Outcome after laparoscopic and open resections of posterosuperior segments of the liver

BACKGROUND

Laparoscopic resection of posterosuperior (PS) segments of the liver is hindered by limited visualization and curvilinear resection planes. The aim of this study was to compare outcomes after open and laparoscopic liver resections of PS segments.

METHODS

Patients who underwent minor open liver resection (OLR) and laparoscopic liver resection (LLR) between 2006 and 2014 were identified from the institutional databases of seven tertiary referral European hepatobiliary surgical units. Propensity score-matched analysis was used to match groups for known confounders. Perioperative outcomes including complications were assessed using the Dindo-Clavien classification, and the comprehensive complication index was calculated. Survival was analysed with the Kaplan-Meier method.

RESULTS

Some 170 patients underwent OLR and 148 had LLR. After propensity score-matched analysis, 86 patients remained in both groups. Overall postoperative complication rates were significantly higher after OLR compared with LLR: 28 versus 14 per cent respectively (P = 0·039). The mean(s.d.) comprehensive complication index was higher in the OLR group, although the difference was not statistically significant (26·7(16·6) versus 18·3(8·0) in the LLR group; P = 0·108). The mean(s.d.) duration of required analgesia and the median (range) duration of postoperative hospital stay were significantly shorter in the LLR group: 3·0(1·1) days versus 1·6(0·8) days in the OLR group (P < 0·001), and 6 (3-44) versus 4 (1-11) days (P < 0·001), respectively. The 3-year recurrence-free survival rates for patients with hepatocellular carcinoma (37 per cent for OLR versus 30 per cent for LLR; P = 0·534) and those with colorectal liver metastases (36 versus 36 per cent respectively; P = 0·440) were not significantly different between the groups.

CONCLUSION

LLR of tumours in PS segments is feasible in selected patients. LLR is associated with fewer complications and does not compromise survival compared with OLR.

Liver transplantation in neurological Wilson's Disease: is there indication? A case report

Wilson's disease (WD) is an autosomal recessive disorder characterized by copper overload. In this disease, inadequate hepatic excretion leads to copper accumulation in the liver, brain, kidney, and cornea. Severe neurological symptoms can develop in patients with WD, often in the absence of relevant liver damage: it is unclear whether liver transplantation (LT) could reverse neurological symptoms, and at present LT is not recommended in this setting. We report a case of regression of neurological symptoms in a patient affected by WD with prevalent neurological involvement. A 19-year-old man with disabling neuropsychiatric symptoms from WD that included frontal ataxia, akinesia, dystonia, tremors, and behavioral disorders in the presence of preserved liver function (Model for End-Stage Liver Disease score=7; Child-Turcotte-Pugh score=A5) underwent LT in November 2009. At the time of LT, encephalic magnetic resonance imaging (MRI) indicated diffuse neurodegenerative alterations involving subtentorial and supratentorial structures; bilateral Kayser-Fleischer ring was present. Four years after LT, laboratory tests show normalized copper metabolism and excellent liver function test results. Encephalic MRI shows a substantial improvement of already-known signal alterations at nuclei thalamus and putamen, mesencephalon, and pons. Kayser-Fleischer ring disappeared from the right eye, but a little remnant is still visible in the left eye. At neurological examination, all of the previous symptoms and signs are no longer present and behavioral disorders are no longer present; psychosocial functions are completely restored. The present case provides some evidence that LT may be a valid therapeutic option for WD patients with marked neurological impairment, particularly in those no longer responsive to chelation therapy.

Effects of antihypertensive treatments on incidence of diabetes: a case-control study

AIMS

Aim of this case-control study is the assessment of the relationship between antihypertensive treatment and incidence of diabetes in an unselected cohort of subjects participating in a screening program for diabetes.

METHODS

A case-control study nested within a cohort of nondiabetic subjects with a mean follow-up of 27.7 ± 11.3 months was performed, comparing 40 cases of incident diabetes and 160 controls matched for age, sex, body mass index, fasting plasma glucose, 2-h post-load glycemia, smoking and alcohol abuse.

RESULTS

When considering antihypertensive treatment at enrolment, a lower proportion of cases was exposed to ACE-inhibitors/angiotensin receptor blockers (ACE-i/ARB) in comparison with controls. A non-significant trend toward a higher exposure to diuretics, which were mainly represented by thiazide diuretics, was observed in cases. In a multivariate analysis, including both ACE-i/ARB and diuretics, a protective effect of ACEi/ARB, and an increased risk with diuretics were observed. Similar results were obtained in alternative models, after adjusting for systolic and diastolic blood pressure at enrolment, diagnosis of hypertension, concurrent treatment with β-blockers or calcium-channel blockers, and number of antihypertensive medications.

CONCLUSIONS

Diuretics seem to be associated with a higher incidence of diabetes, whereas treatment with ACEi/ARB could have a protective effect.

Sirolimus in liver transplant recipients: a large single-center experience

Sirolimus (SRL) is a newer immunosuppressant whose possible benefits and side effects in comparison to calcineurin inhibitors (CNIs) still have to be addressed in the liver transplantation setting. We report the results of the use of SRL in 86 liver transplant recipients, 38 of whom received SRL as the main immunosuppressant in a CNI-sparing regimen. Indications for the use of SRL were: impaired renal function (n = 32), CNI neurotoxicity (n = 16), hepatocellular carcinoma (HCC) at high risk of recurrence (n = 21), recurrence of HCC (n = 6), de novo malignancies (n = 4), cholangiocarcinoma (n = 1), and the need to reinforce immunosuppression (n = 6). Among patients on SRL-based treatment, four episodes of acute rejection were observed, three of which occurred during the first postoperative month. Renal function significantly improved when sirolimus was introduced within the third postoperative month, while no change was observed when it was introduced later. Neurological symptoms resolved completely in 14/16 patients. The 3-year recurrence-free survival of patients with HCC on SRL was 84%. Sixty-two patients developed side effects that required drug withdrawal in seven cases. There was a reduced prevalence of hypertension and new-onset diabetes among patients under SRL. In conclusion, SRL was an effective immunosuppressant even when used in a CNI-sparing regimen. It was beneficial for patients with recently developed renal dysfunction or neurological disorders.

Psychological adaptation and quality of life of adult intestinal transplant recipients: University of Bologna experience

INTRODUCTION

Intestinal transplantation has become an accepted therapy for individuals permanently dependent on total parenteral nutrition (TPN) with life-threatening complications. Quality of life and psychological well-being can be seen as important outcome measures of transplantation surgery.

METHODS

We evaluated 24 adult intestinal transplant recipients and 24 healthy subjects (a control group). All subjects were administered the Italian Version of the Psychological Well-Being Scales (PWB) by C. Ryff, the World Health Organization Quality of Life-Brief (WHOQOL), and the Symptom Questionnaire (SQ) by R. Kellner and G.A. Fava, a symptomatology scale. Quality of life and psychological well-being were assessed in transplant recipients in relationship to the number of rejections, the number of admissions, and the immunosuppressive protocol.

