Association of the kidney allocation system with dialysis exposure before deceased donor kidney transplantation by preemptive wait-listing status

BACKGROUND

It is unknown whether the new kidney transplant allocation system (KAS) has attenuated the advantages of preemptive wait-listing as a strategy to minimize pretransplant dialysis exposure.

METHODS

We performed a retrospective study of adult US deceased donor kidney transplant (DDKT) recipients between December 4, 2011-December 3, 2014 (pre-KAS) and December 4, 2014-December 3, 2017 (post-KAS). We estimated pretransplant dialysis durations by preemptive listing status in the pre- and post-KAS periods using multivariable gamma regression models.

RESULTS

Among 65 385 DDKT recipients, preemptively listed recipients (21%, n = 13 696) were more likely to be white (59% vs 34%, P < 0.001) and have private insurance (64% vs 30%, P < 0.001). In the pre- and post-KAS periods, average adjusted pretransplant dialysis durations for preemptively listed recipients were <2 years in all racial groups. Compared to recipients who were listed after starting dialysis, preemptively listed recipients experienced 3.85 (95% Confidence Interval [CI] 3.71-3.99) and 4.53 (95% CI 4.32-4.74) fewer average years of pretransplant dialysis in the pre- and post-KAS periods, respectively (P < 0.001 for all comparisons).

CONCLUSIONS

Preemptively wait-listed DDKT recipients continue to experience substantially fewer years of pretransplant dialysis than recipients listed after dialysis onset. Efforts are needed to improve both socioeconomic and racial disparities in preemptive wait-listing.

Association between Medicaid Expansion under the Affordable Care Act and Preemptive Listings for Kidney Transplantation

BACKGROUND AND OBJECTIVES

Before 2014, low-income individuals in the United States with non-dialysis-dependent CKD had fewer options to attain health insurance, limiting their opportunities to be preemptively wait-listed for kidney transplantation. We examined whether expanding Medicaid under the Affordable Care Act was associated with differences in the number of individuals who were pre-emptively wait-listed with Medicaid coverage.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the United Network of Organ Sharing database, we performed a retrospective observational study of adults (age≥18 years) listed for kidney transplantation before dialysis dependence between January 1, 2011-December 31, 2013 (pre-Medicaid expansion) and January 1, 2014-December 31, 2016 (post-Medicaid expansion). In multinomial logistic regression models, we compared trends in insurance types used for pre-emptive wait-listing in states that did and did not expand Medicaid with a difference-in-differences approach.

RESULTS

States that fully implemented Medicaid expansion on January 1, 2014 ("expansion states," n=24 and the District of Columbia) had a 59% relative increase in Medicaid-covered pre-emptive listings from the pre-expansion to postexpansion period (from 1094 to 1737 listings), compared with an 8.8% relative increase (from 330 to 359 listings) among 19 Medicaid nonexpansion states (P<0.001). From the pre- to postexpansion period, the adjusted proportion of listings with Medicaid coverage decreased by 0.3 percentage points among nonexpansion states (from 4.0% to 3.7%, P=0.09), and increased by 3.0 percentage points among expansion states (from 7.0% to 10.0%, P<0.001). Medicaid expansion was associated with absolute increases in Medicaid coverage by 1.4 percentage points among white listings, 4.0 percentage points among black listings, 5.9 percentage points among Hispanic listings, and 5.3 percentage points among other listings (P<0.001 for all comparisons).

CONCLUSIONS

Medicaid expansion was associated with an increase in the proportion of new pre-emptive listings for kidney transplantation with Medicaid coverage, with larger increases in Medicaid coverage among racial and ethnic minority listings than among white listings.

Director of anesthesiology for liver transplantation: existing practices and recommendations by the United Network for Organ Sharing

A new Organ Procurement and Transplantation Network/United Network for Organ Sharing bylaw recommends that all centers appoint a director of liver transplant anesthesia with a uniform set of criteria. We obtained survey data from the Liver Transplant Anesthesia Consortium so that we could compare existing criteria for a director in the United States with the current recommendations. The data set included responses from adult academic liver transplant programs before the new bylaw. The respondent rates were within statistical limits to exclude sampling bias. All centers had a director of liver transplant anesthesia. The criteria varied between institutions, and the data suggest that the availability of resources influenced the choice of criteria. The information suggests that the criteria used in the new bylaw reflect existing practices. The bylaw plays an important role in supporting emerging leadership roles in liver transplant anesthesia and brings greater uniformity to the directorship position.

