Renal function at two years in liver transplant patients receiving everolimus: results of a randomized, multicenter study

In a 24-month prospective, randomized, multicenter, open-label study, de novo liver transplant patients were randomized at 30 days to everolimus (EVR) + Reduced tacrolimus (TAC; n = 245), TAC Control (n = 243) or TAC Elimination (n = 231). Randomization to TAC Elimination was stopped prematurely due to a significantly higher rate of treated biopsy-proven acute rejection (tBPAR). The incidence of the primary efficacy endpoint, composite efficacy failure rate of tBPAR, graft loss or death postrandomization was similar with EVR + Reduced TAC (10.3%) or TAC Control (12.5%) at month 24 (difference -2.2%, 97.5% confidence interval [CI] -8.8%, 4.4%). BPAR was less frequent in the EVR + Reduced TAC group (6.1% vs. 13.3% in TAC Control, p = 0.010). Adjusted change in estimated glomerular filtration rate (eGFR) from randomization to month 24 was superior with EVR + Reduced TAC versus TAC Control: difference 6.7 mL/min/1.73 m(2) (97.5% CI 1.9, 11.4 mL/min/1.73 m(2), p = 0.002). Among patients who remained on treatment, mean (SD) eGFR at month 24 was 77.6 (26.5) mL/min/1.73 m(2) in the EVR + Reduced TAC group and 66.1 (19.3) mL/min/1.73 m(2) in the TAC Control group (p < 0.001). Study medication was discontinued due to adverse events in 28.6% of EVR + Reduced TAC and 18.2% of TAC Control patients. Early introduction of everolimus with reduced-exposure tacrolimus at 1 month after liver transplantation provided a significant and clinically relevant benefit for renal function at 2 years posttransplant.

Everolimus with reduced tacrolimus improves renal function in de novo liver transplant recipients: a randomized controlled trial

In a prospective, multicenter, open-label study, de novo liver transplant patients were randomized at day 30±5 to (i) everolimus initiation with tacrolimus elimination (TAC Elimination) (ii) everolimus initiation with reduced-exposure tacrolimus (EVR+Reduced TAC) or (iii) standard-exposure tacrolimus (TAC Control). Randomization to TAC Elimination was terminated prematurely due to a higher rate of treated biopsy-proven acute rejection (tBPAR). EVR+Reduced TAC was noninferior to TAC Control for the primary efficacy endpoint (tBPAR, graft loss or death at 12 months posttransplantation): 6.7% versus 9.7% (-3.0%; 95% CI -8.7, 2.6%; p<0.001 for noninferiority [12% margin]). tBPAR occurred in 2.9% of EVR+Reduced TAC patients versus 7.0% of TAC Controls (p = 0.035). The change in adjusted estimated GFR from randomization to month 12 was superior with EVR+Reduced TAC versus TAC Control (difference 8.50 mL/min/1.73 m(2) , 97.5% CI 3.74, 13.27 mL/min/1.73 m(2) , p<0.001 for superiority). Drug discontinuation for adverse events occurred in 25.7% of EVR+Reduced TAC and 14.1% of TAC Controls (relative risk 1.82, 95% CI 1.25, 2.66). Relative risk of serious infections between the EVR+Reduced TAC group versus TAC Controls was 1.76 (95% CI 1.03, 3.00). Everolimus facilitates early tacrolimus minimization with comparable efficacy and superior renal function, compared to a standard tacrolimus exposure regimen 12 months after liver transplantation.

The ischemic preconditioning paradox in deceased donor liver transplantation-evidence from a prospective randomized single blind clinical trial

While animal studies show that ischemic preconditioning (IPC) is beneficial in liver transplantation (LT), evidence from few smaller clinical trials is conflicting. From October 2003 to July 2006, 101 deceased donors (DD) were randomized to 10 min IPC (n = 50) or No IPC (n = 51). Primary objective was efficacy of IPC to decrease reperfusion (RP) injury. Both groups had similar donor risk index (DRI) (1.54 vs. 1.57). Aminotransferases on days 1 and 2 were significantly greater (p < 0.05) in IPC recipients. In multivariate analyses, IPC had an independent effect only on day 2 aspartate transferase. Prothrombin time, bilirubin and histological injury were similar in both groups. IPC had no significant effect on plasma TNF-alpha, IL-6 and IL-10 in the donor and TNF-alpha and IL-6 in the recipient. In contrast, IPC recipients had a significant rise in systemic IL-10 levels after RP (p < 0.05) and had fewer moderate/severe rejections within 30 days (p = 0.09). Hospital stay was similar in both groups. One-year patient and graft survival in IPC versus No IPC were 88% versus 78% (p = 0.1) and 86 versus 76% (p = 0.25), respectively. IPC increases RP injury after DDLT, an 'IPC paradox'. Other potential benefits of IPC are limited. IPC may be more effective in combination with other preconditioning regimens.