RESULTS

Intestinal transplant recipients reported significantly higher scores in the "personal growth" category (P = .036) and lower scores in the "positive relation with others" (P = .013) and "autonomy" (P = .007) dimensions of PWB, compared with the controls. In the WHOQOL, the scores of transplant recipients were lower only in the psychological domain (P = .011). Transplant recipients reported significantly higher scores in the "somatic symptom" (P = .027) and "hostility" (P = .018) dimensions of the SQ, compared with the controls. Transplant recipients with number of admissions >8 reported higher scores in "anxiety" (P = .019) and "depression" (P = .021) scales of the SQ, and the patients with a Daclizumab protocol reported higher scores in "depression" (P = .000) and "somatic symptom" (P = .008) of the SQ. There were no significant differences regarding number of rejections and socio-demographic variables.

CONCLUSION

Improvement of psychological well-being in the transplant population may be related to the achievement of the goal of transplantation: recovery of bowel function. But the data confirmed that the transplant experience required a long and difficult adaptation trial to the new condition of "transplant recipient."

Liver transplantation for hepatocellular carcinoma: results of down-staging in patients initially outside the Milan selection criteria

Conventional criteria for liver transplantation for patients with hepatocellular carcinoma are single HCC <or= 5 cm or less than or equal to three HCCs <or= 3 cm. We prospectively evaluated the possibility of slightly extending these criteria in a down-staging protocol, which included patients initially outside conventional criteria: single HCC 5-6 cm or two HCCs <or= 5 cm or less than six HCCs <or= 4 cm and sum diameter <or= 12 cm, but within Milan criteria in the active tumors after the down-staging procedures. The outcome of patients down-staged was compared to that of Milan criteria after liver transplantation and since the first evaluation according to an intention-to-treat principle. From 2003 to 2006, 177 patients with HCC were considered for transplantation: the transplantation rate was comparable between the Milan and down-staging groups: 88/129 cases (68%) versus 32/48 cases (67%), respectively. At a median follow-up of 2.5 years after transplantation, the 1 and 3 years' disease-free survival rates were comparable: 80% and 71% in the Milan group versus 78% and 71% in the down-staging. The actuarial intention-to-treat survival was 27/48 patients (56.3%) in the down-staging and 81/129 cases (62.8%) in the Milan group, p = n.s. The proposed down-staging criteria provide a comparable outcome to the conventional criteria.

Clinical trial: peg-interferon alfa-2b and ribavirin for the treatment of genotype-1 hepatitis C recurrence after liver transplantation

BACKGROUND

Treatment of hepatitis C virus (HCV) recurrence after liver transplantation (LT) is difficult with low response rates.

AIM

To assess the safety and efficacy of pegylated-interferon (PEG-IFN) alfa-2b + ribavirin (RBV) in patients with post-LT recurrent genotype-1 HCV and to establish stopping rules according to response.

METHODS

Fifty-three patients with post-LT HCV recurrence were enrolled. Patients received PEG-IFN alfa-2b 1.0 micro/kg/week plus RBV 8-10 mg/kg/day for 24 weeks. Those with 'early virological response at week 24' (EVR24) continued treatment for 24 weeks (group A). Patients without EVR24 were randomized to continue (group B) or to discontinue (group C).

RESULTS

Overall sustained virological response (SVR) was 26% (14/53). Alanine aminotransferase, rapid virological response, EVR12, EVR24, undetectable serum HCV-RNA at weeks 12 (cEVR12) and 24 (cEVR24) were related to SVR. cEVR12 and cEVR24 (OR: 14.7; 95% CI: 2.02-106.4) were independent predictors of SVR. All patients with SVR, had cEVR12. No patient in groups B and C achieved end-of-treatment response. One patient in group B had SVR.

CONCLUSIONS

Pegylated-interferon alfa-2b was effective in one of four of patients with HCV genotype 1 after LT. Treatment should be discontinued in patients with no virological response at week 12. Further studies are needed to evaluate whether a longer treatment period may be beneficial in patients with > or =2 log10 drop in HCV-RNA at week 24.

Liver transplantation for recurrent hepatocellular carcinoma on cirrhosis after liver resection: University of Bologna experience

Liver resection (LR) for patients with small hepatocellular carcinoma (HCC) with preserved liver function, employing liver transplantation (LT) as a salvage procedure (SLT) in the event of HCC recurrence, is a debated strategy. From 1996 to 2005, we treated 227 cirrhotic patients with HCC transplantable: 80 LRs and 147 LTs of 293 listed for transplantation. Among 80 patients eligible for transplantation who underwent LR, 39 (49%) developed HCC recurrence and 12/39 (31%) of these patients presented HCC recurrence outside Milan criteria. Only 10 of the 39 patients underwent LT, a transplantation rate of 26% of patients with HCC recurrence. According to intention-to-treat analysis of transplantable HCC patients who underwent LR (n = 80), compared to all those listed for transplantation (n = 293), 5-year overall survival was 66% in the LR group versus 58% in patients listed for LT, respectively (p = NS); 5-year disease-free survival was 41% in the LR group versus 54% in patients listed for LT (p = NS). Comparable 5-year overall (62% vs. 73%, p = NS) and disease-free (48% vs. 71%, p = NS) survival rates were obtained for SLT and primary LT for HCC, respectively. LR is a valid treatment for small HCC and in the event of recurrence, SLT is a safe and effective procedure.

Macrophage migration inhibitory factor (MIF) and oligoarticular juvenile idiopathic arthritis (o-JIA): association of MIF promoter polymorphisms with response to intra-articular glucocorticoids

OBJECTIVES

To address the clinical relevance of macrophage migration inhibitory factor (MIF) promoter polymorphisms in oligoarticular juvenile idiopathic arthritis (o-JIA) by evaluating their associations with serum and SF MIF levels, with response to intra-articular glucocorticoid injections and with outcome of the disease.

METHODS

Seventy-five Caucasian patients with o-JIA were studied. Alleles of the -794 CATT variable number of tandem repeats (VNTR) and of the -173 G/C single nucleotide polymorphism (SNP) were identified by capillary electrophoresis following fluorescently labelled PCR and by allelic discrimination assay, respectively. MIF levels were measured by ELISA. The association of MIF promoter polymorphisms with polyarticular extension, Childhood Health Assessment Questionnaire (CHAQ) score at the last follow-up visit and occurrence of chronic anterior uveitis was evaluated only in patients with a follow up > 5 years.

