A real-time, telemetric method for continuous measurement of portal pressures

The ability to longitudinally monitor portal and splanchnic pressures would greatly enhance the understanding of acute and chronic liver disease by helping to assess the immediate and long-term impact of therapeutic manipulations. However, a technique for measuring portal pressures in the ambulatory setting is not currently available. To overcome this difficulty, we utilized an approach that involved the implantation of a miniature telemetric device, equipped with a specially-designed pressure transmission catheter, into the spleen of an anesthetized mouse. Using this approach, portal pressures were measured continuously over 5 d in conscious, unrestrained animals, the availability of which will help facilitate studies of the portal circulation requiring long-term stability.

The hepatoadrenal syndrome: a common yet unrecognized clinical condition

OBJECTIVE

Adrenal failure is common in critically ill patients, particularly those with sepsis. As liver failure and sepsis are both associated with increased circulating levels of endotoxin and proinflammatory mediators and reduced levels of apoprotein-1/high-density lipoprotein, we postulated that adrenal failure may be common in patients with liver disease.

DESIGN

Clinical study.

SETTING

Liver transplant intensive care unit.

PATIENTS

The study cohort included 340 patients with liver disease.

INTERVENTIONS

Based on preliminary observational data, all patients admitted to our 28-bed liver transplant intensive care unit (LTICU) undergo adrenal function testing. An honest broker system was used to extract clinical, hemodynamic, medication, and laboratory data on patients admitted to the LTICU from March 2002 to March 2004. A random (stress) cortisol level <20 microg/dL in a highly stressed patient (respiratory failure, hypotension) was used to diagnose adrenal insufficiency. In all other patients, a random cortisol level <15 microg/dL or a 30-min level <20 microg/dL post-low-dose (1 microg) cosyntropin was considered diagnostic of adrenal insufficiency. Patients were grouped as follows: a) chronic liver failure; b) fulminant hepatic failure; c) patients immediately status post-orthotopic liver transplantation receiving a steroid-free protocol of immunosuppression; and d) patients status post-remote liver transplant (>/=6 months). The decision to treat patients with stress doses of hydrocortisone was at the discretion of the treating intensivist and transplant surgeon.

MEASUREMENTS AND MAIN RESULTS

Two-hundred and forty-five (72%) patients met our criteria for adrenal insufficiency (the hepatoadrenal syndrome). Eight (33%) patients with fulminant hepatic failure, 97 (66%) patients with chronic liver disease, 31(61%) patients with a remote history of liver transplantation, and 109 (92%) patients who had undergone liver transplantation under steroid-free immunosuppression were diagnosed with adrenal insufficiency. The high-density lipoprotein level at the time of adrenal testing was the only variable predictive of adrenal insufficiency (p < .0001). In vasopressor-dependent patients with adrenal insufficiency, treatment with hydrocortisone was associated with a significant reduction (p = .02) in the dose of norepinephrine at 24 hrs, whereas the dose of norepinephrine was significantly higher (p = .04) in those patients with adrenal failure not treated with hydrocortisone. In vasopressor-dependent patients without adrenal insufficiency, treatment with hydrocortisone did not affect vasopressor dose at 24 hrs. One hundred and forty-one patients (26.4%) died during their hospitalization. The baseline serum cortisol was 18.8 +/- 16.2 microg/dL in the nonsurvivors compared with 13.0 +/- 11.8 microg/dL in the survivors (p < .001). Of those patients with adrenal failure who were treated with glucocorticoids, the mortality rate was 26% compared with 46% (p = .002) in those who were not treated. In those patients receiving vasopressor agents at the time of adrenal testing, the baseline cortisol was 10.0 +/- 4.8 microg/dL in those with adrenal insufficiency compared with 35.6 +/- 21.2 microg/dL in those with normal adrenal function. Vasopressor-dependent patients who did not have adrenal failure had a mortality rate of 75%.

CONCLUSIONS

Patients with liver failure and patients post-liver transplantation have an exceedingly high incidence of adrenal failure, which may be pathophysiologically related to low levels of high-density lipoprotein. Treatment of patients with adrenal failure may improve outcome. High baseline serum cortisol levels may be a maker of disease severity and portend a poor prognosis.