Transplant surgery fellow perceptions about training and the ensuing job market-are the right number of surgeons being trained?

The American Society of Transplant Surgeons (ASTS) sought whether the right number of abdominal organ transplant surgeons are being trained in the United States. Data regarding fellowship training and the ensuing job market were obtained by surveying program directors and fellowship graduates from 2003 to 2005. Sixty-four ASTS-approved programs were surveyed, representing 139 fellowship positions in kidney, pancreas and/or liver transplantation. One-quarter of programs did not fill their positions. Forty-five fellows graduated annually. Most were male (86%), aged 31-35 years (57%), married (75%) and parents (62%). Upon graduation, 12% did not find transplant jobs (including 8% of Americans/Canadians), 14% did not get jobs for transplanting their preferred organ(s), 11% wished they focused more on transplantation and 27% changed jobs early. Half fellows were international medical graduates; 45% found US/Canadian transplant jobs, particularly 73% with US/Canadian residency training. Fellows reported adequate exposure to training volume, candidate selection, pre/postoperative care and organ procurement, but not to donor management/selection, outpatient care and core didactics. One-sixth noted insufficient 'mentoring/preparation for a transplantation career'. Currently, there seem to be enough trainees to fill entry-level positions. One-third program directors believe that there are too many trainees, given the current and foreseeable job market. ASTS is assessing the total workforce of transplant surgeons and evolving manpower needs.

Report of a national conference on liver allocation in patients with hepatocellular carcinoma in the United States

A national conference was held to better characterize the long-term outcomes of liver transplantation (LT) for patients with hepatocellular carcinoma (HCC) and to assess whether it is justified to continue the policy of assigning increased priority for candidates with early-stage HCC on the transplant waiting list in the United States. The objectives of the conference were to address specific HCC issues as they relate to liver allocation, develop a standardized pathology report form for the assessment of the explanted liver, develop more specific imaging criteria for HCC designed to qualify LT candidates for automatic Model for End-Stage Liver Disease (MELD) exception points without the need for biopsy, and develop a standardized pretransplant imaging report form for the assessment of patients with liver lesions. At the completion of the meeting, there was agreement that the allocation policy should result in similar risks of removal from the waiting list and similar transplant rates for HCC and non-HCC candidates. In addition, the allocation policy should select HCC candidates so that there are similar posttransplant outcomes for HCC and non-HCC recipients. There was a general consensus for the development of a calculated continuous HCC priority score for ranking HCC candidates on the list that would incorporate the calculated MELD score, alpha-fetoprotein, tumor size, and rate of tumor growth. Only candidates with at least stage T2 tumors would receive additional HCC priority points.

ASTS recommended practice guidelines for controlled donation after cardiac death organ procurement and transplantation

The American Society of Transplant Surgeons (ASTS) champions efforts to increase organ donation. Controlled donation after cardiac death (DCD) offers the family and the patient with a hopeless prognosis the option to donate when brain death criteria will not be met. Although DCD is increasing, this endeavor is still in the midst of development. DCD protocols, recovery techniques and organ acceptance criteria vary among organ procurement organizations and transplant centers. Growing enthusiasm for DCD has been tempered by the decreased yield of transplantable organs and less favorable posttransplant outcomes compared with donation after brain death. Logistics and ethics relevant to DCD engender discussion and debate among lay and medical communities. Regulatory oversight of the mandate to increase DCD and a recent lawsuit involving professional behavior during an attempted DCD have fueled scrutiny of this activity. Within this setting, the ASTS Council sought best-practice guidelines for controlled DCD organ donation and transplantation. The proposed guidelines are evidence based when possible. They cover many aspects of DCD kidney, liver and pancreas transplantation, including donor characteristics, consent, withdrawal of ventilatory support, operative technique, ischemia times, machine perfusion, recipient considerations and biliary issues. DCD organ transplantation involves unique challenges that these recommendations seek to address.