A novel autoantibody to a 155-kd protein is associated with dermatomyositis

OBJECTIVE

In polymyositis and dermatomyositis (DM), identified autoantibodies occur in <50% of adult patients and in a smaller proportion of children. This study was undertaken as part of a larger effort to define novel autoantibodies that assist in the clinical evaluation of myositis.

METHODS

Sera from children and adults satisfying criteria for idiopathic inflammatory myopathies and from patients with other connective tissue diseases (CTDs), patients with noninflammatory myopathies, and healthy individuals were tested for autoantibodies by immunoprecipitation (IP). A previously unrecognized autoantibody that immunoprecipitated a 155-kd protein along with a weaker 140-kd protein was seen. When the presence of this anti-p155 autoantibody in test sera was suggested based on IP results, it was confirmed by immunoblotting of immunoprecipitates.

RESULTS

Sera from 51 of 244 myositis patients (21%), including 30 with juvenile DM (29%), 5 with juvenile CTD-associated myositis (33%), 8 with adult DM (21%), 6 with cancer-associated DM (75%), and 2 with adult CTD-associated myositis (15%), were found to have anti-p155 autoantibody. One of 49 patients with lupus, and none of 89 others without myositis, had anti-p155. Caucasian patients with anti-p155 had a unique HLA risk factor, DQA1*0301 (odds ratio 5.4, corrected P = 0.004). In adults with anti-p155, of several clinical features assessed only the frequency of V-sign rash was increased, but patients with this antibody were clinically distinct from those with autoantibodies to aminoacyl-transfer RNA synthetases.

CONCLUSION

A newly recognized autoantibody, anti-p155, is associated with DM and cancer-associated DM, and is one of the most common autoantibodies in this condition, occurring as frequently in children as in adults. The clinical features and immunogenetics associated with anti-p155 differ from those associated with antisynthetases.

Immunogenetic differences between Caucasian women with and those without silicone implants in whom myositis develops

OBJECTIVE

To determine whether patients in whom myositis develops after they receive silicone breast implants have distinct clinical, serologic, and/or immunogenetic features compared with patients with myositis who do not have silicone implants.

METHODS

A preliminary case series study was followed by a larger, independent, matched case-control study to evaluate women in whom myositis developed after they received silicone implants (MASI patients) compared with healthy women with silicone implants and women with myositis but without silicone implants (idiopathic inflammatory myopathy; IIM patients).

RESULTS

In a preliminary study, 11 MASI patients differed from 76 IIM patients in having an increased frequency of HLA-DQA1*0102 (odds ratio [OR] 9.8, 95% confidence interval [95% CI] 1.77-96.79) and decreased frequencies of the myositis-associated risk factor DRB1*0301 (OR 0.1 [95% CI 0.002-0.63]) and its linked allele DQA1*0501 (OR 0.2 [95% CI 0.02-0.87]). A subsequent independent, matched case-control study revealed that although clinical features and autoantibodies did not differ significantly between the MASI and IIM groups, MASI patients again had decreased frequencies of DRB1*0301 (OR 0.2 [95% CI 0.07-0.72]) and DQA1*0501 (OR 0.2 [95% CI 0.08-0.84]) compared with IIM patients. Additional comparisons between MASI patients from both studies combined (n = 37) and a larger population of IIM patients (n = 453) suggested that HLA-DQA1*0102 may be uniquely associated with MASI (OR 2.6 [95% CI 1.25-5.46]).

CONCLUSION

Women in whom inflammatory myopathy develops after they receive silicone implants constitute an immunogenetically distinct group of patients with myositis. These and other data suggest that autoimmune diseases as now defined may consist of multiple distinct entities, each of which is characterized by different genes and environmental exposures.

Oxidative stress in fatty livers of obese Zucker rats: rapid amelioration and improved tolerance to warm ischemia with tocopherol

