Oral Valganciclovir as a Preemptive Treatment for Cytomegalovirus (CMV) Infection in CMV-Seropositive Liver Transplant Recipients

Prevention of Cytomegalovirus Infection in Solid Organ Transplant Recipients: Guidelines by the Korean Society of Infectious Diseases and the Korean Society for Transplantation

Cytomegalovirus (CMV) is the most important opportunistic viral pathogen in solid organ transplant (SOT) recipients. The Korean guideline for the prevention of CMV infection in SOT recipients was developed jointly by the Korean Society for Infectious Diseases and the Korean Society of Transplantation. CMV serostatus of both donors and recipients should be screened before transplantation to best assess the risk of CMV infection after SOT. Seronegative recipients receiving organs from seropositive donors face the highest risk, followed by seropositive recipients. Either antiviral prophylaxis or preemptive therapy can be used to prevent CMV infection. While both strategies have been demonstrated to prevent CMV infection post-transplant, each has its own advantages and disadvantages. CMV serostatus, transplant organ, other risk factors, and practical issues should be considered for the selection of preventive measures. There is no universal viral load threshold to guide treatment in preemptive therapy. Each institution should define and validate its own threshold. Valganciclovir is the favored agent for both prophylaxis and preemptive therapy. The evaluation of CMV-specific cell-mediated immunity and the monitoring of viral load kinetics are gaining interest, but there was insufficient evidence to issue recommendations. Specific considerations on pediatric transplant recipients are included.

Postoperative hyperglycemia may negatively impact cytomegalovirus infection in seropositive liver transplant recipients: a retrospective cohort study

The aim of the study was to evaluate the association between postoperative hyperglycemia and CMV infection. We analyzed 741 CMV seropositive recipients, of livers from seropositive living donors, who underwent preemptive CMV treatment without CMV prophylaxis. The primary outcome was early CMV infection within 1 month after surgery. Hyperglycemia was defined when mean postoperative blood glucose concentration was >180 mg/dl based on previous research and guidelines. Survival analysis was performed using the Fine and Gray model by accounting for the competing risk of CMV infection-unrelated death. Of the 741 recipients (hyperglycemic group, n = 287; nonhyperglycemic group, n = 454), 372 (50.2%) recipients developed cytomegalovirus (CMV) infection within 1 month after surgery. CMV infection risk was significantly higher in hyperglycemic group than in nonhyperglycemic group in univariable analysis [hazard ratio (HR) 1.34, 95% confidence interval (CI), 1.08-1.66; P = 0.007] and in multivariable analysis (HR 1.25, 95% CI 1.0-1.54; P = 0.038). CMV infection risk was also significantly associated with recipient age, graft ischemia time, model for end-stage liver disease score, and preoperative neutrophil-to-lymphocyte ratio (P < 0.05). In conclusion, preventing postoperative hyperglycemia appears to be an important factor decreasing the risk of CMV infection in seropositive liver transplant recipients undergoing preemptive CMV treatment.

Predictors of incisional hernia in adult liver transplant recipients

PURPOSE

Incisional hernia is a complication following abdominal operation. Patients undergoing liver transplantation have a high risk of developing incisional hernia because of immunosuppression. The purpose of this study was to evaluate incisional hernia after liver transplantation and to identify risk factors for hernia formation in those patients.

METHODS

We retrospectively reviewed 1044 adult patients with more than 2 years of follow-up in patients who underwent liver transplantation from January 2000 to December 2015.

RESULTS

Incisional hernia was identified in 79 patients with more than 2 years of follow-up. The overall incisional hernia rate was 7.6%. The mean age and body mass index (BMI) of the patients with incisional hernia were 55 ± 9 years and 25.3 ± 3.7 kg/m², respectively. No significant differences in gender, diagnosis, diabetes, Child-Pugh score, model for end-stage liver disease (MELD) score, donor type, hepatorenal syndrome, varix bleeding, ascites, hepatic encephalopathy, ventilator use, spontaneous bacterial peritonitis (SBP), or bile leakage were found between patients who did and did not develop incisional hernia. Patients with acute rejection before hernia development were more to have herniated patients hernia (p < 0.05).

CONCLUSION

Age greater than 55 years and high BMI were significant risk factors. We identified risk factors for the development of incisional hernia. Based on these risk factors, attention should be paid to incisional hernia in older and obese patients.

Risk-guided strategy to prevent cytomegalovirus associated complications after liver transplantation

Aim: We evaluated a risk-guided strategy to prevent cytomegalovirus-associated complications (CMV-ac) after liver transplantation (LT). Patients & methods: Forty liver graft recipients were stratified according to their CMV risk status to prophylactic (high risk, HR and group) or pre-emptive antiviral treatment (intermediate, IR, and low risk, LR and group). A detailed analysis of clinical and virological data was performed. Results: 8/40 patients were classified within the HR, 28/40 within the IR and 4/40 within the LR group. Incidence of CMV viremia was 3/8 (38%) in the HR, 9/28 (32%) in the IR and 0/5 in the LR group. Mortality rate of CMV-ac was 0%. Conclusion: A risk-guided antiviral strategy is effective to prevent severe CMV-ac up to 1 year after LT.