Sonographic diagnosis and outcome of hepatic artery thrombosis after orthotopic liver transplantation in adults

OBJECTIVE

The objective of our study was to determine the timing and frequency of symptomatic hepatic artery thrombosis in an adult orthotopic liver transplant population, the sensitivity of Doppler sonography for this diagnosis, and the clinical and sonography outcomes in this population.

MATERIALS AND METHODS

The subjects included all adult recipients with orthotopic liver transplants during a 10.5-year period. A retrospective review of all cases of hepatic artery thrombosis detected on angiography or at surgery was correlated with sonography findings at diagnosis. Clinical and sonography outcomes were recorded. Patients were divided into early (< 1 week) and late hepatic artery thrombosis groups. Hepatic artery thrombosis was considered primary or secondary due to treatment of other hepatic artery complications.

RESULTS

Of 522 transplants, 25 (4.8%) developed hepatic artery thrombosis that was primary in 18 (3.5%), with five early (1.0%) and 13 late (2.5%), and secondary in seven (1.3%). Sensitivities of sonography compared with angiography were 100% for detection of early hepatic artery thrombosis and 72.7% for late hepatic artery thrombosis. Seventeen patients (68%) with an episode of hepatic artery thrombosis are currently alive, 11 of whom have irreversible hepatic artery thrombosis; in 10 of the 11 cases, sonography showed that collateral arterial flow had developed. The mean survival was 51.4 months in the patients with irreversible hepatic artery thrombosis, eight of whom had documented biliary or septic complications (or both).

CONCLUSION

Hepatic artery thrombosis is uncommon after liver transplantation in adults. Sonography is extremely sensitive for the detection of hepatic artery thrombosis in symptomatic patients during the immediate postoperative period. Sonography becomes less sensitive as the interval between transplantation and diagnosis of hepatic artery thrombosis increases due to collateral arterial flow. Patients with irreversible hepatic artery thrombosis typically develop interval arterial collaterals that can be seen on sonography. Biliary and septic complications are common but usually are self-limited.

Mycophenolate mofetil for renal dysfunction in liver transplant recipients on cyclosporine or tacrolimus: randomized, prospective, multicenter pilot study results

BACKGROUND

Liver transplantation (LTX) recipients with renal dysfunction may benefit from mycophenolate mofetil (MMF) and reduction or discontinuation of nephrotoxic calcineurin inhibitors (CNI). The authors report the first randomized, multicenter pilot studies of this approach (one study for patients on cyclosporine [CsA] and one for those on tacrolimus [Tac]).

METHODS

Patients 3 to 27 months post-LTX with greater than 20% reduced renal function since LTX, and creatinine 1.8 to 4.0 mg/dL, creatinine clearance 20 to 60 mL/min, or both, were randomized to discontinuation (group 1) or 50% reduction (group 2) of CNI dose, together with MMF 1.5 g administered twice daily and prednisone. Endpoints included measured glomerular filtration rate (GFR) 52 weeks after study entry and biopsy-proven rejection.

RESULTS

In the CsA and Tac trials, 15 and 12 patients, respectively, completed the 52-week follow-up. In the CsA trial, the mean GFR at baseline and week 52 were 35.0 and 57.8 mL/min (>15% improvement, five of six; unchanged, one of six) for group 1 and 46.0 and 63.8 mL/min (>15% improvement, four of nine; unchanged, three of nine; >15% deterioration, two of nine) for group 2. In the Tac trial, GFRs were 55.4 and 56.0 mL/min (>15% improvement, two of five; unchanged, three of five) for group 1 and 46.7 and 60.2 mL/min (>15% improvement, four of seven; unchanged, three of seven) for group 2. Mild or moderate rejection occurred in 38% and 9% of patients in groups 1 and 2 of the CsA trial and in 14% of each group of the patients in the Tac trial.

CONCLUSIONS

These pilot studies show that in LTX recipients with renal dysfunction, MMF allows CNI dose reduction or discontinuation, improving or stabilizing GFR in most patients.