Fatty livers in humans and rats are less tolerant of ischemia, endotoxin, and alcohol. We hypothesized that fatty livers of obese (Ob) Zucker rats are oxidatively stressed and oxidative stress could be relieved by antioxidant treatment, leading to improved tolerance to ischemia. Total glutathione (GSH), tocopherol (TOC), ascorbic acid (AA), catalase (CAT), superoxide dismutase (SOD), and selenium-glutathione peroxidase (Se-GPx) were measured in the livers of Ob and lean (Ln) Zucker rats before and after treatment with high-dose TOC and ascorbate. Also, survival in treated Ob rats following a lethal 90 minutes of partial in vivo warm ischemia was examined. Fatty livers of Ob rats contained significantly less GSH, TOC, and CAT, in comparison with livers of Ln rats. Immunoblotting showed significantly decreased CAT protein without changes in mRNA in fatty livers. There were no significant differences in AA, SOD, and Se-GPx between the 2 groups. Pretreatment with TOC and ascorbate over 48 hours completely corrected the decreases in GSH, TOC, and CAT. Most importantly, TOC with or without ascorbate pretreatment significantly improved survival in Ob rats following ischemia in a dose-dependent manner. In conclusion, TOC administration corrected the oxidative stress in fatty livers of Ob Zucker rats and improved survival following lethal ischemia. Additional studies are needed to determine the efficacy of TOC-a relatively inexpensive agent-in treating patients with fatty livers in a variety of clinical conditions, possibly including liver transplantation.

Successful nonfreezing, subzero preservation of rat liver with 2,3-butanediol and type I antifreeze protein

BACKGROUND

Organ cryopreservation is hindered by ice inflicted damage. Nonfreezing preservation of livers at subzero temperatures might offer advantages over current preservation.

METHODS

Sprague-Dawley rats were divided into three groups. UW livers (n = 6) were stored in University of Wisconsin (UW) solution at +4 degrees C. UWB livers (n = 6) were perfused ex vivo with UW + 10% 2,3-butanediol at < or =7 degrees C and stored at -4 degrees C. AFP livers (n = 4) were preserved identical to UWB livers, except for addition of 1 mg/ml of type I antifreeze protein. After 24 h livers were perfused with Krebs-Henseleit buffer (37 degrees C) for 60 min. Bile production, O(2) consumption (O(2)C), taurocholate extraction, and lactate dehydrogenase (LDH) release during perfusion and liver adenine nucleotide content and energy charge at the end of perfusion were measured. Cell membrane integrity was determined by trypan blue infusion.

RESULTS

Ice formation was prevented in all livers stored at -4 degrees C. Bile production, O(2)C, and taurocholate extraction were similar among three groups. Livers stored at -4 degrees C contained significantly more adenine nucleotides than livers stored at +4 degrees C but the energy charge was similar. LDH release was significantly greater (P < 0.05) in the AFP group vs UWB and UW (63 vs 28 and 21 mU/min/g liver, respectively). Hepatocyte and sinusoidal cell trypan blue uptake was similar in all three groups.

CONCLUSIONS

Butanediol with or without AFP was effective in preventing ice formation up to 24 h in rat livers stored at -4 degrees C. Although as effective as current +4 degrees C protocols, subzero preservation for longer periods needs to be achieved prior to clinical application.

C282Y mutation and hepatic iron status in hepatitis C and cryptogenic cirrhosis

BACKGROUND

Increased iron deposition in liver is seen in both primary and secondary hemochromatosis. However, it is not uncommon to see significant iron deposition in a liver biopsy, explant, or autopsy specimen without any significant clinical risk factor. Because of the discovery of the candidate gene (HFE) for hereditary hemochromatosis, we may now be able to screen high-risk patient populations for the abnormal mutation (C282Y).

MATERIALS AND METHODS

In this study we analyzed the livers of 50 transplant patients with a diagnosis of either hepatitis C cirrhosis or cryptogenic cirrhosis for the prevalence of the more common C282Y mutation of the HFE gene and correlated the findings to hepatic iron concentration.

RESULTS

Of the 26 cases of hepatitis C cirrhosis, 3 were found to be heterozygous for the C282Y mutation. Of the 22 cases of cryptogenic cirrhosis, 1 was found to be heterozygous for the C282Y mutation. Stainable iron was increased in hepatitis C cirrhosis (76.9%) as compared to cryptogenic cirrhosis (50%) (P =. 05). Of the 3 heterozygotes with hepatitis C cirrhosis, 2 showed hepatic iron concentrations of 3+ and 4+, and 1 showed 1+.

CONCLUSIONS

We conclude that patients with hepatitis C have an increased tendency to accumulate iron in the liver, and mutations in the HFE gene play a minor role in hepatic accumulation of iron in these patients.

Kaposi's sarcoma in a liver transplant series

At our center one hundred eighteen patients have received liver transplants between July 1, 1991 and December 10, 1997. We describe the only one of them to our knowledge who developed Kaposi's sarcoma. It was disseminated, involving the gastrointestinal tract, lungs, multiple lymph nodes and peripancreatic soft tissues. She had no cutaneous Kaposi's sarcoma. Her massive gut involvement was not apparent clinically, even by colonoscopic examination with multiple biopsy specimens. She was diagnosed at postmortem examination.

