Celiac disease in autism spectrum disorder: data from an Italian child cohort

BACKGROUND

In recent decades some studies described the frequent co-occurrence of celiac disease autoimmunity and overt celiac disease in patients with autism. Therefore, it was suggested that celiac disease could play a possible role in the etiopathogenesis of autism spectrum disorder. However, several other studies have not confirmed this association. The aim of the present study was to elucidate the potential association between autism spectrum disorder and celiac disease.

METHODS

We prospectively collected data from an Italian cohort of 223 children at the time of their clinical diagnosis of autism spectrum disorder in the 2019-2020 period. A serological celiac disease screening was performed and data were available for 196 patients; male (M):female (F) ratio = 4.4:1; median age = 3.6 years; age range = 1.6-12.8 years. Full-blown celiac disease was established according to the diagnostic algorithm of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) 2012 or 2019 guidelines. Fisher's exact test was used to compare the celiac disease seroprevalence and prevalence in our autism spectrum disorder cohort and in the Italian healthy pediatric population studied by Gatti et al. to highlight the possible differences between the two groups.

RESULTS

A not statistically significant difference between the celiac disease seroprevalence in our autism spectrum disorder cohort (4.08%) and Gatti's Italian healthy group (2.22%) was found, p = 0.0810; OR = 1.871. A similar result emerged for overt celiac disease prevalences (2.24% versus 1.58%, respectively), p = 0.2862; OR = 1.431.

CONCLUSIONS

Our data validates a weakness of association between autism spectrum disorder and celiac disease. On the basis of our results, a regular screening for CD in patients with ASD is not recommended to a greater extent than in the general population.

Neonatal presentation of genetic epilepsies: Early differentiation from acute provoked seizures

OBJECTIVE

Although most seizures in neonates are due to acute brain injury, some represent the first sign of neonatal onset genetic epilepsies. Delay in recognition and lack of expert assessment of neonates with epilepsy may result in worse developmental outcomes. As in older children and adults, seizure semiology in neonates is an essential determinant in diagnosis. We aimed to establish whether seizure type at presentation in neonates can suggest a genetic etiology.

METHODS

We retrospectively analyzed the clinical and electroencephalographic (EEG) characteristics of seizures in neonates admitted in two Level IV neonatal intensive care units, diagnosed with genetic epilepsy, for whom a video-EEG recording at presentation was available for review, and compared them on a 1:2 ratio with neonates with seizures due to stroke or hypoxic-ischemic encephalopathy.

RESULTS

Twenty neonates with genetic epilepsy were identified and compared to 40 neonates with acute provoked seizures. Genetic epilepsies were associated with pathogenic variants in KCNQ2 (n = 12), KCNQ3 (n = 2), SCN2A (n = 2), KCNT1 (n = 1), PRRT2 (n = 1), and BRAT1 (n = 2). All neonates with genetic epilepsy had seizures with clinical correlates that were either tonic (18/20) or myoclonic (2/20). In contrast, 17 of 40 (42%) neonates with acute provoked seizures had electrographic only seizures, and the majority of the remainder had clonic seizures. Time to first seizure was longer in neonates with genetic epilepsies (median = 60 h of life) compared to neonates with acute provoked seizures (median = 15 h of life, p < .001). Sodium channel-blocking antiseizure medications were effective in 13 of 14 (92%) neonates with tonic seizures who were trialed at onset or during the course of the epilepsy.

SIGNIFICANCE

Seizure semiology is an easily accessible sign of genetic epilepsies in neonates. Early identification of the seizure type can prompt appropriate workup and treatment. Tonic seizures are associated with channelopathies and are often controlled by sodium channel-blocking antiseizure medications.

Analysis of the Trend Over Time of High-Urgency Liver Transplantation Requests in Italy in the 4-Year Period 2014-2017

BACKGROUND

The national protocol for the handling of high-urgency (HU) liver organ procurement for transplant is administered by the Italian National Transplant Center. In recent years, we have witnessed a change in requests to access the program. We have therefore evaluated their temporal trend, the need to change the access criteria, the percentage of transplants performed, the time of request satisfaction, and the follow-up.

METHODS

We analyzed all the liver requests for the HU program received during the 4-year period of 2014 to 2017 for adult recipients (≥18 years of age): all the variables linked to the recipient or to the donor and the organ transplants are registered in the Informative Transplant System as established by the law 91/99. In addition, intention to treat (ITT) survival rates were compared among 4 different groups: (1) patients on standard waiting lists vs (2) patients on urgency waiting lists, and (3) patients with a history of transplant in urgency vs (4) patients with a history of transplant not in urgency.