RESULTS

Neither of the MIF promoter polymorphisms was associated with serum MIF levels, nor with the long-term outcome of o-JIA. The -173 G/C SNP was significantly associated with both SF MIF levels and duration of response to intra-articular glucocorticoid injection. Carriers of a MIF -173 C allele were 4 times more likely to relapse within 3 months. No association was found between the different MIF CATT alleles and both SF MIF levels and duration of response to intra-articular glucocorticoids.

CONCLUSION

Our study shows the clinical relevance of the MIF -173 G/C SNP in o-JIA and suggests that the -173 C allele may represent a predictor of poor response to intra-articular glucocorticoid treatment.

Italian Experience in Adult Clinical Intestinal and Multivisceral Transplantation: 6 Years Later

PATIENTS AND METHODS

Between December 2000 and November 2006, 28 isolated intestinal transplants and nine multivisceral transplants (five with liver) from cadaveric donors have been performed for short gut syndrome (n = 15), chronic intestinal pseudo-obstruction (n = 10), Gardner's syndrome (n = 9), radiation enteritis (n = 1), intestinal atresia (n = 1), and massive intestinal angiomatosis (n = 1). Indications for transplantations were: loss of venous access, recurrent sepsis due to central line infection, and/or major electrolyte and fluid imbalance. Liver dysfunction was present in 19 cases. All patients were adults of median age at transplant of 34.7 years and mean weight 59.6 kg. All recipients were on total parenteral nutrition for a mean time of 38.8 months. Mean donor/recipient body weight ratio was 1.1.

RESULTS

The mean follow-up was 892 +/- 699 days. Twenty-five patients were alive (67.5%) with 3-year patient survivals of 70% for isolated intestinal transplantations and 41% for the multivisceral transplantations (P = .01). The mortality rate was 32.5% with losses due to sepsis (63%) or rejection. Our 3-year graft survival rates were 70% for isolated intestinal transplantations and 41% for multivisceral transplantations (P = .02); graftectomy rate was 16%. These were 88% of grafts working properly with patients on regular diet with no need for parenteral nutrition.

DISCUSSION AND CONCLUSIONS

Induction therapy has reduced the doses of postoperative immunosuppressive agents, especially in the first period, lowering the risk of renal failure and sepsis, mucosal surveillance protocol for early detection of rejection dramatically reduced the number of severe acute chronic rejections.

Coping Strategies in Intestinal Transplantation

The psychological construct of coping has been studied extensively in other medical populations and has more recently been applied in the field of transplant psychology. Coping can be defined as all abilities used by people to face problematical and stressful situations, as the data in literature describe the experience of transplantation. The purpose of this study was to describe the coping styles used by 25 intestinal transplant recipients. To assess the coping strategies, we used the Italian version of Coping Orientation to Problems Experienced (COPE) by Sica, Novara, Dorz, and Sanavio (1997). The authors divided these strategies into three classes: problem-focused, emotion-focused, and potentially disadaptive strategies. This questionnaire is usually used in a medical setting. Even if the long process of psychological-clinical adaptation required by intestinal transplantation put patients in a passive acceptance of their situation and their incapacity to face it, our patients showed high levels of problem-focused strategies, indicators of positive outcomes for this intervention. Anyway, this is a slow and gradual path that goes with the psychological distress and the need for a peculiar psychological support of problem-focused strategies. The result suggested that assessment of coping strategies should be explored in intestinal transplant to encourage the use of action-oriented methods and discourage those with possible negative effects.

Rejection Episodes and 3-Year Graft Survival Under Sirolimus and Tacrolimus Treatment After Adult Intestinal Transplantation

PURPOSE

Mammalian target of rapamycin (mTOR) inhibitors have been recently introduced in clinical practice after intestinal transplantation. We focused on Sirolimus (Rapamycin) to examine effects on rejection and graft survival following intestinal transplantation.

PATIENTS AND METHODS

Twenty isolated intestinal recipients and 5 multivisceral patients (2 with liver) in our series were divided into 3 groups: patients started on Sirolimus (because of nephrotoxicity or biopsy-proven rejection), who continued therapy longer than 3 months (n = 11); patients started on Sirolimus (because of nephrotoxicity or biopsy-proven rejection), who received therapy less than 3 months because of side effects (n = 4); and a control group, who never received rapamycin (n = 10).

RESULTS

During prolonged treatment combined with Tacrolimus (Prograf), both Sirolimus groups showed a decreased number of acute cellular rejections (P < .01). Cumulative 3-year graft and patient survival rates were 81% in the Sirolimus greater than 3 months group, 100% in the Sirolimus less than 3 months group, and 80% and 90% in the control group, respectively (P = .63 and P = .62).

CONCLUSION

In our experience, the use of mTOR-inhibitors in combination with calcineurin-inhibitors seemed to be more effective than monotherapy to reduce the number of rejections. Side effects can limit its use as maintenance therapy.

Twenty-five consecutive isolated intestinal transplants in adult patients: a five-yr clinical experience

PATIENTS AND METHODS

Between December 2000 and December 2005, 25 isolated intestinal transplants from cadaveric donors have been performed for short gut syndrome (short bowel syndrome, 52%), chronic intestinal pseudo-obstruction (24%), Gardner syndrome (16%), radiation enteritis (4%) and massive intestinal angiomatosis (4%). Indications for transplantation were: loss of venous access, recurrent sepsis due to central line infection, major electrolyte and fluid imbalance. Liver dysfunction was present in 13 cases. All patients were adult; median age was 36.3 yr and mean weight at transplantation 61.6 kg. All recipients were on life-threatening parenteral nutrition for a mean time of 23.7 months. Mean donor/recipient body weight ratio was 1.08. Rejection monitoring was accomplished by graft ileoendoscopies and intestinal biopsies through the temporary ileostomy. Our immunosuppressive regimen was based on induction therapy with three different protocols: daclizumab for induction, tacrolimus and steroids as maintenance therapy; alemtuzumab for induction and low-dose tacrolimus as maintenance; thymoglobulin for induction and maintenance based on low-dose tacrolimus. Closure of the abdomen at the end of transplantation represented a technical problem with several options performed: graft reduction, only skin closure, prothesic meshes, abdominal closure in two steps, cutaneous flaps and abdominal wall transplant in one case.

RESULTS

The mean hospital stay was 37 days. The mean follow-up 27 months. Twenty patients are alive (80%) with two- and five-yr patient survival rate of 80% and 66%; mortality rate was 20% due to sepsis in all cases. Our two- and five-yr graft survival rate is 76% and 64%, graftectomy rate was 16%. Sixteen grafts are working properly, with no need of parenteral nutrition. We diagnosed 35 mild acute cellular rejection (ACRs), seven moderate ACRs and three severe ACRs (two needed graftectomy). We experienced two episodes of chronic rejection biopsy-proven. Rapamicine was added in case of renal failure or biopsy-proven intestinal rejection. Graft-vs.-host disease was not seen in our series while post-transplant lymphoproliferative disease in two cases. After discharge, the most common indication for medical support was dehydration. The abdominal wall transplant did not experience any rejection.

