The use of extracorporeal photopheresis for allograft rejection in liver transplant recipients

BACKGROUND

Originally introduced for cutaneous T-cell lymphomas and autoimmune diseases, extracorporeal photopheresis (ECP) has been proven effective to reverse allograft rejection. The aim of the present work was to show the results of a single-center experience with ECP for the treatment of biopsy-proven rejection in selected liver transplant (LT) recipients.

PATIENTS AND METHODS

A retrospective review of five LT patients (M:F=4:1; median age 51 years) undergoing ECP for biopsy-proven allograft rejection between January 1996 and December 2003. In this period 476 LT were performed on 441 patients.

RESULTS

The indications for LT were three cases of HCV-related cirrhosis, complicated by hepatocellular carcinoma in two; one HBV-HDV-alcoholic cirrhosis; and one fulminant HBV hepatitis. All patients received calcineurin-inhibitor (CNI)-based immunosuppression with induction using anti-IL2R monoclonal antibodies. Indications for ECP were: ductopenic rejection in one patient with HCV recurrence; steroid-resistant acute rejection in two; acute rejection in a major ABO-mismatched liver graft; and one acute rejection in a patient with a proven allergy to steroids. The median interval from LT to inception of ECP was 43 days. The median number of ECP sessions per patient was 20. During the course of ECP, two patients tested positive for CMV antigenemia, associated in one case with bacterial pneumonia. All patients tolerated ECP and there were no procedure-related complications. At a median follow-up of 7.9 months after start of ECP, neither rejection relapses nor HCV/HBV recurrences have been observed. Three patients are off ECP with complete reversal and low-dose immunosuppression. Two patients are still receiving ECP with full-dose immunosuppression: one has achieved normal liver function but ECP is indicated due to a major ABO-incompatible liver graft, while the other patient's liver functions have not yet returned to baseline values.

Plasma exchange for polyradiculoneuropathy following kidney transplantation: a case report

We describe a case of polyradiculoneuropathy (PRN) following living donor kidney transplantation, without clinical evidence of preexisting infection. In this study plasma exchange treatment resulted 6 days later in improvement in extremity weakness and paresthesias in the upper and lower extremities. Total neurological recovery was obtained 3 months after the onset of symptoms.

[Assessment and measurement of pain in infants and children]

The assessment of global pain in infants and children involves the analysis of subjective, behavioural and physiological components, beyond the psychological, familiar and environmental factors that influence and modulate the manifestation of painful symptom. Therefore, researchers and clinicians need valid and reliable instruments to obtain a correct measure of pain. Although subjective indices carry out a fundamental role in the assessment of pain (instruments adjusted to the age of the child), behavioural and physiological indices should be used when intelligence deficit or serious physical handicaps exclude such possibility. Behavioural aspects, associated and correlated to physiological changes, allow to obtain a reliable enough measure of pain. In this paper, the main instruments for measuring pain in infants and children will be described, and their advantages and disadvantages underlined.