Effect of increasing gastric pH with famotidine on the absorption and oral pharmacokinetics of the inotropic agent vesnarinone

The effect of famotidine, an H2 receptor blocker, on the oral absorption and pharmacokinetics of the novel agent vesnarinone was investigated after oral administration of 60 mg vesnarinone with and without pretreatment with intravenous famotidine. The single-blind, randomized, two-way crossover study was conducted in 12 volunteers, with a washout period of 7 days between the two treatments. A pH monitor was used to ensure that gastric pH of the subjects was < or = 3 in the absence of and > or = 5 in the presence of famotidine. A significant decrease in maximum concentration (Cmax) and increase in time to Cmax (tmax) was observed for vesnarinone during treatment with famotidine, whereas area under the concentration-time curve (AUC) was similar for both treatments. The physicochemical properties of the drug support the above observations. Therefore, therapies that increase gastric pH will affect the rate but not the extent of absorption of vesnarinone or the safety or efficacy profile of vesnarinone.

Critical preservation injury in rat fatty liver is to hepatocytes, not sinusoidal lining cells

BACKGROUND

Fatty livers are more prone to primary nonfunction after transplantation. We hypothesized that sinusoidal lining cells (SLCs) in fatty livers of obese Zucker rats are more susceptible to ischemia/reperfusion injury than in normal livers.

METHODS

Cold University of Wisconsin solution-preserved (30 min or 24 hr) livers from obese and lean Zucker rats were perfused ex vivo for 90 min with oxygenated warm acellular buffer containing hyaluronate. Bile output, alanine transferase, and hyaluronate clearance were measured during reperfusion. Trypan blue was infused at completion of reperfusion to assess cell membrane integrity. Another group of 24-hr preserved livers were reperfused with cold hypoxic buffer to differentiate the effects of preservation from reoxygenation.

RESULTS

After 30 min of preservation, fatty livers had significantly decreased flow (1.9 vs. 2.6 ml/g/min), increased resistance, decreased hyaluronate clearance (17 vs. 35 microg/g liver) and lower bile output (13 vs. 42 microl/g) in comparison with normal livers. Hepatocyte and SLC trypan blue uptake were minimal and similar in both groups. After 24 hr of preservation, flow (2.0 vs. 2.0), resistance, hyaluronate clearance, and bile output were similar in both fatty and normal livers. The SLC trypan blue uptake was increased but similar in both groups (22 vs. 20%). In contrast, a significantly greater number of hepatocytes were trypan blue-stained in fatty livers (32 vs. 0.6%), accompanied by a marked increase in lactate dehydrogenase and alanine transferase release. Hypoxic reperfusion caused a significant decrease in hepatocyte and SLC trypan blue uptake.

CONCLUSIONS

Fatty livers demonstrate impaired hepatocyte and SLC function, after even a very brief preservation. With increasing preservation, hepatocytes appear to be more susceptible to injury than SLCs. Reoxygenation appears to be important in triggering this event.

Recurrent familial prolonged intrahepatic cholestasis of pregnancy associated with chronic liver disease

Four Puerto Rican sisters had recurrent prolonged cholestasis of pregnancy without preexisting or intercurrent hepatic disorders. Available information was reviewed on the course, mechanism, and sequelae of prolonged recurrent cholestasis after 14 pregnancies in the 4 sisters. Etiologic, clinical, laboratory, radiological, and morphological studies of the liver and biliary tract were assessed. Each sister had contraceptive pill-induced pruritus. Prolonged recurrent cholestasis in the eldest sister was followed by cirrhosis and death. The second and third sisters had biopsy evidence of portal triaditis and fibrosis after five and three pregnancies, respectively. Intrahepatic cholestatic cirrhosis was present after three pregnancies in the youngest sister, necessitating an orthotopic liver transplantation; a posttransplantation pregnancy was also associated with prolonged cholestasis. Recurrent prolonged intrahepatic cholestasis of pregnancy was followed by periportal fibrosis or cirrhosis in 4 sisters. This finding suggests that patients with prolonged cholestasis after pregnancy should be followed up for evidence of ongoing liver disease, should be counseled on the potential of recurrence and disease progression in future pregnancies, and should alert family members at risk of possible occurrence of the syndrome.

Blood transfusions in liver recipients: a conundrum or a clear benefit in the cyclosporine/tacrolimus era?