RESULTS

Out of the 370 requests included in the study, 291 (78.7%) were satisfied with liver transplantation. Seventy-nine requests (21.3%) have not been processed, but if we consider only the real failures, this percentage falls to 13.1% and the percentage of satisfied requests rises to 86.9%. The average waiting period for liver transplantation (LT) is 1.7 days and most requests (74%) are met in less than 24 hours, if we consider the hours between the registration of the request and the donor reporting . The percentage of late retransplantations is 2.1%. The clinical indication for HU-LT that appears to improve over time is hepatic artery thrombosis (82.5%). The overall 1-year patient survival is 68.3%. The overall 1-year graft survival, performed on all the patients, is 89% and all the indications for HU-LT appear to go well over time with an average survival rate greater than 85%.

CONCLUSIONS

The indications for HU-LT are changing according to the changes in the hepatologic field in recent years. The centralized management of requests has proven to be successful in optimizing responses. Urgent LT is confirmed to be lifesaving in its timeliness.

Network Model for Optimal Aircraft Location for Human Organ Transportation Activities

BACKGROUND

The efficiency of transport phases is a key factor in successful organ transplant operations. Reliability, safety, and punctuality must be in compliance with the European Union and national frameworks and be consistent with economic, quantitative, and level-of-service parameters. In this study we investigated the optimal numbers and locations of aircraft in the Italian territory by comparing performance indexes related to different time intervals and service design scenarios.

METHODS

An integer linear programming model is described as an optimal service solution for covering the demand for extraregional organ transport by air between June 2015 and May 2016. Restrictions on aircraft utilization and actual length of the missions in cases of incompatible activities are the relevant input data of the model.

RESULTS

Based on mission durations and their origin and destination, the model returns the optimal number and location of aircraft in various scenarios. The performance parameters required by law and the need to guarantee the service from/to the whole territory, together with the transplant figures performed and transplant center locations, have been taken into account to determine the most efficient spatial and numerical allocation.

CONCLUSION

The efficient design of an urgency-based service such as the transportation of organs for transplant purposes is not an easy task. Nevertheless, knowledge of the logistic chain and continuous monitoring and update of data and performance parameters can allow for collection of useful information to guarantee a high-performing service.

Hepatitis C Virus Positive Patients on the Waiting List for Liver Transplantation: Turnover and Characteristics of the Population on the Eve of the Therapeutic Revolution With Direct-Acting Antivirals

INTRODUCTION

Antivirals direct acting (DAA) for hepatitis C virus (HCV) have brought a revolution in the field of transplantation. It is likely to think that in the future patients on the waiting list for liver transplantation (LT) will no longer be registered for HCV-related cirrhosis but for liver disease from other causes. On the eve of this change, we show a snapshot of the Italian waiting list for LT.

METHODS

From October 1, 2012 to September 30, 2013, we estimated the total number of patients on the liver waiting list as intention to treat (ITT), the number of incident cases, and the delistings, particularly in the HCV positive (HCV+) population. Gender, median age, etiology and prognosis of liver disease, presence of hepatocellular carcinoma (HCC), reason for delisting, mean waiting time for LT, and rate of death on waiting list were evaluated.

RESULTS

In the time period, there were 517 new patients who were HCV+ (median age, 53 years): 255 (49.3%) mono-infected with HCV, 236 (45.7%) co-infected with HCV and hepatitis B virus (HBV), 11 (2.1%) co-infected with HCV and human immunodeficiency virus (HIV), and 15 (2.9%) co-infected with HCV, HBV, and HIV. The median model for end-stage liver disease (MELD) score at listing was 17 and HCC was present in 206 (39.8%) cases. HCV+ patients delisted were 442 (61.9%), 355 (80.3%) for LT. The mean waiting time to transplantation was 1.9 months; the percentage of death was 7.6%.

CONCLUSIONS

This snapshot of the waiting list for LT in the year before the advent of DAA drugs will allow us to assess whether and how they will change the waiting list for LT when we start to look at the impact of new therapies on the waiting list.

Transport of Human Organs in Italy: Location, Time, and Performances

INTRODUCTION

The outcome of transplantation activities depends on a variety of unpredictable factors. Up-to-date criteria on organ allocation foresee an efficient transport chain along with compliant performance parameters.

METHODS AND OBJECTIVES

The Centro Nazionale Trapianti and the Department of Civil, Chemical, Environmental, and Materials Engineering of the University of Bologna (respectively, CNT and DICAM) have been updating a national database of organ transplantation activities to investigate performance parameters and the main causes of disruption.

