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Abstract
Chronic liver disease has been associated with pulmonary dysfunction both before and after liver transplantation. Post-liver transplantation pulmonary complications can affect both morbidity and mortality often necessitating intensive care during the immediate postoperative period. The major pulmonary complications include pneumonia, pleural effusions, pulmonary edema, and atelectasis. Poor clinical outcomes have been known to be associated with age, severity of liver dysfunction, and preexisting lung disease as well as perioperative events related to fluid balance, particularly transfusion and fluid volumes. Delineating each and every one of these pulmonary complications and their associated risk factors becomes paramount in guiding specific therapeutic strategies.
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Geramizadeh B, Motevalli D, Nikeghbalian S, Malek Hosseini SA. Histopathology of post-transplant liver biopsies, the first report from iran. HEPATITIS MONTHLY 2013; 13:e9389. [PMID: 24032049 PMCID: PMC3768203 DOI: 10.5812/hepatmon.9389] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 01/07/2013] [Accepted: 02/18/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Evaluation of a transplanted liver by Imaging techniques and enzyme changes is sensitive to hepatocellular or biliary problems, but in most instances liver allograft biopsies are performed in order to find out the final reason for these changes. OBJECTIVES It's been about 17 years (with more than 1326 cases) since the first liver transplantation in the Namazi Hospital of Shiraz University of Medical Sciences while during the last five years the number of post liver transplant biopsies have increased. Until now there has been no report of the pathological results of post liver transplant needle biopsies from Iran. MATERIALS AND METHODS During the last 5 years, there have been 382 post liver transplant biopsies. We studied the clinical charts and pathological results of all needle biopsies. RESULTS A total of 382 needle biopsies were performed on 287 patients aged between 1 and 64 years old. The earliest specimen was obtained within the first few hours following transplantation, and the last was gathered 3209 days (261 ± 523) post-transplantation. Acute rejection was the most common diagnosis, which occurred in 180 (47%) of specimens. Among other complications were vascular problems (8.6%), preservation/reperfusion (I/R) injury (7%), chronic rejection (5.2%), biliary injury/obstruction (3.4%), recurrence of primary disease (2.6%), drug-induced hepatic injury (1.8%), cirrhosis (1.6%), sepsis (1.4%), cytomegalovirus hepatitis (1.4%), post-transplantation lymphoproliferative disease (1%) and Venous outflow obstruction (0.5%). CONCLUSIONS The most common pathological diagnosis of post-transplant liver needle biopsies has been acute rejection, followed by ischemia due to hepatic artery thrombosis, preservation/reperfusion injury, and chronic rejection.
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Affiliation(s)
- Bita Geramizadeh
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Department of Pathology, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding author: Bita Geramizadeh, Department of Pathology, Shiraz University of Medical Sciences, 71345-1864 Shiraz, IR Iran. Tel: +98-7116474331, Fax: +98-7116474331, E-mail:
| | - Dorna Motevalli
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Saman Nikeghbalian
- Department of Surgery, Transplant Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Seyed Ali Malek Hosseini
- Department of Surgery, Transplant Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
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Naini BV, Lassman CR. Liver Transplant Pathology: Review of Challenging Diagnostic Situations. Surg Pathol Clin 2013; 6:277-93. [PMID: 26838975 DOI: 10.1016/j.path.2013.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Histopathologic assessment of allograft liver biopsies has an important role in managing patients who have undergone liver transplantation. In this review, several topics are discussed that create diagnostic problems in transplant pathology, with emphasis on pathologic features and differential diagnosis. The topics discussed are acute cellular rejection, late acute rejection (centrizonal/parenchymal rejection), chronic rejection, plasma cell hepatitis, idiopathic posttransplant chronic hepatitis, fibrosing cholestatic hepatitis, selected viral infections (cytomegalovirus, Epstein-Barr virus, and hepatitis E), and acute antibody-mediated rejection.
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Affiliation(s)
- Bita V Naini
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 1P-172 CHS, Los Angeles, CA 90095-1732, USA.
| | - Charles R Lassman
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, 13-145 CHS, Los Angeles, CA 90095-1732, USA
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The value of pre-emptive therapy for cytomegalovirus after liver transplantation. Transplant Proc 2012; 44:1357-61. [PMID: 22664015 DOI: 10.1016/j.transproceed.2011.11.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 11/04/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) infections are among the most common infections following liver transplantation. The main preventive methods for CMV infections are universal prophylaxis and pre-emptive therapy. In our study, we adopted a pre-emptive strategy in a higth-risk group of donor CMV-positive (D+)/recipient CMV-negative (R-) casses. We investigated whether this strategy was safe and effective to prevent CMV disease. METHODS One hundred fifty-nine liver transplantation recipients who underwent over a 15-year period were retrospectively analyzed after follow-up for at least 6 months (mean, 63 months). Weekly quantitative polymerase chain reaction (PCR) measurements were performed to detect viral DNA. No CMV drug prophylaxis was given: antiviral CMV therapy was initiated when the PCR for CMV-DNA was >400 copies/mL. RESULTS Fifty-one of 159 liver transplant recipients enrolled in the study received antiviral therapy. High-risk patients (D+/R-) developed CMV infections significantly more often than D-/R- serostatus (P = .005). CMV disease was diagnosed in 12% of CMV-positive patients. Independent of serostatus in 14 cases (27.5%) virological recurrence of CMV infection occurred after primary treatment. Survival analysis showed no significant difference between patients with versus without CMV infection (P = .950). No relationship could be found between transplant rejection and CMV infection (P = .349). CONCLUSION Our results showed that a pre-emptive strategy to prevent CMV disease was possible, even among the serological high-risk group. Only 12% of cases with CMV infection went on to manifest CMV disease with organ involvement. Survival curves were similar among patients with versus without CMV infections.