Blood transfusions are common in patients with end-stage liver disease (ESLD), and their effects on sensitization, rejection, and liver graft survival are not well known. These effects were examined in 121 recipients of primary liver grafts, surviving > or = 30 days. Ninety-six (79%) patients received transfusions before transplantation. Transfusion recipients had significantly fewer severe or recurrent rejection episodes (18%), compared with patients who did not receive transfusions (42%, P=0.006), if the first transfusion was > or = 90 days before the transplant. Patients with alcoholic ESLD (n=49) had significantly fewer severe rejection episodes when compared with the nonalcoholic (n=72) patients (12% vs. 35%, P=0.004). The transfusion benefit was, however, more apparent and significant in the nonalcoholic (26% vs. 56% in nontransfused, P=0.02) than among the alcoholic recipients (6% vs. 25%, P=0.1). This finding is, most likely, due to a combination of a higher rate of severe rejection and the statistical power of the larger number of recipients in the nonalcoholic group. This finding is further corroborated by a multivariate analysis in which blood transfusions retained their benefit (P<0.05) independent of recipient's age and diagnosis. Graft and patient survival were not significantly different in the transfused versus nontransfused groups. Transfusion recipients had a higher panel antibody (11.4+/-23.4 vs. 2.7+/-8.1, P<0.02) but no increased risk of a positive crossmatch. In liver recipients, blood transfusions diminish the risk of rejection independent of recipient's age and the cause of ESLD.

Deceptive prothrombin and activated partial thromboplastin times in alcoholic cirrhosis

It is believed that perioperative hemorrhage, in the hepatoportal area, results from a coagulopathy. This study determined if this could be quantitated by a modified recalcification time (MRT) test developed in our laboratory. Unlike prothrombin (PT) and activated partial thromboplastin times (APTT), the MRT is performed with whole blood to ensure the role of blood cells and chemicals (particularly tissue factor, a potent procoagulant) in the coagulation process. Candidates for liver transplantation (n = 11) were studied. Samples (5 mL) of citrated venous blood were obtained from the patients. Aliquots (1 mL) from these samples were divided into groups of vials labeled C, S, and E. Groups C and S received 20 microL saline and group E, 20 microL of saline containing 10 micrograms of Escherichia coli endotoxin (055: B5W). Vial C was incubated for 10 minutes and vials S and E for 120 minutes, all at 37 degrees C. Then, the MRT was determined on 300 microL of blood from each vial after adding 40 microL of 0.1M calcium chloride. Mean MRT values (minutes +/- standard deviation) for C (MRTC), for S (MRTS), and for E (MRTE) were compared with like values from healthy controls (n = 29). Despite prolonged PT and APTT values, MRT values were shortened in patients with cirrhosis. This hypercoagulability detected by the MRT exonerates a hemorrhagic coagulopathy and possibly implicates widened and thinned gaps in the walls of the portal venous tributaries as the cause of perioperative hemorrhage.

Wedge-shaped intrahepatic cholangiocarcinoma: MRI-pathologic correlation

On magnetic resonance imaging (MRI) studies, wedge-shaped areas of signal abnormality noted in association with liver lesions have been attributed to secondary phenomena and are said to be substantially larger than the actual tumor. We describe the MRI and pathological appearance of a wedge-shaped cholangiocarcinoma. In cases where therapy might be affected, biopsy of wedge-shaped MRI abnormalities associated with hepatic malignancy should be considered for accurate tumor staging.

31P nuclear magnetic resonance study of phospholipids in ischemia/reperfusion injury in a rat fatty liver model

Obese Zucker rats are susceptible to increased hepatic ischemia/reperfusion (I/RP) injury. Increased lipid peroxidation occurs in this model with warm ischemia. We hypothesized that a severe depletion of phospholipids (PL) occurs with warm I/RP in fatty livers. Obese (Ob) and lean (Ln) Zucker rats were subjected to 90 min of in vivo partial hepatic warm I followed by RP. Total lipids extracted from one gm of liver (median lobe) taken at the end of 1, 2 and 6 hr of RP and sham (Sh) surgery (n=5 Ln & Ob) were analyzed by 202.3 MHz 31P NMR, which provided good resolution of individual PL. Obese (Sh) rats contained 22% more PL than Ln (P= < 0.01). Ischemia caused similar decreases in PL in both Ob (to 67% Sh) and Ln rats (62%). Following 2 hr RP, PL in Ob rats decreased further (46% Sh) and recovered only marginally at 6 hr (53%), in marked contrast to the rapid recovery in Ln to preischemic levels (110% Sh at both 2 and 6 hr; P=<0.001). Mole percents of individual PL did not change significantly except for lysophosphatidylcholine, which increased from 0.43 to 1.3% (Sh vs. 6 hr RP) in the Ob, but decreased from 0.98 to 0.52% in Ln animals (P = <0.001). Fatty livers thus are more vulnerable to phospholipid depletion in response to warm ischemia/reperfusion than normal livers.