Indirect Outcomes Associated with Cytomegalovirus (Opportunistic Infections, Hepatitis C Virus Sequelae, and Mortality) in Liver-Transplant Recipients with the Use of Preemptive Therapy for 13 Years

BACKGROUND

The effect of preemptive therapy on indirect sequelae associated with cytomegalovirus (CMV) in liver-transplant recipients has not been clearly delineated.

METHODS

Thirteen years of outcome with the use of preemptive therapy were assessed in a cohort of 216 consecutive liver-transplant recipients.

RESULTS

The incidence of major infections (31% vs. 44.3%), bacterial infections (31% vs. 39.2%), bacteremia (19% vs. 29.1%), or fungal infections (3.4% vs. 7.6%) did not differ significantly for patients with CMV infection who received preemptive therapy compared with those who never developed CMV infection and did not receive antiviral prophylaxis for CMV (P>0.20 for all variables). The rate of opportunistic infections also did not differ when patients were stratified by primary CMV infection, reactivation infection, or no CMV infection. Recurrent hepatitis C virus (HCV) hepatitis occurred in 55.6% of the patients with CMV treated with preemptive therapy and 49.8% of those without CMV infection (P>0.20). The probability of survival at 6 months, 12 months, 2 years, and 3 years was also comparable for the two groups.

CONCLUSIONS

Liver-transplant recipients with CMV infection, including high-risk R-/D+ patients, when followed using the preemptive therapy approach had no significant difference in meaningful outcomes such as opportunistic superinfections, HCV recurrence rates, rejection, and survival when compared with the patients in whom CMV infection never developed and who did not receive antiviral prophylaxis for CMV.

Efficacy of valganciclovir administered as preemptive therapy for cytomegalovirus disease in liver transplant recipients: impact on viral load and late-onset cytomegalovirus disease

BACKGROUND

The efficacy of valganciclovir used as preemptive therapy for cytomegalovirus (CMV) disease in liver transplant recipients is not known.

METHODS

Between 1996 and 2004, surveillance testing using CMV antigenemia was performed at weeks 2, 4, 6, 8, 10, 12, and 16 posttransplant. A total of 28.8% (17/59) of the patients from 2001 to 2004 with antigenemia who received valganciclovir as preemptive therapy were compared with 26.2% (21/80) of the patients from 1996 to 2000 who received oral ganciclovir as preemptive therapy.

RESULTS

The mean decline in the antigenemia level after initiation of valganciclovir and oral ganciclovir was 80.5% versus 50.7% at 1 week, 99.5% versus 89.4% at 2 weeks, and 100% versus 97.7% at 4 weeks, respectively. A higher proportion of patients who received valganciclovir (64.7%) belonged to the high-risk group (R-/D+) than patients who received oral ganciclovir (33.3%, P=0.10). Recurrent shedding was documented in 47.1% (8/17) of the patients in the valganciclovir group and 28.6% (6/21) of the patients in the oral ganciclovir group (P>0.20). Recurrent shedding correlated significantly with R-/D+ CMV serostatus and baseline CMV antigenemia level, regardless of the study group. No patient in either group developed CMV disease during or after the period of surveillance monitoring. The incidence of opportunistic infections and patient outcome did not differ for the valganciclovir group versus the oral ganciclovir group or patients without CMV infection (P>0.20).

CONCLUSION

Antigenemia-directed valganciclovir as preemptive therapy seems to be effective for the prevention of CMV disease in liver transplant recipients, including high-risk patients.

Use of alemtuzumab and tacrolimus monotherapy for cadaveric liver transplantation: with particular reference to hepatitis C virus