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Bosch W, Heckman MG, Diehl NN, Shalev JA, Pungpapong S, Hellinger WC. Association of cytomegalovirus infection and disease with death and graft loss after liver transplant in high-risk recipients. Am J Transplant 2011; 11:2181-9. [PMID: 21827609 DOI: 10.1111/j.1600-6143.2011.03618.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In the era of effective antiviral chemoprophylaxis, cytomegalovirus (CMV) disease has been inconsistently associated with increased mortality in liver transplant (LT) recipients. A retrospective study evaluating the association of CMV infection and disease occurring within 1 year of transplant with the endpoints of death or the combined endpoint of graft loss or death was undertaken in a cohort of 227 CMV donor seropositive, recipient seronegative first LT recipients. Associations were evaluated using Cox proportional hazards regression models. CMV infection and disease occurred in 91 (40%) and 43 (19%) patients, respectively. Forty-eight (21%) died while 58 (26%) sustained graft loss or death. In multivariable analysis, CMV infection was associated with an increased risk of death (RR: 2.24, p = 0.008) and graft loss or death (RR: 2.85, p < 0.001). CMV disease was also associated with an increased risk of death (RR: 2.73, p = 0.003) and graft loss or death (RR: 3.04, p = 0.001). CMV infection and disease occurring within the first year after LT in high-risk recipients is associated with increased risk of death and of graft loss or death. Investigation of strategies to further reduce the risk of CMV infection and disease in high-risk LT recipients is warranted.
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Affiliation(s)
- W Bosch
- Division of Infectious Diseases Division of Biostatistics Division of Transplant Division of Liver Transplant, Mayo Clinic Florida, Jacksonville, FL, USA.
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Scott GM, Naing Z, Pavlovic J, Iwasenko JM, Angus P, Jones R, Rawlinson WD. Viral factors influencing the outcome of human cytomegalovirus infection in liver transplant recipients. J Clin Virol 2011; 51:229-33. [PMID: 21641274 DOI: 10.1016/j.jcv.2011.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 04/14/2011] [Accepted: 05/09/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) remains the leading viral cause of disease following orthotopic liver transplantation (OLT) despite the availability of antiviral agents for prophylaxis and therapy. OBJECTIVE Examine the viral factors that influence the outcome of CMV infection following valganciclovir prophylaxis or laboratory-guided preemptive therapy in OLT recipients. STUDY DESIGN The value of valganciclovir prophylaxis and laboratory-guided preemptive therapy for the prevention of CMV infection and disease was observed in 64 OLT recipients. Prophylaxis was given to all CMV seronegative recipients receiving a liver from a seropositive donor (D+R-; n=15), and all other recipients were randomised to receive either prophylaxis (n=24) or laboratory-guided preemptive therapy (n=25). Recipients were monitored for CMV DNAemia, viral load, emergence of antiviral resistant strains and co-infections. RESULTS CMV end-organ disease and antiviral resistant strains only occurred in D+R- recipients despite the use of prophylaxis in these patients. The D+R- recipients commencing prophylaxis immediately following transplantation had better outcomes compared to those for whom prophylaxis was delayed due to renal impairment. Prophylaxis reduced the incidence of CMV DNAemia, persistent infection, and high viral loads for CMV seropositive (D-R+and D+R+) recipients, but laboratory-guided preemptive therapy effectively controlled CMV infection and prevented disease in these OLT recipients. CONCLUSION Delaying the commencement of valganciclovir prophylaxis may be associated with worse outcomes for high-risk OLT recipients. Laboratory-guided pre-emptive therapy remains an alternative approach for seropositive recipients at lower risk of CMV disease.
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Affiliation(s)
- G M Scott
- Virology Division, Department of Microbiology, SEALS, Prince of Wales Hospital, Sydney, Australia
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Abstract
Human cytomegalovirus (HCMV) is a beta herpes virus with a double stranded DNA genome of 240kbp. The virus is prevalent and establishes a latent infection in most adults. HCMV is an opportunistic pathogen for patients with impaired cellular immunity. HCMV pneumonia is a common presentation of HCMV disease in immunocompromised patients. The incidence of HCMV pneumonitis can be as high as 90% in lung transplant recipients. This paper takes a fresh look at the challenging perspectives of molecular, immunologic, cellular, diagnostic, clinical, and therapeutic characteristics of HCMV infection as future targets for development of antiviral strategies.