RESULTS

Between June 2015 and July 2016, 617 of 1061 organs have been shipped by air (making for 486 flight events), of which 407 were accompanied by medical equipment. Origin/destination and distance matrixes have been drawn for both road and air transport. Each airport node is ranked based on the n° of organs ingoing/outgoing and each route link on its frequency. Performance parameters such as average speed, distance covered, and time have been computed and compared with each organ's cold ischemia time (CIT). Average distance frontiers are rather homogeneous, but much effort is necessary to reduce the number of events performed with approximately 90% or more of CIT spent.

CONCLUSIONS

The monitoring of organ transplantation activities' performance is a standalone action within Europe to support strategic policies to optimize the system. Thus, a clearer awareness on performances and issues related to organ transport has been made possible: analyses show that the higher uncertainty associated with total time of displacement by air is due to the steps which take place by road (length and paths must be optimized) and lung transports generally perform weaker than heart transports due to longer average distances travelled and smaller average speeds, often resulting in a total displacement time greater than 90% of CIT.

Adacolumn Granulocyte-Apheresis for Alcoholic Hepatitis: Preliminary Study

INTRODUCTION

Alcoholic hepatitis (AH) is an acute-on-chronic inflammatory response affecting the liver. It has been recognized that white blood cells (WBCs) are involved in the pathogenesis and in the prognosis of AH. The aim of study was to use Adacolumn, which can selectively adsorb myeloid linage leucocytes (granulocytes and monocytes/macrophages) from the blood in the column and improve the clinical status of patients.

MATERIALS

Six patients with a diagnosis of AH were treated with Adacolumn granulocyte-apheresis therapy.

INCLUSION CRITERIA

patients not responders to corticosteroids therapy with Maddrey Discriminant Function (MDF) >32 and MELD score 20-26. The patients underwent five 1-hour sessions for 5 consecutive days with a follow-up at 28 days. The column was placed in an extracorporeal setting with a perfusion rate of 30 mL/min and a duration of 60 minutes. Liver parameters, WBC count, proinflammatory cytokines, coagulation, and predictive scores were valued before and after the cycle of apheresis treatment.

RESULTS

After 5 days, the findings showed a significant improvement of WBC count (P < .014) and cytokines such as interleukin (IL)-6 (P < .019), tumor necrosis factor α (TNFα) (P < .02), and IL-8 (P < .029). The results probably determined a reduction of aspartate transaminase (AST; P < .02) and alanine transaminase (ALT; P < .011), although we did not observe a significant improve in bilirubin, prothrombin time (PT), and Maddrey score. The improvement of MELD score, depending on an improvement of international normalized ratio for administration of plasma, was not considered. At day 28 of follow-up, PT, IL-6, TNFα, AST and ALT results significantly improved.

CONCLUSIONS

The Adacolumn apheresis was safe and was able to determine an improvement of clinical status of patients with reduction of inflammatory markers. More patients are needed to validate these results.

Adult Wilms tumor: Case report

Wilms tumor (WT) occurs infrequently in adults. Even rarer is adult WT with extension by direct intravascular spread into the right side of the heart. The present report describes a WT with intracaval and intracardiac extension in a 38-year-young man. In addition, thrombus extension above the infrahepatic IVC represents a major technical topic for surgeons because of the possible occurrence of uncontrollable hemorrhages and tumor fragmentation. We report the results of a surgical approach to caval thrombosis including the isolation of the IVC from the liver as routinely performed during liver harvesting. The morphologic and immune-histochemical findings confirmed the diagnosis.

Cytokine level modifications: molecular adsorbent recirculating system versus standard medical therapy

INTRODUCTION

Acute-on-chronic liver failure (ACLF) is a systemic inflammatory reaction, which is characterized by a predominantly proinflammatory cytokine profile, causing the transition from stable cirrhosis to ACLF. The aim of the present study was to evaluate the changes in several cytokines associated with inflammatory liver disease and liver regeneration among 15 ACLF patients treated with the Molecular Adsorbent Recirculating System (MARS) compared with 15 patients treated with standard medical therapy (SMT). The subjects showed various disease etiologies but similar values for Model End-stage Liver Disease scores.

METHODS

In the MARS group, 15 (10 male and 5 female) patients were treated with MARS (Gambro). The number of MARS applications was nine; the length of applications was 8 hours. In the SMT group; 15 (10 male and 5 female) patients were treated with SMT. The patients were monitored for 30 days from inclusion with a survival follow-up at 3 months. Statistical results were calculated with SPSS14.0 (SPSS Inc, Chicago, Ill). A P < .07 was considered significant.