Extended survival by urgent liver retransplantation after using a first graft with metastasis from initially unrecognized donor sarcoma

A 58-year-old man underwent orthotopic liver transplantation for polycystic liver disease. Shortly after the procedure, it was discovered that the donor harbored a sarcoma of the aortic arch that had metastasized to the spleen, and bilateral renal cell carcinomas. The two sole organ recipients, our liver recipient and a lung recipient at another institution, were both listed for urgent retransplantation, which they received from the same second donor. The liver explant contained metastatic sarcoma. Twenty-four months survival following lung retransplantation has been previously reported. We report the 76-month disease-free survival in the liver recipient.

Successful re-use of liver allografts: three case reports and a review of the UNOS database

The donor organ shortage has compelled transplant centers to use organs from non-traditional sources. One example is the re-use of a previously transplanted organ, such as a kidney or liver. We report three cases detailing the successful re-use of liver allografts. In all three cases, the index recipient was declared brain-dead very soon post-transplant, but was felt to have a well-functioning liver graft. Important points in these cases were to ensure that the liver graft was functioning well in the index recipient, that it appeared normal per biopsy examination, and that ischemic time was kept very short at the time of the second transplant. We queried the United Network for Organ Sharing (UNOS) database for similar cases, and found 11 such cases, which we briefly describe herein.

Long-term outcome of controlled, non-heart-beating donor liver transplantation

BACKGROUND

Previous reports have established the feasibility of using livers from controlled, non-heart-beating donors (CNHBD) with good immediate graft function. This has been largely borne out of necessity because of the donor shortage.

METHODS

Retrospective database review for the last 7 years (1995-2002), encompassing 19 patients receiving CNHBD, with follow-up period of 1,000 +/- 694 days, median 762 days. Detailed review of recipient characteristics, operative and clinical course, immunosuppression, complications, survival rates, and comparison with the results obtained in patients receiving transplants of allografts procured in standard fashion, from heart-beating donors

RESULTS

Kaplan-Meier patient survival rates were 100%, 89.5%, and 83.5% at 30 days, 1, and 2 years, respectively, which is not different from recipients of livers procured from heart-beating cadaveric donors (P=0.74, log-rank test). Five patients died at a mean follow-up time of 492 (range 46-1,103) days. The causes of death were related to secondary sclerosing cholangitis (n=1), cardiac failure (n=1), and sepsis (n=3). Two (10.5%) recipients underwent retransplantation, one for primary graft nonfunction and one because of biliary cast syndrome with cholangitis. Significant preservation damage (ALT>2,000) developed in five patients, but this did not affect survival. The incidence of vascular (15.6% vs. 9.6%, P=0.34) and biliary complications (10.55 vs. 13.8%, P=0.68) was no different than for those recipients receiving standard cadaveric donors.

CONCLUSIONS

CNHBD safely expands the donor pool with similar long-term results as those obtained in patients receiving organs from brain-dead donors under standard procurement techniques.

Liver transplantation using an organ donor with HELLP syndrome

BACKGROUND

The shortage of organs for liver transplantation has forced transplant centers to expand the donor pool by using donors traditionally labeled as marginal. One such example is liver transplantation using a donor with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), a disorder of late pregnancy that involves the liver as one of the target organs.

METHODS

Two patients who died from complications of HELLP syndrome were evaluated for attempted multi-organ procurement. Donor characteristics, gross and microscopic liver findings, and procurement and transplant outcomes were reviewed.

RESULTS

One of the liver allografts was successfully transplanted; the other was not procured because of poor macroscopic appearance.

CONCLUSION

It is possible to successfully transplant the liver from a donor that succumbs to HELLP syndrome, provided there is adequate recovery of liver function before procurement.

Combined liver and pancreas procurement from a controlled non-heart-beating donor with aberrant hepatic arterial anatomy

BACKGROUND

The critical shortage of transplantable organs has resulted in the use of extended donors, including non-heart-beating donors (NHBDs). Combined procurement of both a whole pancreas and a liver from a single cadaver is always anatomically feasible. However, when aberrant vasculature is present, the potential for vascular injury increases. Because the rapid flush technique is used in NHBD procurement, the inability to palpate arterial pulsation may also increase the chance of vascular damage.

METHODS

We report a case of a successful combined procurement of hepatic, pancreatic, and renal grafts from a controlled NHBD with right replaced and left accessory hepatic arteries.