Peri-operative chylous ascites

Chylous ascites occurs when lymphatics are disrupted due to primary lymphatic disease, infection, malignancy, or chronic liver disease. It may also occur following inadvertent interruption of abdominal lymphatics during surgery involving retroperitoneal dissection. It is suggested by some that during liver transplantation, severed hepatic lymphatics should be ligated or stented to avoid post-operative pleural and abdominal accumulation of chylous fluid. The occurrence of chylous ascites and the need to ligate lymphatics after orthotopic transplantation was assessed in 180 consecutive patients subjected to this procedure. Pre-operative chylous ascites present in one patient resolved following transplantation. Three patients who required retroperitoneal dissection to complete the biliary anastomosis via choledochojejunostomy or perform a hepatic artery graft developed post-operative chylous ascites which rapidly resolved without complications. These findings indicate special attention to transacted hepatic lymphatics is not required during orthotopic liver transplantation. Chylous ascites rarely occurs after liver transplantation and its transitory development is due to retroperitoneal dissection.

Studies of hepatic warm ischemia in the obese Zucker rat

The effects of warm ischemia were investigated in obese Zucker rats with severe hepatic steatosis in order to develop a nontransplant fatty liver ischemia model. Obese (Ob) and lean (Ln) Zucker rats were subjected to in vivo partial hepatic warm ischemia of 45 or 90 min. Injury was assessed by serum alanine aminotransferase, animal survival, and liver histology. Liver lipids were quantified in control animals. After 90-min ischemia and 2-hr reperfusion, liver malondialdehyde was measured and neutrophils in 12 microscopic fields were counted after esterase staining. After 45 and 90 min of ischemia, Ob animals had significantly higher alanine aminotransferase at 1-hr and 24-hr reperfusion, compared with Ln animals (P < 0.01). After 90 min of ischemia, none of the Ln and 8/9 Ob animals died within 48 hr (P < 0.01). Histologically, Ob animals had more hepatocyte necrosis than did Ln animals. Hepatic neutral and phospholipid content (mg/g) in Ob versus Ln animals was 45.2 +/- 2.6 versus 8.2 +/- 0.7 (P < 0.01) and 36.2 +/- 1.9 versus 27 +/- 2.2 (P < 0.05), respectively. After reperfusion, liver malondialdehyde content increased significantly in Ob animals (8.5 +/- 0.4 vs. 12.3 +/- 0.8 pM/mg protein; P < 0.05), but not in Ln animals. Neutrophils, scant in control livers, increased significantly (P < 0.01) after ischemia/RP, but it increased to a similar degree in Ob and Ln animals. Obese Zucker rats with hepatic steatosis are more susceptible to warm ischemia/reperfusion injury than lean animals, and lipid peroxidation may be an important contributory mechanism. Further studies in this model might help to investigate the human problem.

New Jersey research: frontiers of hepatology

Diagnostic criteria and prognosis have been revised for patients with liver and biliary tract diseases. This information provides an improved knowledge base for new preventive measures, therapeutic modalities, and outcome research at UMDNJ-New Jersey Medical School Liver Center.

The first 50 liver transplants in New Jersey

New Jersey's first liver transplant was performed on February 14, 1989, at UMDNJ-New Jersey Medical School. By May 1992, 50 patients, ranging in age from 16 to 65 years, had been transplanted. Liver transplantation is an accepted method of treatment for end-stage liver disease.

Liver transplantation for hepatoblastoma. The American experience

The current role of liver transplantation in treating malignant tumors of the liver is uncertain, except for select histologic types. Pooled data on the results of liver transplantation in 12 children with hepatoblastoma is presented here. One half of the children are alive 24 to 70 (44 +/- 19) months after transplantation with no evidence of recurrence. Three patients (25%) died of tumor recurrence and three (25%) died of other causes. Unifocal and intrahepatic tumors were associated with better prognosis compared to the multifocal tumors and tumors with extrahepatic spread (p = 0.04 and 0.13). Microscopically vascular invasion and the predominance of embryonal and/or anaplastic epithelium were associated with a poor prognosis compared to the tumors with no vascular invasion and with predominantly fetal epithelium (p = 0.08 and 0.1). It is concluded that continued efforts to treat unresectable hepatoblastomas by liver transplantation is justified and the role of adjuvant chemotherapy in improving the results needs to be better defined.

Mucocele of the cystic duct remnant in eight liver transplant recipients: findings at cholangiography, CT, and US

The case histories and radiologic studies of eight liver transplant recipients who developed a mucocele of the allograft cystic duct remnant were retrospectively evaluated. All patients had clinical and/or laboratory evidence of biliary obstruction or cholangitis from 2 weeks to 3.3 years following transplantation. Cholangiographic, ultrasound (US), and computed tomography (CT) images were available for review in eight, five, and four patients, respectively. Cholangiograms demonstrated an extrinsic mass compressing the common hepatic duct in seven of eight patients. US and CT showed fairly well- to well-defined round fluid collections adjacent to the common hepatic duct in three and two patients, respectively. The findings of this study suggest that the detection at cholangiography of an extrinsic mass compressing the common hepatic duct appears to be specific for a mucocele of the allograft cystic duct remnant. CT and US images may offer confirmatory evidence.