RESULTS

In the MARS group, we observed significant changes in the levels of Interleukin (IL)-6, IL-1, IL-10, and tumor necrosis factor (TNF)-alpha in association with improved hepatocyte growth factor. Patient survival at 3 months was 60%. The SMT group showed only a significant change in TNF-alpha (P = .03). Patient survival at 3 months was 30%.

CONCLUSION

The MARS liver support device corrected pathophysiologies of ALF and may be used to enhance spontaneous recovery or as a bridge to transplantation.

Predictive factors of recurrence of hepatocellular carcinoma after liver transplantation: a multivariate analysis

We analyzed predictive risk factors for recurrence of hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLT). We retrospectively analyzed the clinical data from 109 consecutive HCC patients who underwent OLT at our center from 1988 to 2007. We excluded all patients who died due to factors other than tumor recurrence within the first year (n = 24). The remaining 85 patients were enrolled in either a recurrence group (A; n = 19) or a nonrecurrence group (B; n = 66). Upon univariate analysis, the 2 groups were significantly different for 11 parameters. Group A included more females (P = .05), noncirrhotic liver recipients (P = .003), "up-to 7 status" patients (HCC with 7 as the sum of the size of the largest tumor [cm] and the number of tumors, P < .0001), patients exceeding Milan criteria (MC; P < .0001) or University of California San Francisco (UCSF) criteria (P < .0001), and OLT performed before 1999 (P = .003). Group A also showed a higher number of lesions (P = .035), a greater sum of diameters of the lesions (P < .0001), a major number of macrovascular (P < .0001) and microvascular invasions (P < .0001), and an increased number of G3-G4 grading (P = .006). Only microvascular invasion (P = .007) and exceeding UCSF criteria (P = .003) were independent risk factors for recurrence upon multivariate analysis. Patients with both these parameters are not candidates for OLT. Microvascular invasion is a good predictive parameter, but is impossible to detect preoperatively. New pre-OLT predictive risk factors are needed to achieve optimal results.

Pathfast presepsin assay for early diagnosis of bacterial infections in surgical patients: preliminary study

BACKGROUND

Various biomarkers have been studied for diagnosing bacterial infections, seeking to stop the sepsis cascade. Presepsin, which is ∼13 kDa in size, has been identified to increase specifically in the blood of sepsis patients. Additionally, measurement of presepsin is useful to evaluate the severity of infection and monitor clinical responses. We evaluated the analytical and clinical performance of the Pathfast presepsin (PFP) assay system for early diagnosis of infection.

MATERIALS AND METHODS

From November 2011 to June 2012 we studied 70 adult patients, including 35 cadaveric organ transplant recipients and 35 abdominal surgery patients. The 32 female and 38 male subjects had a mean age of 56.1 years (range, 19-70). Heparinized whole blood for PFP assay was tested at 48 hours after surgery together with blood cultures.

RESULTS

The mean presepsin level (PL) in the 50 positive patients was 3,957.45 pg/mL (range 255-20,000). For transplant patients, PL was 3,034.43 ± 2,880.791 pg/mL, with 30 positive results. Microbiologic findings confirmed the presence of bacterial infections within 69 ± 2.5 hours from enrollment despite that when the test was performed, 70% showed no sign or symptom of infection. In 15 abdominal surgery patients, the PFP test was negative with negative blood cultures. The positive PFP test in 20 other abdominal surgery patients showed PL of 2,363 ± 7,988.47 pg/mL in the absence of signs or symptoms of infection in 25% of them. The 20 positive patients showed positive blood cultures within 67 ± 1.8 hours from enrollment.

CONCLUSIONS

The PFP test had a (100%) sensitivity to show the presence of infection in a short time (15 min), confirmed by positive blood cultures.

Expanded criteria for hepatocellular carcinoma after liver transplantation: a 20-year evolution

BACKGROUND/AIM

Milan Criteria (MC) consent excellent survivals for hepatocellular carcinoma (HCC) after liver transplantation (LT). However, several new expanded criteria were proposed, with the intent to increase the HCC patients eligible for LT, maintaining acceptable recurrence rates. The aim of the present study was to analyze a cohort of HCC patients, evaluating the evolutions in its management during the last 20 years and comparing the disease-free survivals among three different periods.