RESULT

The liver and the pancreas were successfully transplanted to two different recipients in two different institutions without any complications. All grafts are functioning well at 14 months of follow-up.

CONCLUSION

Safe procurement of both the liver and pancreas is possible from certain controlled NHBDs, even with aberrant anatomy.

Liver transplantation for patients on methadone maintenance

Most transplant programs require abstinence of at least 6 months from alcohol and illicit drugs before orthotopic liver transplantation (OLT). However, there are no published data regarding OLT outcomes in patients who are currently on methadone maintenance treatment (MMT) as part of the treatment of their heroin addiction at the time of OLT. The objective of this study is to evaluate our experience regarding the outcome of OLT in patients with end-stage liver disease (ESLD) who were on MMT at the time of OLT. Between March 1993 and May 1999, a total of 185 patients with ESLD underwent OLT at our center. Five transplant recipients (2.7%) had a history of heroin abuse and had undergone drug and alcohol rehabilitation, but could not be weaned off methadone. Pre-OLT status, drug history, perioperative course, compliance with medical therapy, post-OLT follow-up, and patient and allograft survival were analyzed in detail in these patients. All patients on MMT underwent uneventful OLTs. Their compliance with medications and follow-up was excellent. One patient was weaned completely off methadone after OLT. Post-OLT mean hospital stay in this group was 43 +/- 25 days. Although the number of patients was small, long-term outcome of liver transplant recipients on MMT appears similar to that of patients not on MMT who underwent OLT during this period. Our results suggest cirrhotic patients on MMT should be considered for OLT if they meet the same psychosocial requirements as patients with alcohol abuse. Furthermore, it is not necessary for patients to be weaned off methadone before OLT.

Cigarette smoking is associated with an increased incidence of vascular complications after liver transplantation

Hepatic artery thrombosis (HAT) and other vascular complications are significant causes of morbidity after liver transplantation. Although cigarette smoking increases the risk of vascular complications after renal transplantation, its impact after liver transplantation remains unknown. Between May 1995 and April 2001, 288 liver transplantations were performed in 263 patients. Vascular complications developed in 39 patients (13.5%) (arterial complications, 28 patients [9.7%]; venous complications, 11 patients [3.8%]). Patient demographics, comorbid illnesses, and risk factors were analyzed using the Mann-Whitney U test, Chi-squared test, and Fisher's exact test. In patients with a history of cigarette smoking, incidence of vascular complications was higher than in those without history of cigarette smoking (17.8% v 8%, P =.02). Having quit cigarette smoking 2 years before liver transplantation reduced the incidence of vascular complications by 58.6% (24.4% v 11.8%, P =.04). The incidence of arterial complications was also higher in patients with a history of cigarette smoking compared with those without such history (13.5% v 4.8%, P =.015). Cigarette smoking cessation for 2 years also reduced the risk of arterial complications by 77.6% (21.8% v 5.9%, P =.005). However, the incidence of venous complications was not associated with cigarette smoking. Furthermore, there was no significant association between development of vascular complications and all other characteristics studied. Cigarette smoking is associated with a higher risk for developing vascular complications, especially arterial complications after liver transplantation. Cigarette smoking cessation at least 2 years before liver transplantation can significantly reduce the risk for vascular complications. Cigarette smoking cessation should be an essential requirement for liver transplantation candidates to decrease the morbidity arising from vascular complication after liver transplantation.

Safe use of livers from donors with positive hepatitis B core antibody

Thirty-five patients received liver transplants using liver donors who had positive test results for the hepatitis B core antibody (HBcAb). In the same time frame, 195 patients received HBcAb-negative liver donors. Mean follow up for patients receiving HBcAb-positive donors was 25 months. All patients receiving HBcAb-positive donors were monitored for recurrence of hepatitis B (HBV) with HBV DNA assays. There was no de novo HBV in recipients of HBcAb-negative grafts. In the group of patients receiving HBcAb-positive donors, 4 of 35 patients died within 3 months after transplant with no evidence of HBV recurrence at time of death. Four patients were transplanted for HBV-related disease and were postoperatively placed on lamivudine and hepatitis B immune globulin (HBIG). HBV recurrence was seen in one of these patients. Of the remaining 27 patients, three of three mismatched patients (HBcAb-positive donor to HBcAb-negative recipient) developed de novo HBV (100%). Of 24 matched patients (HBcAb-positive donor to HBcAb-positive recipient), only two (7%) developed recurrent HBV allograft reinfection. All de novo and recurrent HBV infections were successfully managed with HBIG and lamivudine therapy. Survival for this subgroup of patients receiving HBcAb-positive donors for non-HBV-related liver disease was 100%. We conclude that the judicious use of HBcAb-positive donors is reasonably safe and associated with low morbidity and mortality, with the appropriate follow-up protocols. Additionally, lamivudine use can be reserved for those cases with de novo or recurrent HBV in the liver allograft, or, selectively, as prophylaxis in those recipients patients who are naïve to HBV and receive an HBcAb-positive donor.

