The aim of this position paper is to review the available evidence on pregnancy in liver transplant recipients and to provide national Italian recommendations for clinicians caring for these patients.

Factors associated with 1,25-dihydroxyvitamin D3 concentrations in liver transplant recipients: a prospective observational longitudinal study

The aim of the study was to identify factors associated with 1,25(OH)2D3 concentrations in liver transplant recipients with emphasis on the renal function and catabolism. We also tested the hypothesis that tacrolimus increases 1,25(OH)2D3 concentrations. Serum 25(OH)D3, 1,25(OH)2D3, and 24,25(OH)2D3 were measured in 41 patients before, at 2 weeks and 3 months after transplantation. Dose-adjusted tacrolimus concentration was used as a surrogate marker of CYP3A4 activity. Factors associated with 1,25(OH)2D3 were identified using multivariate linear regression analysis. The median 1,25(OH)2D3 levels remained stable: 55 versus 46 pg/ml (P = 0.36) despite an increase in 25(OH)D3 from 18 ng/ml at baseline to 26 ng/ml (P = 0.03), serum albumin (34 to 41 g/l, P = 0.02), and comparable eGFR at baseline and month 3 (94 and 92 ml/min, respectively, P = 0.15). At 3 months 19 % of patients had 1,25(OH)2D3 < 25 pg/ml. Low eGFR and a low dose-adjusted tacrolimus concentration were both independently associated with 1,25(OH)2D3 at 3 months. Liver transplant recipients with impaired renal function or a low dose-adjusted tacrolimus concentration suggesting a high CYP3A4 are at risk of low 1,25(OH)2D3 concentrations. The use of tacrolimus does not lead to an increase in 1,25(OH)2D3 concentrations in a clinical setting.

Methodological aspects of anti-human leukocyte antigen antibody analysis in solid organ transplantation

Donor human leukocyte antigen (HLA)-specific antibodies (DSA) play an important role in solid organ transplantation. Preexisting IgG isotype DSA are considered a risk factor for antibody mediated rejection, graft failure or graft loss. The post-transplant development of DSA depends on multiple factors including immunogenicity of mismatched antigens, HLA class II typing of the recipient, cytokine gene polymorphisms, and cellular immunoregulatory mechanisms. De novo developed antibodies require special attention because not all DSA have equal clinical significance. Therefore, it is important for transplant clinicians and transplant immunologists to accurately characterize DSA. In this review, the contemporary immunological techniques for detection and characterization of anti-HLA antibodies and their pitfalls are described.

The impact of gender and NASH on chronic kidney disease before and after liver transplantation

BACKGROUND & AIMS

Chronic kidney disease (CKD) after liver transplant (LT) is associated with increased long-term mortality. The impact of gender on CKD before and after LT is unknown. To further define risk factors and analyse gender differences in the incidence and progression of CKD after liver transplant.

METHODS

Four hundred and fifty-five consecutive adult primary solitary LT recipients were included. Iothalamate clearance tests performed over time were analysed.

RESULTS

Mean age was 51.4 ± 10.4 years with 63% males. A percentage of 29.1% of females and 21.1% of males had a GFR<60 ml/min/1.73 m(2) and 10.2% of females and 5.9% of males had GFR<30 ml/min/1.73 m(2) prior to transplant. At 1 year, 52.6% of recipients tested (69.6% females, 43.0% males) had GFR<60 ml/min/1.73 m(2) and 7.3% (11.6% females, 4.9% males) had GFR<30 ml/min/1.73 m(2) . Pre-LT GFR<60 ml/min/1.73 m(2) [OR 3.28, (1.76-6.10), P ≤ 0.001], female gender (OR 2.96, (1.72-5.10), P < 0.001) and age [OR 1.09, (1.05-1.12), P < 0.001] were independently predictive of stage ≥3 CKD at 1 year post-LT. Female gender [OR 2.52, (1.25-4.71), P = 0.004], age [OR 1.05, (1.02-1.08), P = 0.003] and NASH [OR 2.95, (1.06-8.21), P = 0.039] were independently predictive of ≥stage 3 CKD at 5 years post-LT. Pre-LT diabetes was associated with stage 4 CKD at 5 years [OR 2.91, (1.33-6.36), P = 0.008] post-LT.

CONCLUSIONS

In addition to age and pre-LT CKD, female gender and NASH are independent predictors of ≥stage 3 CKD post-LT. Gender-based approaches to optimize modifiable risk factors are needed to improved post-transplant renal function.

Prospective evaluation of metabolic syndrome and its components among long-term liver recipients

BACKGROUND & AIMS

Survival after liver transplantation (LTx) has increased. Metabolic syndrome (MS) is widely reported in patients in the early years after LTx; few studies have researched this condition in relatively long-term liver recipients. To describe, prospectively, the prevalence of MS, its components and its associated factors in relatively long-term liver recipients.

METHODS

A total of 117 patients were evaluated in 2008 (median of 3 years after LTx, range 0-13 years) and in 2012 (median of 7 years after LTx, range 3-17 years) for the presence of MS [using modified NCEP Adult Treatment Panel III and International Diabetes Federation (IDF) criteria]; its components; and its associated factors, including demographic, socioeconomic, lifestyle, clinical, body composition (measured using bioelectric impedance) and dietetic factors.

RESULTS

MS increased over the years (IDF, 43.1-53.3%, P=0.12; and NCEP, 34.3-44.8%, P=0.03). Blood glucose increased over the years (98.8±24.7 to 109.2±33.3 mg/dl, P<0.01), which resulted in an increased prevalence of glucose intolerance (34.2-48.6%, P<0.01). Waist circumference (93.3±14.3 to 99.4±14.9 cm, P<0.01) and body fat (30.3±8.9 to 31.8±10.3%, P=0.03) also increased. The MS associated factors (P<0.05) were age [Odds ratio (OR) 1.05, confidence interval (CI) 1.02-1.11], family history of diabetes (OR 3.38, CI 1.19-9.61), body mass index (BMI) prior to liver disease (OR 1.39, CI 1.19-1.63) and body fat (OR 1.09, CI 1.03-1.14). The MS components were associated (P<0.05) with greater age, family history of diabetes, current and previous BMI, body fat, current corticosteroid use, lack of exercise and greater carbohydrate and fat intakes.

CONCLUSION

MS prevalence increased over the years after LTx because of the increases in waist circumference and blood glucose. MS and its components are associated with modifiable factors, such as greater BMI, body fat and carbohydrate and fat intake.

Overweight in liver transplant recipients

This review aims to describe the incidence and prevalence of overweight and obesity after liver transplantation and the consequences associated with it. Literature review consultation was conducted in Medline / PubMed, SciELO, EMBASE and LILACS, with the combination of the following keywords: liver transplantation, overweight, obesity, weight gain. Overweight is incident on more than 60% of patients undergoing liver transplantation and obesity rates exceed 20% in the first year after surgery, during which occurs the largest relative weight gain. Studies have shown that between 60% and 70% of patients undergoing liver transplantation are overweight after the third year, 90% with abdominal obesity. Associated factors are, among others, advanced age, family history of overweight and excess weight prior to liver disease. The contribution of immunosuppressive medication remains controversial. Some of the consequences of overweight are liver steatosis, steatohepatitis, diabetes mellitus, hypertension, dyslipidemia, cardiovascular disease and death.