DISCUSSION AND CONCLUSIONS

Induction therapy has reduced the amount of postoperative immunosuppressive agents, especially in the first period, lowering the risk of renal failure and sepsis and the mucosal surveillance protocol for early detection of rejection dramatically reduced the number of severe ACR.

Daclizumab and alemtuzumab as induction agents in adult intestinal and multivisceral transplantation: A comparison of two different regimens on 29 recipients during the early post-operative period

INTRODUCTION

Induction therapy has been recently adopted for intestinal transplant.

PATIENTS AND METHODS

We compared during first 30 days post-transplantation 29 recipients, allocated in two groups, treated with Daclizumab (Zenapax) or Alemtuzumab (Campath-1H).

RESULTS

During first month, 45% of Daclizumab recipients experienced six acute cellular rejections (ACRs) of mild degree, while 63% of them developed an infection requiring treatment. We found three acute cellular rejections in 17.6% of Alemtuzumab recipients, two with moderate degree; 64.7% of them required treatment for infection.

DISCUSSION AND CONCLUSIONS

Graft and patient 3-years cumulative survival rate were not significantly different between groups. Alemtuzumab seems to offer a better immunosuppression during first month.

Steroids in intestinal transplantation

BACKGROUND

Recently, new immunosuppressive protocols after intestinal transplantation have been proposed to avoid steroids use and their adverse effects. We evaluated the impact of steroids on survival and post-transplant complications in our experience.

PATIENT AND METHODS

In our retrospective study we considered the mean daily dosage of steroids received by 25 patients after intestinal/multivisceral transplantation (minimal follow-up was six months). We analyzed graft and patient survival rates, correlation with rejection and infectious episodes and steroids side effects.

RESULTS

After a mean follow-up of three yr, we did not find any significant difference in steroid doses between our immunosuppressive protocols. Patients with a mean dosage of prednisone higher than 20 mg/d experienced a lower graft (p = 0.009) and patient (p = 0.02) survival rate. The side effects of steroids after transplant were similar. Infections were more frequent during steroids administration (p = 0.04).

DISCUSSION AND CONCLUSION

Steroids therapy may be useful to treat acute rejection, but in our experience high steroids regimen did not improve graft and patient survival, increasing infectious rate. We assumed that high dose of steroids can be avoided as maintenance therapy, except in selected cases.

Effect of total enterectomy, pancreatectomy, and portal vein ligation on liver function and histology: a case report

Impaired hepatic function and histology have been observed in experimental models of diversion of the portal vein blood inflow from the liver and among patients with intestinal failure. Survival after total enterectomy, pancreatectomy, and portal vein ligation, and the effect of such a condition on liver function have never been reported in humans. Herein a 32-year-old woman with familial adenomatous polyposis and multiple desmoid tumors involving the mesentery and the retroperitoneum underwent total enterectomy and pancreatectomy followed by en bloc transplantation of the stomach, small bowel, and pancreas. Due to early graft failure, the patient underwent graftectomy, ligation of the portal vein, and external drainage of the common bile duct. Liver function tests were checked daily and a liver biopsy performed 15 days after graftectomy. The patient died of a ruptured mycotic aneurysm of the abdominal aorta at 27 days after the graftectomy. Liver function tests remained normal throughout the postoperative period; liver biopsy showed normal hepatic architecture with mild portal inflammation and cholestasis and spotty necrosis. Total enterectomy with pancreatectomy and ligation of the portal vein are compatible with survival in humans (at least in the short term), allowing normal hepatic function with minimal histological alterations to the liver.

Artificial neural network is superior to MELD in predicting mortality of patients with end-stage liver disease

BACKGROUND

Despite its accuracy, the model for end-stage liver disease (MELD), currently adopted to determine the prognosis of patients with liver cirrhosis, guide referral to transplant programmes and prioritise the allocation of donor organs, fails to predict mortality in a considerable proportion of patients.

AIMS

To evaluate the possibility to better predict 3-month liver disease-related mortality of patients awaiting liver transplantation using an artificial neural network (ANN).

PATIENTS AND METHODS

The ANN was constructed using data from 251 consecutive people with cirrhosis listed for liver transplantation at the Liver Transplant Unit, Bologna, Italy. The ANN was trained to predict 3-month survival on 188 patients, tested on the remaining 63 (internal validation group) unknown by the system and finally on 137 patients listed for liver transplantation at the King's College Hospital, London, UK (external cohort). Predictions of survival obtained with ANN and MELD on the same datasets were compared using areas under receiver-operating characteristic (ROC) curves (AUC).

RESULTS

The ANN performed significantly better than MELD both in the internal validation group (AUC = 0.95 v 0.85; p = 0.032) and in the external cohort (AUC = 0.96 v 0.86; p = 0.044).

CONCLUSIONS

The ANN measured the mortality risk of patients with cirrhosis more accurately than MELD and could better prioritise liver transplant candidates, thus reducing mortality in the waiting list.

Analysis of risk factors for early hepatic artery thrombosis after liver transplantation. Possible contribution of reperfusion in the early morning

BACKGROUND

Since the incidence of myocardial infarction and other cardiovascular ischaemic events is highest in early morning, on account of a relative hypercoagulable state occurring in this time period, an attempt was made to test whether reperfusion of the hepatic artery at this time of the day, at liver transplantation, produces an increased risk of early thrombosis.

METHODS

The records of 255 consecutive patients receiving a first transplant for chronic liver disease were retrospectively analysed. As possible risk factors, for early post-operative thrombosis (<30 days from transplantation), several medical and surgical parameters were taken into consideration. Arterial reperfusion was considered to have taken place at a time of high coagulability when occurred between 6.00 a.m. and 10.00 a.m. on the basis of previous reports.

RESULTS

Logistic regression identified donor age (OR for age >60: P=0.017), bench reconstruction of the artery (OR: 5.06, P=0.013) and time of high coagulability at reperfusion (OR 2.93, P=0.087), as independently associated with early hepatic artery thrombosis.

CONCLUSIONS

The present findings identified three independent predictors of early hepatic thrombosis, warranting stricter post-surgical follow-up of patients presenting such conditions. Interestingly, these factors are consistent with arterial reperfusion in the early morning being associated with an increased risk of early hepatic artery thrombosis, suggesting relative coagulative imbalances to provide a contribution in the pathogenesis of this severe complication of liver transplantation.

Recovery From Liver Dysfunction After Adult Isolated Intestinal Transplantation Without Liver Grafting

PURPOSE

We sought to evaluate liver function recovery after isolated intestinal transplantation in adults with irreversible intestinal failure.