Nonobstructing colonic dilatation and colon perforations following renal transplantation

Nonobstructing colonic dilatation has not been commonly reported following renal transplantation, and colon perforations carry a high morbidity and mortality in this population. During a 7-year period, nonobstructing colonic dilatation developed in 13 adults 1 to 13 days after renal transplantation. Twelve (92%) of the 13 had poorly functioning allografts. Five (83%) of the 6 with and 2 (29%) of the 7 without colonoscopy had resolution of nonobstructing colonic dilatation. Of the seven right-sided colon perforations during this period, six were associated with nonobstructing colonic dilatation. An additional 4 patients had diverticular perforations in the left colon. Of a total of 11 patients with colon perforation, 7 had surgery within 24 hours of the perforation and 6 (86%) of these survived. Only 1 (25%) of the 4 having surgery more than 24 hours later survived. Six of the survivors retained functioning allografts. Nonobstructing colonic dilatation seems to be a potential complication of poor graft function after renal transplantation, and colonoscopy is effective in its treatment. In patients with colon perforations, early surgery and reduced immunosuppression are essential in decreasing mortality.

Splenic infarction complicating pediatric liver transplantation: incidence and CT appearance

In children it is often necessary to ligate the splenic artery and the main collateral supply to the spleen during liver transplantation. The complication of splenic infarction has been observed on postoperative CT in such patients. The purpose of our study was to determine the incidence and CT appearance of splenic infarction and to correlate its occurrence with a vascular cause related to the operative procedure. During a 2 year period, 26 of 94 (28%) children receiving liver transplants developed splenic infarction as shown by CT. Infarction generally occurred within 2 weeks of transplantation. Computed tomography demonstrated variable portions of splenic involvement with hypodense lesions. Twenty-two of 39 (56%) patients whose splenic artery was ligated developed splenic infarctions. Only 4 of 55 (7%) patients whose splenic artery was left intact had splenic infarctions on postoperative CT. We conclude that there is an increased incidence of splenic infarction in pediatric liver transplant recipients. The incidence of infarction is related to ligation of the splenic artery and collateral pathways.

Hepatic bilomas due to hepatic artery thrombosis in liver transplant recipients: percutaneous drainage and clinical outcome

During the past 4 years, the authors performed catheter drainage in 15 patients (five adults and 10 children) with 16 hepatic allografts who had intrahepatic bilomas after occlusion of the hepatic artery. Ten of the 16 (62%) allografts (in four adults and six children) were replaced within 4 months of drainage: Nine were replaced because of biliary sepsis or abscess, and one was replaced because of the absence of biliary-enteric communication. Most of these patients had cholangiographic evidence of extensive bile duct necrosis. In two patients, retransplantation was avoided for longer than 2 years. One of these needed a new liver because of multiple central biliary strictures. Four patients have now lived for 30-44 months since initiation of drainage without needing new livers. Despite drainage, the outcome of most of these allografts has been poor. However, in some liver transplant recipients who have had hepatic artery thrombosis, biloma drainage can prolong allograft survival and prevent retransplantation.

Childbearing after liver transplantation

Seventeen female patients who underwent orthotopic liver transplantation between June 1973 and June 1987 became pregnant 5 months to 11 years after transplantation. Immunosuppression was maintained with combinations of prednisone, cyclosporine, and azathioprine prior to and during pregnancy. One patient discontinued immunosuppression after knowledge of pregnancy, taking only azathioprine sporadically. Mean age at time of delivery was 26 years. Twelve patients had no alteration in liver function studies; 7 patients demonstrated mild or moderate enzyme elevations prior to delivery, with one case of rejection confirmed by percutaneous liver biopsy. Major problems related to pregnancy were hypertension, anemia, and hyperbilirubinemia. Twenty live births occurred (2 patients had 2 separate pregnancies, one patient had a set of twins); 13 were by cesarean section, 7 by vaginal delivery. Eleven of the 13 cesarean births were premature by gestational age. All vaginal births were term. Toxemia of pregnancy and early rupture of membranes were the principal indications for cesarean section. There were no congenital abnormalities or birth defects and all the children are surviving well. Fifteen of 16 children older than one year all have normal physical and mental development, with one child manifesting immature speech development. Four children are under one year, all with normal milestones thus far. Sixteen of the 17 mothers are alive from 2-18 years after transplantation; the only death was from a lymphoma, almost 4 years after transplantation and 2 1/2 years after delivery. This experience suggests that women undergoing liver transplantation can safely bear children despite an increased risk of premature cesarean births. The effect of chronic immunosuppression of female pediatric patients on their reproductive potential later in adulthood remains to be fully evaluated but the results so far are favorable.