Tacrolimus conversion improves hyperlipidemic states in stable liver transplant recipients

With improvements in surgical technique and the advent of new and more effective immunosuppressive agents, survival rates in liver transplant recipients have dramatically improved. However, hyperlipidemia frequently develops in patients administered cyclosporine-based immunosuppression long-term, although it appears to occur less often with newer, tacrolimus-based regimens. We sought to determine whether an isolated change in the baseline immunosuppressive regimen (cyclosporine to tacrolimus) would improve hyperlipidemic states in these patients. Twenty-one long-term stable liver transplant recipients with hyperlipidemia, manifested by elevated cholesterol and/or triglyceride levels, were offered conversion to tacrolimus from cyclosporine A therapy. Lipid profiles were monitored at baseline (while on cyclosporine therapy) and at 1 and 3 months after conversion to tacrolimus therapy. There were no other medication manipulations. After conversion to tacrolimus therapy, mean cholesterol levels decreased from 251 to 202 mg/dL at 1 month (P <.001) and 194 mg/dL at 3 months (P <.001). Similarly, triglyceride levels decreased from 300 to 207 mg/dL by 1 month (P =.011) and 203 mg/dL by 3 months (P <.001). There was also a statistically significant decrease for very low-density lipoprotein levels at 3 months (P =.005) and low-density lipoprotein levels at 1 and 3 months (P =.013 and P =.014, respectively). High-density lipoprotein levels did not significantly change after conversion to tacrolimus therapy. Conversion was not accompanied by adverse side effects, and patients tolerated the change well. In conclusion, simple conversion from cyclosporine to tacrolimus-based immunosuppression therapy is safe and improves posttransplantation hyperlipidemia in a subgroup of liver transplant recipients.

Controlled non-heart-beating donor liver transplantation: a successful single center experience, with topic update

BACKGROUND

The critical shortage of transplantable organs necessitates utilization of unconventional donors. We describe a successful experience of controlled non-heart-beating donor (NHBD) liver transplantation.

METHODS

Controlled NHBDs had catastrophic head injury, prognosis for no meaningful recovery, decision to withdraw life support, and subsequent consent for donation. After stopping mechanical ventilation in the operating room, death determination by a nontransplant caregiver, and rapid aortic cannulation, liver and kidneys were recovered.

RESULTS

Controlled NHBDs contributed 5% of hepatic allografts (8/164) from August 1996 through June 1999 (9% in 1998). Sixteen NHBDs afforded 8 livers and 24 kidneys. Liver donors (n=8) were 11-66 years old; half were >50 years old. Premortem alanine aminotransferase was 25-157 U/L. Arrest occurred 3-27 min after stopping ventilation. Perfusion started 3-5 min after incision, and <22 min after hypotension (mean arterial pressure: <50 mmHg). Patient and graft survivals are 100% at 18+/-12 months follow-up. There was no intraoperative complication, reperfusion syndrome, poor graft function, primary nonfunction, arterial thrombosis, biliary complication, or serious infection. Postoperative day 2 prothrombin time was 13+/-1 sec. Peak alanine aminotransferase was 980+/-601 U/L. Intensive care unit and posttransplant lengths of stay were 2+/-2 and 10+/-7 days, respectively. Soon after transplantation there was frequent temporary hyperbilirubinemia (five of eight recipients; bilirubin peak: 7-29 mg/dl, 2-3 weeks after transplantation) and rejection (4/8 recipients, <3 weeks after transplantation).