PATIENTS AND METHODS

Over a 5-year period, we transplanted 34 adult patients, 25 of whom received an isolated intestinal graft, 4 a multivisceral graft without a liver, and 5, a multivisceral graft with a liver. Among the group of patients transplanted with the isolated graft we selected 14 recipients with pretransplant liver dysfunction, namely, a serum bilirubin >2 mg/dL (normal value: 1.2) and/or transaminases >100 IU/mL (NV, 37/40). Other inclusion criteria were total parenteral nutrition, period > 3 months, no diagnosis of portal hypertension or cirrhosis. Two patients had biopsy-proven liver fibrosis.

RESULTS

At discharge, all patients recovered liver function to normal values: mean bilirubin blood level was 0.9 +/- 0.96 mg/dL (range: 0.3-1.6) and mean transaminases were 26 +/- 9 and 31 +/- 18 IU/mL (range: 10-44/27-65). After a mean follow-up of 2 years, only one patient has an elevated alanine aminotransferase level without clinical signs of liver disease. Type of pretransplant liver disease did not impact on survival rates.

CONCLUSION

In selected cases, an isolated intestinal or a multivisceral graft without a liver can represent a "liver salvage therapy" for an early failing liver in patients with irreversible intestinal failure. Pretransplant liver disease is not a negative prognostic factor.

Results of intestinal and multivisceral transplantation in adult patients: Italian experience

PURPOSE

We report our experience with intestinal and multivisceral transplantation in Italy.

METHODS

We performed 23 adult isolated intestinal transplants and seven multivisceral ones, three with liver, between December 2000 and June 2005. Indications for transplantation were loss of venous access (n = 14), recurrent sepsis (n = 10), and electrolyte-fluid imbalance (n = 6), 14 of whom also presented with total parenteral nutrition (TPN)-related liver dysfunction. Immunosuppression was based on induction agents like daclizumab (followed by tacrolimus and steroids) in the first period; alemtuzumab or thymoglobulin (with tacrolimus) in a second period after 2002.

RESULTS

The mean follow-up was 742 +/- 550 days. Three-year patient actuarial survival rate was 88% for intestinal transplants and 42% for multivisceral (P = .015). Three-year graft actuarial survival rate was 73% for intestinal patients and 42.8% for multivisceral (P = .1). Graft loss was mainly due to rejection (57%). Complications were mainly represented by bacterial infections (92% of patients), relaparotomies (82%), and rejections (72%). Full bowel function without any parenteral nutrition or intravenous fluid support was achieved in 60% of recipients with functioning bowel including 95% on a regular diet. One patient underwent abdominal wall transplantation as well.

DISCUSSION AND CONCLUSION

Intestinal transplantation has achieved high rates of patient and graft survival with even longer follow-up. Early referral of patients, especially in cases of TPN-liver disease, is mandatory to obtain good outcomes and avoid high mortality rates on the transplant waiting list. Immunosuppressive management remains the key factor to increase the success rate.

Surgical approach to complicated intestinal failure for benign disease in adult patients: transplantation or surgical rehabilitation?

Surgical approaches to complicated benign intestinal failure are gaining acceptance, especially in the pediatric population. Less international experience has been obtained in adult patients, who are usually treated with total parenteral nutrition (TPN). An intestinal rehabilitation program was started in our institution with comprehensive medical rehabilitation, surgical bowel rescue, and transplantation. Among 38 adult patients referred by our gastroenterologists for bowel rehabilitation and surgically treated in our institution, 92.2% received TPN on admission. After careful evaluation, 71% underwent transplantation. Five patients died, but 18 recipients were completely weaned off TPN at follow-up. Eleven patients underwent surgical resection of the affected bowel and a subsequent program of intestinal rehabilitation: they were all alive and weaned off TPN at discharge. At a 2-year mean follow-up, deaths occurred only in the transplant population. Therefore, intestinal surgical rescue, if successful, is optimal in adult patients.

Twenty-Seven Consecutive Intestinal and Multivisceral Transplants in Adult Patients: A 4-Year Clinical Experience

Adult isolated intestinal and multivisceral transplantation is gaining acceptance as the standard treatment for patients with intestinal failure with life-threatening parenteral nutrition-related complications. We report our 4-year experience with intestinal and multivisceral transplantation. We performed 20 isolated small bowel and seven multivisceral ones, including three with liver. The underlying diseases were mainly short bowel syndrome due to intestinal infarction, chronic intestinal pseudo-obstruction, and Gardner syndrome. Indications for transplant were loss of central venous access in 14 patients, recurrent sepsis in eight patients, and major electrolyte and fluid imbalance in five patients. One-year patient actuarial survival rate was 94% for isolated intestinal transplants and 42% for multivisceral recipients (P = .003), while 1-year graft actuarial survival rate was 88.4% for isolated small bowel patients and 42.8% for multivisceral ones (P = .01). The death rate was 18.5%. Our graftectomy rate was 14.8%. Our immunosuppressive protocols were based on induction agents such as alemtuzumab, daclizumab, and antithymocyte globulins. The majority of our complications were bacterial infections, followed by rejections and relaparotomies; most rejection episodes were treated with steroid boluses and tapering. We believe that our results were due to optimal candidate and donor selection, short ischemia time, and use of induction therapy. Multivisceral transplantation is a more complex procedure with less frequent clinical indications than isolated small bowel transplant, but our data concerning multivisceral transplants include only a small number of patients and require further evaluation.

Octogenarian livers successfully transplanted in patients with fulminant hepatic failure

Although octogenarian livers have been transplanted successfully in elective settings, their safety in the case of fulminant hepatic failure has not yet been reported. From November 1998 to June 2003, we transplanted 3 livers from 80-, 82-, and 86-year-old donors. The donors were hemodynamically stable with an intensive care unit stay ranging from 24-48 hours. Cold ischemia time was from 260 minutes to 526 minutes. Mild macrosteatosis was present in 2 donors. Donor and recipient characteristics as well as posttransplantation evolution were evaluated. Two cases had uneventful courses and all recipients are well at 39, 21, and 5 months, respectively. The second recipient underwent retransplantation at 15 days due to technical complications. Livers from octogenarian donors may be safely used in an emergency to save patients. Age does not represent a limit for individually assessed and highly selected donors.

Donor pool expansion in liver transplantation

INTRODUCTION

The shortage of donors has made it necessary to consider older subjects, those with mild or moderate steatosis, and those who are HBcAb- or hepatitis C virus (HCV)-positive as marginal donors.

MATERIALS AND METHODS

From April 1986 to January 2002, 690 orthotopic liver transplantations (OLTs) were performed in 603 patients. In this series we used 68 donors older than 70 years, 51 with steatosis (38 mild, 12 moderate, and 1 severe), 44 were HBcAb-positive and 6 were HCV-positive.