METHODOLOGY

HCC patients (n = 122) were transplanted and stratified in three periods: 1st (1988-1998, liberal selection), 2nd (1999-2003, use of MC) and 3rd (2004-2008, use of UCSF criteria). The three periods were analyzed and their survivals were compared.

RESULTS

Statistical differences were reported at univariate analysis regarding to both dimensional (total tumor diameter) and biological (alpha feto-protein, microvascular invasion) HCC features. Comparing the 5-year survival rates, a progressive increase was observed in the three periods (62.6%, 87.9% and 88.4%, respectively), with a significant difference between 1st and the second periods (p = 0.008).

CONCLUSIONS

In our experience, use of UCSF criteria is safe, with a contemporaneous increased number of transplants and better survivals. Introduction of new selection criteria, also based on biological features, is on the way.

Preliminary study of early histomorphometric changes in hepatic steatosis

The first endpoint of this study was to find new markers that document the progression of hepatic steatosis through quantitative histomorphometric analysis in the absence of hemodynamic changes. The second endpoint was to start building a mathematical database to help to achieve a score in the future. For this study we enrolled 130 random patients, including 10 with normal histology despite suspected disease, 70 positive for steatosis, 20 affected by nonalcoholic steato hepatitis, and 30 with hepatitis virus C or B-related cirrhosis. One hundred thirty images were analyzed for a total of 1,320 sinusoids. Each image was processed with a custom program written with the use of the Vision toolbox of the Labview platform, following a semiautomated procedure. The mean sinusoidal areas (SAs) and percentage fractions of parenchymal area occupied by sinusoids (SA/PA) were subdivided into 3 groups. Finally, we analyzed the form of sinusoids, approximating them to an ellipse, to be able to define the relationship between the 2 axes with the aim of proposing a parameter, "local hydraulic resistance" (LHR), that was proportional to the resistance to blood flow within the bounds of the histologic specimen. Among the images, we observed a difference in the size of SAs among the 3 groups of patients, namely, normal, steatotic of different stages, and cirrhotic patients. In fact, there was evidence of a reducted SA when steatosis was <30%, with an average value of 0.0032 mm(2), patients with steatosis of 30%-50% showed an average SA of 0.0024 mm(2), and there was a further reduction among subjects with steatosis grades >50% (mean 0.0017 mm(2)). The LHR value showed that the morphometric parameter SA/PA could be quantitatively interpreted also as a functional impairment relative to the increased resistance opposing blood flow in pathologic conditions.

Hepatic resection for giant haemangioma in a patient with a contemporaneous adult polycystic liver disease

Hepatic resection for giant haemangioma in a patient with a contemporaneous adult polycystic liver disease. According to Gigot classification, and to the characteristics of haemangioma surgery in these patients can be considered safe. We report the case of a 55 year-old man affected by an adult polycystic liver disease (PCLD) and a contemporaneous symptomatic haemangioma of the III segment. At the preoperative imaging scans, APCLD was classified in a type II grading according to Gigot classification. The patient underwent surgery: a wedge resection of the III segment with the exportation of the haemangioma and a fenestration of a large cyst placed in the VIII segment were performed. Post-operative course was regular and the patient was discharged uneventfully in post-operative 9th day, with a total regress of the initial symptoms. APCLD and haemangioma are two benign conditions that do not require surgery except if they cause important symptoms, such as pain. The good clinical conditions of the patient, the moderate gravity of the APCLD and the particular exofitic localisation of the cavernous haemangioma gave us the possibility to make a safe surgery for the patient. To the best of our knowledge, this is the first case reported in literature in which a liver resection for haemangioma in patient with APCLD was performed. In conclusion, liver resection for haemangioma is not contraindicated, mainly if it is symptomatic, even in the contemporaneous presence of an APCLD.

Later diagnosed with a neuroendocrine tumor, case report of a 60-year-old

Neuroendocrine tumours of the colon and rectum are infrequent. Clinical manifestations are not different from standard adenocarcinoma. Symptoms are non specific; the most common are abdominal pain, nausea and vomiting, weight loss and gastrointestinal blood loss. We report an advanced case of transverse colon neuroendocrine carcinoma with multiple metastasis. When these tumours are diagnosed, they have distance disease related to a poor prognosis for the patient. Surgery is the treatment that can offer a greater chance of survival to these patients.

Predictive parameters after molecular absorbent recirculating system treatment integrated with model for end stage liver disease model in patients with acute-on-chronic liver failure

AIM

The aim of study was to highlight parameters that in association with Model for End-stage Liver Disease (MELD) provide predictive criteria for long-term survival after treatment with the Molecular Adsorbent Recirculating System (MARS). Two homogenous groups were studied: one treated with standard medical therapy (SMT) and the other, with MARS.