Liver transplantation for tyrosinemia. A review of 10 cases from the University of Pittsburgh

Results of liver transplantation in 10 patients with tyrosinemia are reviewed. The indications for transplantation were: hepatoma in three, acute liver failure in two, and progressive chronic liver disease in five. One patient died during surgery. Of the remaining nine who survived the operation, one died at six months as a result of bronchial aspiration and aspiration pneumonia, and a second transplanted for hepatoma died five months later with metastases. Seven patients are alive 6 months to 6 1/2 years following transplantation. Of these seven patients, six have normal liver function and a good performance status. One is awaiting retransplantation for chronic rejection. Hepatocellular carcinoma (HCC) was found either preoperatively or incidentally in five patients, all older than 2 years at the time of their transplant. Four of these are alive and well without evidence of tumor with follow-ups between 3 1/2 and 6 1/2. Four of the five patients less than 2 years of age had hepatocellular dysplasia without evidence of carcinoma on histologic examination of the resected liver. This experience suggests that liver transplantation should be considered seriously for children with hereditary tyrosinemia who are more than 2 years of age because beyond that age the incidence of hepatocellular carcinoma (HCC) increases substantially.

Biliary tract complications in orthotopic adult liver transplantation

In a series of orthotopic liver transplantations performed between April and August 1987 at the University of Pittsburgh, the monofilament absorbable suture polyglyconate was compared with a braided absorbable suture, polyglactin 910, for its biliary complication rate over a 6-month postoperative period. Complications that were suture-related (obstruction or leak from the anastomotic site) occurred in 1 of 21 transplantations in the polyglyconate group compared with 8 of 26 in the polyglactin 910 group (p = 0.02). Even though the patient sample was relatively small, it appears that the type of suture used for the biliary anastomosis directly correlates with the outcome. A larger patient trial could confirm these initial results.

Hepatic artery thrombosis after pediatric liver transplantation--a medical or surgical event?

Hepatic artery thrombosis (HAT) is one of the most serious complications after orthotopic liver transplantation, and is associated with a high morbidity and mortality. This study retrospectively reviewed 66 liver transplants in children under the age of 10 years during a year-long period at a single institution. A total of 28 perioperative variables were analyzed to identify responsible factors of HAT. Of the 66 children, 18 (26%) developed HAT within 15 days after the transplant (HAT group); 29 (42%) had an uneventful postoperative course (control group). To avoid the possible influence of other complications 19 patients were excluded. Of the variables compared between the 2 study groups, three surgical factors (diameter of the hepatic artery--greater or less than 3 mm; type of arterial anastomosis--end-to-end versus the use of an iliac graft or aortic conduit; and number of times the anastomosis was redone--one versus more than one), were found to be significantly different (P less than .05) between HAT and control groups. Two medical factors also were significantly different: the use of intraoperative transfusion of fresh frozen plasma (FFP) and the administration of postoperative prophylactic anticoagulant treatment. A heparin and dextran-40 protocol appeared to be effective in preventing HAT (P less than .02). Moreover, after multivariate analysis, anticoagulation therapy was demonstrated to be the major independent variable influencing HAT. A better definition of factors responsible for the occurrence of HAT is required. This study should help in formulating effective methods to decrease the incidence of this dreaded complication after liver transplantation.

Marked transient alkaline phosphatemia following pediatric liver transplantation

An isolated marked transient rise in serum alkaline phosphatase levels in otherwise healthy children is a well-documented occurrence. However, in children undergoing liver transplantation, elevated alkaline phosphatase values raise the possibility of biliary obstruction, rejection, or both. During a 6-year period, 6 of 278 children undergoing liver transplantation exhibited a similar phenomenon as an isolated abnormality. None had rejection, biliary obstruction, or other allograft dysfunction during a long follow-up. Eventually and without intervention, the alkaline phosphatase levels returned to normal. These instructive cases suggest that caution be used in advocating invasive procedures if elevated alkaline phosphatase levels are an isolated abnormality, and close observation with noninvasive testing is recommended.

Obstructing mucocele of the cystic duct after transplantation of the liver

A tension mucocele was created in three hepatic homografts by ligating a low-lying cystic duct during transplant cholecystectomy and by incorporating its outflow end into the anastomosis of the common hepatic duct to the recipient common duct or Roux limb of jejunum. The consequent complication of obstruction of the biliary tract that necessitated reoperation and excision of the mucocele in all three patients can be avoided by the simple expedient of completely removing the cystic duct when feasible or providing egress to the secretion of the cystic duct as described.