RESULTS

Of 68 grafts from donors older than 70 years, 65 were used as a first OLT. These grafts showed 3 PNF, 11 arterial complications, 12 re-OLTs, and 14 deaths with graft survival of 72.3% and 61.34% at 1 and 3 years, respectively. All patients who received the other 3 grafts, which were used for re-OLT, died between postoperative day 21 and 720. Among the 51 grafts with steatosis, we observed 2 PNF of those within the mild steatosis group and graft survival rates of 76.8% and 70.9% at 1 and 3 years, respectively. Forty-four grafts from HBcAb-positive subjects were used in 18 HBsAg-negative and 26 HBsAg-positive recipients. Among the untreated patient group, 1 patient demonstrated hepatitis B virus (HBV) reinfection and 1 patient had de-novo HBV. No reinfection or de novo infections were observed in the 13 patients treated with immunoglobulin or in the 19 patients treated with lamivudine plus immunoglobulin, or in the only patient treated with lamivudine. Graft survival rates were 64.1% and 54.7% at 1 and 3 years, respectively. Among who received 6 patients transplants from HCV-positive donors, we observed 1 recurrence of chronic hepatitis, 1 re-OLT for hepatic vein stenosis, and 1 PNF.

CONCLUSION

Old donors, those with moderate steatosis, or those who are HBcAb- and HCV-positive can be safely used in selected recipients to reduce waiting list mortality.

Combined heart and liver transplantation in four adults with familial amyloidosis: experience of a single center

There are few reports of combined heart and liver transplantation (CHLT) for familial amyloidotic polyneuropathy (FAP). The technique for the operation remains to be defined. Four CHLTs were performed for amyloidogenic transthyretin-related (variant Glu89Gln-ATTR Glu89Gln) cardiomyopathy in our center. Patients 1 and 4 had no serious involvement of other organs, whereas patients 2 and 3 had evident peripheral neuropathy and gastrointestinal motility alterations. Patient 3 also had high-grade orthostatic hypotension. All four patients underwent cardiac and sequential hepatic transplantation with organs procured from the same donor. Venovenous bypass was used in patients 1 and 4 who experienced uncomplicated procedures. The amyloidotic liver of patient 4 was successfully utilized for a domino procedure to treat a patient with hepatocellular carcinoma on cirrhosis. The cardiac performance of patients 1 and 4 remains normal; there has been no progression of amyloidosis at 42 and 1 months after transplantation. Patient 2 had no intraoperative complications but experienced postoperative bleeding, renal failure, sepsis, and heart failure, and finally died of multiorgan failure 2 months after transplant. In patient 3, right hemicolectomy was required intraoperatively due to intestinal ischemia, without significant hemodynamic instability, while extracardiac symptoms of amyloidosis gradually worsened postoperatively. In conclusion, CHLT for ATTR Glu89Gln may be performed even in patients with advanced disease. However, the most compromised patients are more likely to display intraoperative risks, postoperative complications, and worsening of extracardiac, extrahepatic symptoms.

Comparison of Celsior and University of Wisconsin solutions in cold preservation of liver from octogenarian donors

BACKGROUND

Celsior (CS) has recently been proposed as a cold storage solution for thoracic and abdominal organs. We compared University of Wisconsin (UW) and CS solutions for the preservation of livers from old donors, with regard to initial function as well as short- and long-term graft and patient survival.

METHODS

A multicenter retrospective study from 1998 to 2002 includes 30 livers from octogenarian donors preserved in CS (n = 15) or UW (n = 15) solution prior to transplantation. Donor and recipient clinical and laboratory parameters as well as liver biopsy results were evaluated in all cases.

RESULTS

The distribution of the main donor variables as well as recipient characteristics were comparable between groups. Mean cold ischemia time was 421 minutes in the CS group and 474 minutes in the UW group. Mild steatosis was present in 8 cases in the CS group and 7 cases in the UW group. No primary graft dysfunction or arterial or biliary complications were noted. There was 1 acute rejection episode in the CS group and 4 in the UW group. Late postoperative deaths were observed only in the UW group (ie, 7 of 15). Actuarial graft survival was 100% in the CS group vs 86.7% in the UW group (P = NS) at 3 months, and 100% in the CS group vs 52.5% in the UW group (P =.007) at 12 months. Patient survival was 100% in the CS group vs 93.3% in the UW group (P = NS) at 3 months, and 100% in the CS group vs 59.3% in the UW group (P =.01) at 12 months.

CONCLUSIONS

Both CS and UW solutions effectively protect livers obtained from donors >80 years of age during the early postoperative course but the CS group had better long-term results.

Effect of IL-6 on IGF binding protein-3: a study in IL-6 transgenic mice and in patients with systemic juvenile idiopathic arthritis

Stunted growth is a common complication of childhood diseases characterized by chronic inflammation or infections. We previously demonstrated that NSE/hIL-6 transgenic mice, overexpressing the inflammatory cytokine IL-6 since early phase of life, showed a marked growth defect associated with decreased IGF-I levels, suggesting that IL-6 is one of the factors involved in stunted growth complicating chronic inflammation in childhood. Here we show that NSE/hIL-6 mice have normal liver IGF-I production, decreased levels of IGF binding protein-3 (IGFBP-3) and increased serum IGFBP-3 proteolysis. Reduced IGFBP-3 levels results in a marked decrease in the circulating 150-kDa ternary complex, even in the presence of normally functional acid labile subunit. Pharmacokinetic studies showed that NSE/hIL-6 mice have accelerated IGF-I clearance. Patients with systemic juvenile idiopathic arthritis (s-JIA), a chronic inflammatory disease characterized by prominent IL-6 production and complicated by stunted growth associated with low IGF-I levels, have markedly decreased IGFBP-3 levels, increased serum IGFBP-3 proteolysis and normal acid labile subunit levels. Our data show that chronic overproduction of IL-6 causes decreased IGFBP-3 levels, resulting in a decreased association of IGF-I in the 150-kDa complex. Decreased levels of IGF-I appear to be secondary to increased clearance.

Abnormal regulation of interleukin 6 in systemic juvenile idiopathic arthritis

OBJECTIVE

To evaluate the in vitro production of interleukin 6 (IL-6) by peripheral blood mononuclear cells (PBMC) of patients with systemic juvenile idiopathic arthritis (JIA), its regulation by IL-10, and the association of abnormal regulation of IL-6 production with presence of polymorphisms in the regulatory sequence of the IL-6 gene.

METHODS

PBMC were cultured in the absence or presence of lipopolysaccharide (LPS). IL-6 and IL-10 levels were measured by ELISA. Polymorphisms in the regulatory sequences of the IL-6 gene were assessed by restriction fragment length polymorphism analysis and sequencing of amplified regions.