MATERIALS AND METHODS

Twenty acute-on-chronic liver failure patients on the waiting list for liver transplantation and affected by alcoholic cirrhosis with similar MELD scores (20-29) were evaluated for 7 days from inclusion and for 6-month survival. Ten patients (seven males and three females) were treated with MARS. Their mean age was 48.5 years (range = 35-61). The number of MARS applications was six for 6 consecutive days, and the length of the applications was 8 hours. Ten other patients (seven males and three females) were treated with SMT, including prophylaxis against bacterial infections and judicious use of diuretics. The precipitating factors were also treated appropriately. The mean age of the patients was 51 years (range = 37-64). All the variables that were significant upon univariate analysis were enrolled in a receiver operating characteristic analysis, with the intention to detect predictive parameters for patient death at 6 months. We considered a significant area under curve (AUC) value to be greater than 0.5.

RESULTS

Among 11 patients who died within 6 months there were in the MARS group and eight in the SMT group: the 3- and 6-month patient survival rates were 90% and 70% versus 30% and 20% in the two groups, respectively. Nine measures resulted in an AUC > 0.5: DeltaMELD; interleukin (IL)-8; IL-6; tumor necrosis factor- alpha, MELD score; creatinine, bilirubin international normalized ratio (INR) and cardiac index. DeltaMELD and postoperative IL-8 concentrations showed better results (AUC = 0.899), followed by postoperative creatinine (AUC = 0.879), postoperative cardiac index (AUC = 0.833), and postoperative INR (AUC = 0.818). Postoperative creatinine showed the best sensitivity (100%), while IL-8, the best specificity (88.9%).

CONCLUSION

A combination of biochemical and clinical variables probably represent the best way to predict the survival of patients, allowing physicians to select the best therapies for each patient.

Adacolumn treatment in kidney transplant patients with hepatitis C virus

INTRODUCTION

Patients who have undergone kidney transplantation and suffer from hepatitis C (HCV) cannot be treated with standard therapy (pegylated interferon combined with ribavirin) due to the risk of acute rejection. Furthermore, immunosuppressive therapy facilitates the progression of infection and chronic hepatopathies. Monocytes and macrophages are known to produce extrahepatic breeding sites that spread disease. Our aim was to reduce macrophages, granulocytes, monocytes, proinflammatory cells, and viremia levels using an extracorporeal device: Adacolumn Leukocyte Apheresis (Otzuka Electronics, Japan).

METHODS

The Adalcolumn filter is filled with 2-mm cellulose acetate beads immersed in sterile saline solution. These carriers absorb granulocytes and monocytes/macrophanges through their FCR receptors. Six patients affected by viral genotype 1b underwent five 1-hour treatments for 5 consecutive days.

RESULTS

Viremia was reduced in Patients 1, 2, 4, and 6 in association with decreased pro-inflammatory cytokine levels and a normal CD4/CD8 T-cell ratio, after 3 months. Subjects 1 and 3 showed inverted CD4(+)/CD8(+) T-cell ratios, which changed at 4-month follow-up in only patient 1. Subject 5 did not show any changes.

CONCLUSIONS

The treatment was safe without hemodynamic or infectious complications, suggesting that this method could be used in a greater number of patients to evaluate amelioration of increased viremia.

Pediatric acute liver failure with molecular adsorbent recirculating system treatment

BACKGROUND

The prognosis of pediatric acute liver failure (PALF) has been significantly improved by emergency orthotopic liver transplantation (OLT). Since 2004, the molecular adsorbent recirculating system (MARS) has been proposed as a bridging procedure. The aim of our study was to assess its efficacy in children with PALF.

PATIENTS AND METHODS

Since 1999 we performed treatment of 39 fulminant hepatic failure (FHF) cases with MARS. Since September 2004 we treated 6 pediatric patients with FHF who were of mean age 10.6 years (range, 3-15 years) including 4 females and 2 males. In 3 cases the cause of FHF was unknown; in 2 cases, it was induced by paracetamol overdose; and in 1, by acute hepatitis B virus. Inclusion criteria were: bilirubin >15 mg/dL; creatinine >or=2 mg/dL; encephalopathy grade >II; and International normalized ratio (INR) >2.5. Other estimated parameters were: AST and ALT serum levels, lactate, and urine volume. Neurological status was monitored using the Glasgow Coma Scale (GCS). Continuous MARS treatment was performed in all patients with a kit change every 8 hours. Intensive care unit (ICU) treatment was applied to optimize regeneration and to prevent cardiovascular complications.