CONCLUSIONS

NHBDs significantly and safely expanded our donor pool. NHBD surgeons must be capable of rapid procurement. Cautious liberalization of criteria for accepting livers from NHBDs with confounding risk factors is justified. Refined ethics guidelines would broaden approval of NHBDs.

Liver transplantation for autoimmune hepatitis

Publications about liver transplantation (LTX) for autoimmune hepatitis (AIH) have started to emerge, but many issues remain unresolved. We reviewed data on 32 patients transplanted for AIH to determine how pretransplantation and posttransplantation characteristics correlate with recipient outcome, including disease recurrence. Recipients were 37+/- 14 years old; 30 of 32 were women. Most had chronic disease (8 +/- 6 years); 25% had fulminant failure. The majority had ascites (91%), jaundice (88%), elevated prothrombin time (18 +/- 3 seconds), and hypoalbuminemia (2.7 +/- 0.6 g/dL). All had hypergammaglobulinemia (3.0 +/- 1.0 g/dL) and autoantibodies (72% antinuclear, 74% smooth muscle). Only one was HLA A1-B8-DR3 positive. Other autoimmune disorders affected 25% of patients; half improved after transplantation. Actuarial survival was 81% at 1 and 2 years posttransplantation. There was a high frequency of rejection (75% of recipients had 1.7 +/- 0.8 episodes), and 39% of rejections required OKT3. Among 24 recipients with long-term follow-up (27 +/- 14 months), histologically proven recurrent AIH occurred in 25%, 15 +/- 2 months posttransplantation; half (3 patients) required retransplantation 11 +/- 3 months after diagnosis. After retransplantation 2 of 3 patients had re-recurrence within 3 months; 1 received a third LTx. Recurrence occurred in 6 of 18 patients transplanted for chronic disease vs. 0 of 6 transplanted as fulminants (P = not significant [NS]). Patients with and without recurrence had similar rejection profiles. In summary, results of LTx for AIH are excellent. However, AIH patients have a high frequency of rejection and often require OKT3. Furthermore, severe recurrent AIH sometimes develops, particularly in chronic versus fulminant AIH patients and in those already retransplanted for recurrence. Multicenter studies could elucidate the best posttransplantation immunosuppressive regimens for AIH patients.

Persistent hypersplenism early after liver transplant: the role of splenectomy

BACKGROUND

Transient thrombocytopenia is common after liver transplantation, but persisting thrombocytopenia worsens the prognosis after transplant.

METHODS

Two patients underwent splenectomy for persistent thrombocytopenia early after liver transplantation. The first patient had a platelet count of 17,000/mm3 on postoperative day (POD) 6; her hemoglobin and white blood cell counts were normal. Work-ups including bone marrow aspiration, Coombs test, and antiplatelet antibody test were negative. On POD 9, she had abdominal bleeding with a platelet count of 17,000/mm3 despite repeated platelet transfusions, and splenectomy was done. The second patient had a platelet count of 3000/mm3 on POD 14, white blood cell was 1600/mm3, and hemoglobin was 7.7 g/dl. Bone marrow biopsy revealed hypercellular marrow. Because his platelet count remained at 2000/mm3 despite empiric treatment with intravenous immune globulin and methylprednisolone, splenectomy was performed.

RESULTS

The first patient's platelet count rose to 155,000/mm3 by POD 8. The second patient's platelet count reached 210,000/mm3 on POD 5. Neither patient has had an episode of thrombocytopenia at 36 and 32 months after splenectomy.

CONCLUSIONS

Splenectomy can be used after liver transplantation for severe, persistent thrombocytopenic states that cannot be attributed to sepsis, intravascular coagulation, immunological causes, or drug effects.

An improvement on the Bollman method of restraining and collecting thoracic duct lymph from the rat

A method of obtaining rat thoracic duct lymphocytes is described, including a review of the surgical technique, with several modifications, and including an outline of a newly designed rat restrainer that helps to triple thoracic duct output compared to the Bollman restrainer. The new restrainer allows the rat increased mobility but protects the thoracic duct cannula. Unanesthetized 200 g rats yielded 80 ml/day thoracic duct lymph containing 4.2 x 10(4) lymphocytes/ml.