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Affiliation(s)
- Erik Langhoff
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA.
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Kim J, Kim S, Joh JW, Shin M, Kim E, Moon J, Jung G, Choi GS, Kwon C, Lee SK. Preemptive Therapy in Adult Liver Transplant Recipients in CMV-Endemic Area. Transplant Proc 2010; 42:825-9. [DOI: 10.1016/j.transproceed.2010.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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9
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Kim J, Kim S, Joh JW, Shin M, Moon J, Jung G, Choi GS, Kwon C, Lee SK. The Risk Factors for Cytomegalovirus Syndrome and Tissue-invasive Cytomegalovirus Disease in Liver Transplant Recipients Who Have Cytomegalovirus Antigenemia. Transplant Proc 2010; 42:890-4. [DOI: 10.1016/j.transproceed.2010.02.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lautenschlager I. CMV infection, diagnosis and antiviral strategies after liver transplantation. Transpl Int 2009; 22:1031-40. [PMID: 19619175 DOI: 10.1111/j.1432-2277.2009.00907.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Cytomegalovirus (CMV) is a significant pathogen complicating the post-transplant course of organ recipients. In liver transplant patients, the febrile clinical illness caused by CMV may be associated with end-organ disease, such as hepatitis or infection of the gastrointestinal tract. In addition to direct effects, CMV may have indirect effects including the risk of other infections or graft rejection. Recently, major advances in the management of CMV infection have been achieved through the development of new diagnostic techniques and antiviral strategies to prevent CMV disease. Quantitative nucleic acid testing to monitor viral load is now commonly used to diagnose and guide the treatment of CMV infections. The standardization of the testing, however, needs to be improved. There are two main strategies to prevent CMV disease after liver transplantation: prophylaxis and pre-emptive therapy. Both strategies are effective, but also have disadvantages. The disadvantages of prophylaxis include prolonged drug exposure, the development of resistance and, most of all, the development of delayed and late-onset CMV disease. On the other hand, the pre-emptive strategy is based on frequent laboratory monitoring of viral loads, and some patients may develop symptomatic infection before the diagnosis of CMV. This overview summarizes the current status of CMV in liver transplantation.
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Affiliation(s)
- Irmeli Lautenschlager
- Transplant Unit Research Laboratory, Transplantation and Liver Surgery Clinic, and Department of Virology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland.
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Egli A, Bergamin O, Müllhaupt B, Seebach J, Mueller N, Hirsch H. Cytomegalovirus-associated chorioretinitis after liver transplantation: case report and review of the literature. Transpl Infect Dis 2008; 10:27-43. [DOI: 10.1111/j.1399-3062.2007.00285.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rayes N, Seehofer D, Kahl A, Kokott S, Pratschke J, Frei U, Neuhaus P. Long-term outcome of cytomegalovirus infection in simultaneous pancreas–kidney transplant recipients without ganciclovir prophylaxis. Transpl Int 2007; 20:974-81. [PMID: 17680782 DOI: 10.1111/j.1432-2277.2007.00526.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
As cytomegalovirus (CMV) infection frequently occurs in simultaneous pancreas kidney transplantation (SPKT), most centers use general ganciclovir prophylaxis. The aim of the study was to analyze the impact of CMV in a patient cohort with preemptive therapy only. Incidence, course and risk factors of CMV infection were retrospectively analyzed in 94 adult SPK recipients without prophylaxis. Patients with asymptomatic pp65-antigenemia were treated preemptively with intravenous ganciclovir for 14 days. Survival rates after 1, 3, and 5 years were 98%, 97%, and 94% for patients, 96%, 94%, and 88% for renal grafts and 88%, 85%, and 82% for pancreas grafts. CMV infections occurred in 51% of patients and CMV syndrome in 16%. No tissue-invasive disease was observed. Thirty-eight per cent of patients with CMV infection developed a recurrence. Risk factors for CMV in multivariate analysis were the D+/R- constellation, acute rejections, anti-rejection therapy and coronary heart disease. CMV had no impact on patient or graft survival, occurrence of acute or chronic rejection and bacterial infections. Preemptive therapy seems to be safe and effective in SPK recipients, but as the present study was retrospective, prospective randomized studies are needed to confirm our results.
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Affiliation(s)
- Nada Rayes
- Department of General-, Visceral- and Transplant Surgery, Charité University Medicine Berlin, Berlin, Germany.
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Transmission of viral disease to the recipient through the donor liver. Curr Opin Organ Transplant 2007; 12:231-241. [DOI: 10.1097/mot.0b013e32814e6b67] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Immunomodulatory therapy of cytomegalovirus pneumonia after liver transplantation. Chin Med J (Engl) 2006. [DOI: 10.1097/00029330-200609010-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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15
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Rayes N, Seehofer D, Neuhaus P. Cytomegalovirus in liver transplant recipients: there are many ways to Rome. Liver Transpl 2006; 12:326. [PMID: 16447200 DOI: 10.1002/lt.20675] [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] [Indexed: 01/12/2023]
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