RESULTS

We observed a significant improvement among levels of bilirubin (P< .009), ammonia (P< .005), creatinine (P< .02), GCS (P< .002), and predictive criteria and as Sequential Organ Failure Assessment (SOFA) and Pediatric End-Stage Liver Disease (PELD). Three children underwent OLT: 1 died after 5 days due to primary nonfunction and 2 children are alive after a median follow-up of 14 months. In 2 children the MARS treatment led to resolution of clinical status without liver transplantation. One child died before OLT due to sepsis and multiorgan failure.

CONCLUSIONS

We concluded that application of the MARS liver support device in combination with experienced ICU management contributed to improve the clinical status in children with PALF awaiting liver transplantation.

Activated recombinant factor VII in orthotopic liver transplantation

Orthotopic liver transplantation (OLT) is affected by important alterations of hemostasis. The aim of this study was to evaluate the efficacy of recombinant factor VII activated (rFVIIa) to reduce intraoperative bleeding during OLT.

METHODS

Twenty OLT patients were assigned in double-blind way to a rFVIIa group or a control group. Inclusion criteria were hemoglobin > 8 g/dL: INR > 1,5 and fibrinogen > 100 mg/dL. We administered a single bouls of rFVIIa (40 microg/kg) or placebo. We determined INR, partial thromboplastin time, fibrinogen, ATIII, and blood cell counts. Blood products were administered as follows: 4 units of fresh frozen plasma when INR > 1.5, and 1 unit of RBC for Hb < 10 g/dL. The study ended 6 hours after the bolus.

RESULTS

No thromboembolic events occurred. The INR was different between rFVIIa group and the controls at T0 (1.9 vs 1.6 P < .021) and during T1 (1.2 vs 1.6 P < .004). The total transfused red blood cells was 300 mL +/- 133 in rFVIIa group and 570 mL +/- 111 in control group (P < .017). The total fresh frozen plasma was 600 mL +/- 154 in rFVIIa group and 1400 mL +/- 187 in control group (P < .001). Total blood loss was greater in the control group than the rFVIIa group: 1140 mL +/- 112 vs 740 mL +/- 131 (P < .049).

DISCUSSION

The use of rFVIIa during OLT can reduce the risk of bleeding during surgery. The literature has described cases who did not benefit from the treatment. An adequate cut-off of INR, allowed us to treat only patients at greater bleeding risk.

Incidence of fungal infections in a solid organ recipients dedicated intensive care unit

Invasive fungal infections are a significant cause of morbidity and mortality for patients undergoing solid organ transplantation. Our aim was to evaluate the incidence of invasive fungal infections in solid organ recipients within a dedicated intensive care unit (ICU).

MATERIALS AND METHODS

From May 2002 to May 2005, 278 patients undergoing solid organ transplantation (105 liver, 142 kidney, 20 lung, 2 combined liver-kidney, 9 combined pancreas-kidney) were admitted to our posttransplant intensive care unit. We retrospectively analyzed data obtained from the ICU stay. Fungal infection was defined by positivity of normally sterile biological samples and by elevated positivity of normally non sterile biological samples. We did not consider superficial fungal infections and asymptomatic colonizations.

RESULTS

Forty-six patients (16.5%) developed a fungal infection; at least one mycotic agent was isolated from each patient. Candida albicans was the most common pathogen, isolated from 71 % of infected patients (33 of 46). Infected patients showed a mortality rate of 35%, while that for non infected recipients was 3.5%. Total length of ICU stay was the most significant risk factor among infected patients (30.26 days vs 5.04 days P < .0001). Mean time between transplantation and first positive samples was 6.17 days (SD 8.88).

CONCLUSION

Fungal infections in solid organ transplant patients are a major issue because of their associated morbidity and mortality. Candida albicans was the most common pathogen and total length of ICU stay was the most important risk factor.

Is Legalizing the Organ Market Possible?

INTRODUCTION

Two opposing views of the human body have existed since time began. Can it be traded or does its value go beyond a monetary one? Today it is illegal to sell organs but the success of organ transplantation has give rise to an enormous controversy. The continued increase in the need for organs has lead to a major use of live donors. Consequently, clandestine selling of organs is becoming more widespread for two main reasons: scientific progress and market demand. Our aim was to consider the protection of ethical principles through legislation.