Bacterial infection monitoring in the early period after liver transplantation

Purpose

Infection remains the main cause of morbidity and mortality in liver transplantation (LT) recipients; however infection is notoriously difficult to diagnose because its usual signs and symptoms of infection may be masked or absent. This study comprises an analysis of bacterial infections in the early period after LT.

Methods

This is a study of 129 adults who underwent LT from January 2013 to December 2013, and it includes patients who were followed daily from the day of transplantation to 1-week posttransplantation using bacteriological cultures of blood, urine, sputum, and drained ascites.

Results

The following factors were significantly different between the positive and negative culture groups: living donor LT vs. deceased donor LT (odds ratio [OR], 3.269; P = 0.003), model for end-stage liver disease score (OR, 4.364; P < 0.001), and Child-Pugh classification (P = 0.007). Neither positive culture nor negative culture was associated with infection within 4 weeks of surgery (P = 0.03), and most events were due to surgical complications (75%).

Conclusion

Since the full effect of immunosuppression is not yet present during the first month after LT, we suggest that the number of bacterial culture test could be reduced such that they are performed every other day depending on patient's situation.

Extracorporeal membrane oxygenation support for refractory septic shock in liver transplantation recipients

Purpose

This study was designed to assess the outcome of the extracorporeal membrane oxygenation (ECMO) in liver transplantation (LT) recipients with refractory septic shock and predict the prognosis of those cases.

Methods

From February 2005 to October 2012, ECMO was used in 8 cases of refractory septic shock. Laboratory values including lactate and total bilirubin level just before starting ECMO were obtained and sepsis-related organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACH) II score and simplified acute physiology score (SAPS) 3 were calculated. Subsequent peak serum lactate and total bilirubin level, and SOFA score after 24 hours of starting ECMO were measured.

Results

Comparisons were made between survivors and nonsurvivors. ECMO was weaned off successfully in 3 patients (37.5%) and 2 patients (25%) survived to hospital discharge. Clinical scores including SOFA, APACH II, and SAPS3 and laboratory results including lactate, total bilirubin and CRP were not significantly different between survivor and nonsurvivor groups. Lactate level and SOFA score tended to decrease after ECMO support in survivor group and total bilirubin and CRP level tended to increase in nonsurvivor group.

Conclusion

Our findings suggest that the implantation of ECMO might be considered in highly selected LT recipients with refractory septic shock.

Treatment of alpha and beta herpesvirus infections in solid organ transplant recipients

INTRODUCTION

Human herpesviruses frequently cause infections in solid organ transplant (SOT) recipients. Areas covered: We provide an overview of the clinical impact of alpha and beta herpesviruses and highlight the mechanisms of action, pharmacokinetics, clinical indications, and adverse effects of antiviral drugs for the management of herpes simplex virus, varicella zoster virus and cytomegalovirus. We comprehensively evaluated key clinical trials that led to drug approval, and served as the foundation for management guidelines. We further provide an update on investigational antiviral agents for alpha and beta herpesvirus infections after SOT. Expert commentary: The therapeutic armamentarium for herpes infections is limited by the emergence of drug resistance. There have been major efforts for discovery of new drugs against these viruses, but the results of early-phase clinical trials have been less than encouraging. We believe, however, that more antiviral drug options are needed given the adverse side effects associated with current antiviral agents, and the emergence of drug-resistant virus populations in SOT recipients. Likewise, optimized use and strategies are needed for existing and novel antiviral drugs against alpha and beta-herpesviruses in SOT recipients.

Outcome of living donor liver transplantation using right liver allografts with multiple arterial supply

A right liver graft with multiple hepatic artery (HA) stumps can be found in approximately 5% of living donor liver transplantation (LDLT) using a right lobe graft. From January 2000 to June 2014, 1149 patients underwent LDLT procedures. Thirty patients with LDLT using a right lobe graft with multiple HA stumps and 149 patients with LDLT using a right lobe graft with a single HA stump were enrolled. These patients were divided into 3 groups: single HA (group 1, n = 149), multiple HAs with total reconstruction (group 2, n = 19), and multiple HAs with selective partial reconstruction (group 3, n = 11). Selective partial reconstruction was performed only when pulsatile back-bleeding was confirmed after larger HA reconstruction and sufficient intrahepatic arterial flow was confirmed by Doppler ultrasound (DUS). In group 2, the donor HAs were smaller (P < .001), and HA reconstruction took longer (P < .001). However, there was no significant difference among the groups regarding the arterial complication rate, biliary complication rate, and patient and graft survival. In conclusion, selective partial reconstruction of HA stumps for LDLT using a right lobe graft was feasible when intrahepatic arterial communication was confirmed by pulsatile back-bleeding from the smaller artery and DUS. Liver Transplantation 22 1649-1655 2016 AASLD.