RESULTS

Patients' PBMC produced high amounts of IL-6 compared to controls in unstimulated conditions. The IL-10 50% inhibitory dose of LPS stimulated IL-6 production was significantly higher in patients than controls. IL-10 levels produced in the absence or presence of LPS were comparable between patients and controls. The -174 G/C polymorphism in the IL-6 gene does not appear to be correlated with the high unstimulated IL-6 production or with the reduced inhibition by IL-10 observed in patients with JIA. No differences in patients compared to controls and with respect to the published sequence were found in the 3' untranslated region (UTR) of the IL-6 gene.

CONCLUSION

Most patients with JIA have increased unstimulated production of IL-6 and reduced inhibition of IL-6 production by IL-10. This abnormal regulation of IL-6 production is not secondary to a defect in IL-10 production, and is not associated with polymorphism of alleles at position -174 of the 5' flanking region or with mutations in the 3' untranslated region of the IL-6 gene.

In vivo neutralization of human IL-6 (hIL-6) achieved by immunization of hIL-6-transgenic mice with a hIL-6 receptor antagonist

Neutralization of IL-6 represents an attractive therapeutic option in several diseases, including B cell neoplasia, osteoporosis, and autoimmunity. Therapeutic attempts in humans have shown that administration of injectable doses of a mAb to IL-6 does not provide efficient neutralization of the cytokine in vivo. Therefore, alternative approaches are needed. In this study, we evaluated whether the Ab response to human IL-6 (hIL-6) elicited by vaccination with Sant1 (a hIL-6 variant with seven amino acid substitutions) was able to fully correct in vivo the clinical and biological effects of a chronic endogenous overproduction of hIL-6 in the hIL-6-transgenic NSE/hIL-6 mice. Because of the overexpression of hIL-6, occurring since birth, with circulating levels in the nanogram per milliliter range, NSE/hIL-6 mice have a marked decrease in growth rate, associated with decrease in insulin-like growth factor I levels, and represent an animal model of the growth impairment associated with human chronic inflammatory diseases. Following immunization with Sant1, but not with hIL-6, NSE/hIL-6 mice developed high titers of polyclonal Abs to hIL-6. The Abs, acquired by transplacental transfer, effectively neutralized IL-6 activities in vivo as shown by the complete correction of the growth defect and normalization of insulin-like growth factor levels in the hIL-6-transgenic offspring. Immunization with Sant1 could therefore represent a novel and simple therapeutic approach for the specific neutralization of IL-6 in humans.

Treatment of vascular complications following liver transplantation: multidisciplinary approach

BACKGROUND/AIMS

Complications affecting the vascularization of the graft following orthotopic liver transplantation still represent a significant cause of graft loss and patient mortality. Strategies have recently been developed for the early detection and treatment of these complications before irreversible graft failure takes place.

METHODOLOGY

A series of 429 consecutive liver transplants performed on 384 patients between April 1986 and December 1998 was retrospectively reviewed to assess the incidence of all the vascular complications and the results of their treatment with either surgery or interventional radiology.

RESULTS

The incidence of vascular complications was 6.06% for the hepatic artery, 2.56% for the inferior vena cava and 1.16% for the portal vein. As regards anastomotic stenosis and thrombosis, the requirement of retransplantation decreased progressively with the advent of systematic postoperative screening with duplex Doppler ultrasonography and the introduction of graft-salvage procedures, falling from 50% for those cases diagnosed before 1996 to 19% for those diagnosed from 1996 on. Mortality following 18 graft-salvage procedures was 11.1% versus 41.6% following retransplantation. Graft-salvage procedures were successful in 14 out of 18 cases.

CONCLUSIONS

Close surveillance of the vascular anastomoses and multidisciplinary approach to the treatment of vascular complication after liver transplantation considerably reduces graft loss and patient mortality.

Abstension from treatment of low-level pp65 cytomegalovirus antigenemia after liver transplantation: a prospective study

BACKGROUND

Ganciclovir is a highly effective and relatively safe drug to treat cytomegalovirus (CMV) infection in liver transplant patients; CMV resistance to ganciclovir is progressively emerging due to the extensive use of the drug in transplant and AIDS patients; CMV pp65 antigenemia allows early diagnosis of CMV infection and quantitation of the viral load; preemptive antigenemia-guided therapy of CMV infection can prevent CMV disease but the threshold of antigenemia value above which treatment has to be instituted is unclear.

METHODS

To demonstrate the safety of abstention from preemptive treatment in the presence of low levels of antigenemia 77 consecutive liver transplant recipients were prospectively evaluated. Antigenemia was tested twice a week from transplantation until discharge, then once a week until the third postoperative month. In absence of risk factors for CMV disease, namely donor positive/recipient negative CMV serology, treatment with antibodies to lymphocytes and retransplantation, only patients with antigenemia of more than 50 or symptoms possibly related to CMV infection had preemptive treatment.

RESULTS

A total of 32 patients had at least one positive antigenemia test with a value less than 50; 22 (68.7%) spontaneously cleared the virus, 3 were treated with i.v. ganciclovir for the presence of fever, and the other 7 (21,8%) progressed to values of antigenemia of more than 50 and were treated even if asymptomatic. No CMV disease was observed in these patients.

CONCLUSION

CMV antigenemia less than 50 in liver transplant recipients with low and intermediate risk for CMV disease does not mandate preemptive ganciclovir treatment. Close surveillance with repeated determination of antigenemia until its negativization and careful clinical and laboratory monitoring is advisable.

Circulating levels of soluble E-selectin, P-selectin and intercellular adhesion molecule-1 in patients with juvenile idiopathic arthritis

OBJECTIVE

To measure circulating levels of soluble E-selectin (sE-selectin), sP-selectin, and soluble intercellular adhesion molecule-1 (sICAM-1) in patients with active juvenile idiopathic arthritides (JIA), and to evaluate their correlation with disease activity variables and cytokine levels.

METHODS

Serum levels of sE-selectin, sP-selectin, and sICAM-1 were measured by ELISA in 42 patients with JIA and in 15 healthy controls.

RESULTS

Circulating levels of sE-selectin and sICAM-1, but not sP-selectin, were significantly elevated in patients with active systemic JIA. In patients with active polyarticular or pauciarticular JIA serum levels of sE-selectin. sP-selectin, and sICAM-1 were comparable to those of controls. In patients with systemic JIA, levels of sE-selectin and sICAM-1 were significantly correlated with levels of soluble tumor necrosis factor receptor 2 (sTNFR2), but not with those of interleukin 6 (IL-6) or IL-1beta.

CONCLUSION

Patients with active systemic JIA have elevated circulating levels of sE-selectin and sICAM-1. The correlation with sTNFR2, together with previous data on the TNF system in systemic JIA. suggests that TNF activated endothelial cells are the source of sE-selectin and sICAM-1 in this disease.