MATERIALS AND METHODS

Based on the principle that it is morally unacceptable for people to die on a waiting list, we analysed various ways in which the National Health Service could give incentives to live donors, including reimbursement of health expenses, tax relief, pension or early retirement benefits, or education grants for the children. Possible incentives for cadaveric organ donation included reimbursal of health and funeral costs, or increase in widow/er's pension.

CONCLUSION

The tendency may be toward reimbursement of costs rather than actual payments. A legal, ethical organ market could save thousands of human lives, but it must be correctly regulated.

Molecular Adsorbents Recirculating System Treatment in Acute-on-Chronic Hepatitis Patients on the Transplant Waiting List Improves Model for End-Stage Liver Disease Scores

BACKGROUND

The aim of our study was to show an improvement in Model for End-Stage Liver Disease (MELD) score after treatment with Molecular adsorbents recirculating system (MARS) in acute-on-chronic hepatitis (AoCHF) patients. MELD was adopted to determine the prognosis of patients with liver chronic desease. We evaluated the possibility to improve the MELD score of patients awaiting liver transplantation using a liver support device, namely, MARS.

PATIENTS AND METHODS

From September 1999 to April 2006, we treated 80 patients whose diagnoses were hepatitis C, 41.25%; hepatitis B, 27.5%; alcholic, 17.5%; intoxication, 8.75%; primary biliary cirrhosis, 5%. The overall mean age was 45 years (23 to 62), the cohort included 56 men and 24 women. Inclusion criteria were bilirubin >15 mg/dL; MELD >20; encephalopathy >II; and International Normalized Ratio, >2.1. Other parameters evaluated included ammonia, creatinine, lactate, glutamic oxalic transminase, and guanosine 5'-triphosphate. All patients were treated with a mean of 6-hour cycles of MARS (range, 5 to 8 hours) for a minimum of three treatments and a maximum of 20 treatments over 3 months. Clinical conditions were evaluated by improved hemodynamic parameters, kidney function, liver function, coagulation, neurologic status using the SOFA score, Glasgow Coma Scale (GCS), and Acute Physiology and Chronic Health Evaluation II Criteria.

RESULTS

The MELD score for all categories of living patients showed significant improvements at the end of treatment and at 3-months follow-up, but the small number of patients was a limitation to determine prediction of mortality.

CONCLUSION

Our study shows that MARS treatment improved multiple organ functions-liver, renal, neurologic, and hemodynamic. The improved MELD score gave patients on the transplant waiting list longer survival, allowing them a greater opportunity for liver transplantation.

Modifications of Intracranial Pressure After Molecular Adsorbent Recirculating System Treatment in Patients With Acute Liver Failure: Case Reports

Cerebral dysfunction may be fatal in patients with acute liver failure (ALF); intracranial pressure (ICP) monitoring may be mandatory to direct measures to prevent further cerebral edema. Recently the introduction of dialysis with the molecular adsorbent recirculating system (MARS) has improved the outcomes among patients with ALF. The aim of this study was to evaluate ICP changes after MARS treatment among patients with ALF.

METHODS

Three patients -- 14, 18 and 16 years old -- were admitted to the ICU for acute liver failure induced by HBV in two cases and by acetaminophen in the other one. Because of Glasgow Coma Score (GCS) <8, they were intubated and ventilated to protect the airway and maintain moderate hypocapnia. Invasive monitoring of intracranial pressure MARS treatments were performed in all patients.

RESULTS

The patients received MARS treatments every day after their admission to liver transplantation. After MARS therapy the ICP decreased on average from 21 to 7 mm Hg. Significant hemodynamic modifications were not observed and their neurological conditions improved.

CONCLUSION

MARS treatment improved the clinical pictures of these patients increasing the available time to obtain an urgent liver graft.

Intractable pruritus in patients with hepatitis C virus

Intractable pruritus is one of the most common symptoms of chronic liver disease, especially experienced by patients with prolonged cholestasis. It can become the most distressing symptom in patients affected by chronic liver disease, causing a reduction in quality of life, interfering with daily activities, and leading to sleep deprivation or contributing to psychological disturbances up to suicide ideation. Therefore, pruritus that does not respond to medical therapy is an indication for liver transplantation. We treated nine patients with hepatitis C virus affected by intractable pruritus with the molecular adsorbent recirculating system. In each patient, liver function, renal function, and hemodynamic variables were evaluated before and after the treatment. Before undergoing the treatment each patient underwent abdominal ultrasound or computed tomography scan to exclude organic causes for pruritus. We observed a decrease in total bilirubin, creatinine, and bile acids together with a significant improvement in Visual Analog Scale for staging of pruritus in all the patients. Due to the small number of patients the results were not significant.