De novo hepatitis B and C viral infection after liver transplantation

Hepatitis B (HBV) and hepatitis C (HCV) viral infections often recur after orthotopic liver transplantation (OLT), but viral infections acquired with OLT have not been widely investigated. The aim of the study was to evaluate the incidence, evolution, and diagnostic problems of de novo HBV and HCV infections in liver transplant recipients with long-term follow-up. Altogether 121 transplant recipients entered the study. HBV, HDV, and HCV infections were diagnosed by means of serology and the polymerase chain reaction (PCR). Three patients became hepatitis B surface antigen (HBsAg)-positive after OLT, all of whom showed signs of persistent viral replication. Twelve patients became anti-HCV-positive after OLT: After clearance of passive antibodies, active anti-HCV seroconversion was usually delayed. The viral genome was detected in 9 of 12 patients, with fluctuations of viremia during their follow-up. The other three patients, who were HBsAg-positive before and after OLT, were repeatedly HCV-RNA-negative despite persistent anti-HCV reactivity. Four pre-OLT HBsAg-positive patients had evidence of HBV-related liver transplant disease. The remaining 8 of 12 patients experienced repeated alanine aminotransferase increases more than two times normal after transplant. De novo infections due to primary hepatotropic viruses were frequent after OLT in our experience. Early diagnosis of infection, especially when the HCV is involved, may be problematic and should be taken into account in patients showing persistent aminotransferase abnormalities. Monitoring viral markers and accurate evaluation of biopsy specimens are mandatory. The interference between HBV and HCV might play a role in the replicative cycle of one or both viruses in co-infected patients.

[Portosystemic shunts in the treatment of bleeding esophageal varices in cirrhotic patients: between sclerotherapy and transplantation]

In view of the proven efficacy of endoscopic sclerotherapy and the even improving results of liver transplantation, the present role of porto-systemic shunt should be reconsidered. From 1986 (when our liver transplant program began), to March 1994, 59 cirrhotic patients (males = 40, females = 19, mean age 53.17 +/- 12.04) underwent a porto-systemic shunt, 22 under emergency conditions and 37 in an elective setting. Patients were subdivided according to age, emergency or elective surgery, type of operation, and liver function. In the emergency procedures previous sclerotherapy and time between admission and surgery were also considered in the assessment. Mean follow-up was 46.49 +/- 31.48 months. Overall 5-year actuarial survival was 62.5%. In the emergency porto-systemic shunts the worst short-term results were obtained in patients over 55 years of age (p < 0.05) and when operations were performed within the first 24 hours after admission (p < 0.005). Long-term survival was not significantly influenced by the variables considered although patients over 55 years of age and patients with reduced liver function (Child B and C) seemed to have a more dismal outcome. Those patients under 55 years of age, with no portal thrombosis, considered as potential liver transplant candidates, had a better short-term survival rate (p < 0.05) than that of the rest of the patient population studied, mainly because of the better outcome after emergency surgery. Our data confirm the efficacy of porto-systemic shunt procedures in preserving the patient from variceal bleeding. They have a definite role in the complex treatment strategy of portal hypertension, and they must not be considered only a rescue procedure. However, liver transplantation remains the best option to resolve both portal hypertension and the underlying liver disease.

Quantitative assessment of serum beta-2-microglobulin in liver transplant recipients and relationship to liver graft rejection

OBJECTIVE

To investigate the usefulness of serum beta 2-microglobulin determination in the diagnosis of acute liver allograft rejection.

DESIGN

Prospective study.

SETTING

Liver transplant unit.

PATIENTS

Twenty consecutive patients who underwent liver transplantation because of a non-virus-related end-stage liver disease.

METHODS

Serum samples were collected before the transplant, at days 7, 30 and 90 and whenever a clinical complication developed after liver transplantation. beta 2-Microglobulin was quantified using a new quantitative automated microparticle enzyme immunoassay.

RESULTS

Serum beta 2-microglobulin levels increased significantly (P < 0.05) during rejection episodes and correlated with the degree of hepatocyte injury as assessed using serum aspartate aminotransferase levels. Increased beta 2-microglobulin levels were also found in surgical or infectious post-transplant complications. A significant difference in beta 2-microglobulin values was recorded between patients with rejection and only those with bacterial sepsis.

CONCLUSION

Although highly sensitive in recognizing damage to the graft, determination of beta 2-microglobulin was not sufficiently specific to differentiate between rejection and other post-transplantation complications.

Ruptured hepatocellular carcinoma: an important cause of spontaneous haemoperitoneum in Italy

OBJECTIVE

To evaluate the incidence of rupture of the tumour with intraperitoneal bleeding in a series of patients with hepatocellular carcinoma and its relative incidence as a cause of spontaneous haemoperitoneum, and to evaluate the results of the surgical treatment of a consecutive series of patients who presented with spontaneous haemoperitoneum caused by ruptured hepatoma.

DESIGN

Retrospective study.

SETTING

University hospital, Italy.

SUBJECTS

8 patients whose hepatocellular carcinoma ruptured (out of a total of 518) and caused spontaneous haemoperitoneum, and 34 patients who were admitted with spontaneous haemoperitoneum.

INTERVENTIONS

Seven hepatic resections; in one case direct haemostasis was attempted because of the poor hepatic reserve.

RESULTS

Rupture of the tumour with intraperitoneal bleeding occurred in 8/518 (2%) of cases of hepatocellular carcinoma. Ruptured hepatocellular carcinoma was the second most common cause of spontaneous haemoperitoneum (8/34; 24%), after gynaecological diseases (15/34; 44%). Of the 7 patients who presented with ruptured hepatocellular carcinoma and were treated by hepatic resection, 3 are alive (one with a recurrent disease) after a mean follow-up of six months (range 3 to 12 months) and 4 died of carcinomatosis within 12 months. The patient for whom resection was not feasible died immediately postoperatively of irreversible shock.

CONCLUSIONS

Rupture of hepatocellular carcinoma is a relatively common cause of spontaneous haemoperitoneum. Diagnosis at the onset of symptoms has important therapeutic implications: as the results of surgical treatment are unsatisfactory, other procedures with the limited goal of achieving satisfactory haemostasis can be considered if the hepatocellular carcinoma has been diagnosed.

Fatal necrotizing pancreatitis caused by hepatitis B virus infection in a liver transplant recipient

A 32-year-old man who had undergone liver transplantation for fulminant hepatitis due to HBV infection developed fatal acute necrotizing pancreatitis on the 60th post-transplant day, while showing signs of intense viral replication. Immunohistochemistry and in situ hybridization of the pancreas following autopsy showed the presence of HBsAG and HBV-DNA in the cytoplasm of acinar cells, together with the picture of necrotizing pancreatitis. Clinical and histological features seem to indicate that pancreatitis was directly caused by HBV infection.