We have proposed that the mechanisms of alloengraftment and variable acquired tolerance can be facilitated by minimum posttransplant immunosuppression. It was further suggested that the efficacy of minimalistic treatment could be enhanced by preoperative recipient conditioning with an antilymphoid antibody preparation. A total of 76 adults (38 hepatitis C virus [HCV], 38 HCV) were infused with 30 mg alemtuzumab before primary cadaveric liver transplantation and maintained afterward on daily monotherapy unless breakthrough rejection mandated additional agents. In stable patients, the intervals between tacrolimus doses were lengthened ("spaced weaning") after approximately 4 months. Eighty-four contemporaneous nonlymphoid-depleted liver recipients (58 HCV, 26 HCV) were treated with conventional postoperative immunosuppression. The overall incidence of rejection was similar with the two strategies of immunosuppression. With follow-ups of 14 to 22 months, patient and primary graft survival in HCV cases are 97% and 90%, respectively, with alemtuzumab depletion plus minimal immunosuppression versus 71% and 70%, respectively, under conventional immunosuppression. In HCV recipients, current patient and graft survival in the alemtuzumab-pretreated group are 71% and 70% versus 65% and 54%, respectively, under conventional treatment. With both strategies of immunosuppression, the adverse effect of preexisting HCV on survival parameters and graft function already was significant at the 1-year milestone, but its extent was not evident until the second year. With or without HCV, 62% of the 64 surviving lymphoid-depleted patients are on spaced immunosuppression, and four patients receive no immunosuppression. Lymphoid depletion with alemtuzumab and minimalistic maintenance immunosuppression is a practical strategy of liver transplantation in HCV recipients but not HCV recipients.

Bacteremias in liver transplant recipients: shift toward gram-negative bacteria as predominant pathogens

During the 1990s, gram-positive bacteria emerged as major pathogens after liver transplantation. We sought to determine whether the pathogens associated with bacteremias in liver transplant recipients have changed. Patients included 233 liver transplant recipients transplanted between 1989 and 2003. The proportion of all infections due to bacteremias increased significantly over time (P <.0001). Of other major infections, a trend toward a decrease in fungal infections (P =.089) and a significant decrease in cytomegalovirus (CMV) disease (P =.0004) were documented. Whereas the proportion of bacteremias due to gram-negatives increased from 25% in the period of 1989-1993 to 51.8% in 1998-03, that of gram-positive bacteria decreased from 75% in the period of 1989-93 to 48.2% in the period of 1998-2003. Methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae, and Pseudomonas aeruginosa were the most frequent pathogens in bacteremic patients. The incidence of bacteremias due to MRSA and Pseudomonas aeruginosa has remained unchanged (P <.20); however, that due to enteric gram-negative bacteria, particularly Klebsiella pneumoniae has increased (P =.02). Klebsiella pneumoniae isolates in the current quartile were not clonally related. In conclusion, bacteremias as a proportion of all infections in liver transplant recipients have increased significantly over time, due in part to a decline in infections due to other major pathogens, e.g., fungi, primarily Candida species, and CMV. Gram-negative bacteria have emerged as predominant pathogens in bacteremic liver transplant recipients.

T-helper cell responses in liver transplant recipients: correlation with cytomegalovirus and other major infections

Mitogen concanavalin A (ConA) response and cytomegalovirus (CMV)-specific memory response were assessed in 24 liver transplant recipients and compared with healthy subjects. Transplant recipients as compared to healthy subjects had a lower CMV memory response at 2 weeks (P=0.023), and at 1 month (P=0.06), but a comparable response at 3 months. CMV recipient+/donor+(R+/D+) patients had the greatest increase in CMV-specific memory response at 2-3 months as compared to all other groups. Within this R+/D+ group, CMV-specific memory response was significantly more robust in patients who never had CMV infection as compared to those who developed CMV infection (P=0.035). ConA response at 2 weeks was significantly lower in patients with major infections as compared to those without them (SI 5.4 vs. 38.1, P=0.039). Thus, reconstitution of CMV-specific T-helper cell response was distinct for subsets of liver transplant recipients based on the recipient and donor CMV serostatus. Impairment in proliferative response to ConA identified a subgroup of patients with major infections after liver transplantation.

Cryptococcus neoformans Infection in Patients With Cirrhosis, Including Liver Transplant Candidates

We reviewed the cases of patients with cirrhosis, including liver transplant candidates, at our institution in the last 3 years (n = 5) and those individually described in the literature (n = 28), to assess unique characteristics and outcome of cryptococcosis in these patients. Sixty-four percent (21/33) of the patients had no other recognized immunosuppression. Peritonitis (in 45%, 15/33 of the patients) with modest pleocytosis in the ascitic fluid, was the most common presenting feature. Median time to detection of Cryptococcus in the ascitic fluid cultures was 6 days. Overall mortality rate was 81% (26/32); death was deemed attributable to cryptococcosis in 24/26 patients who died. Evaluation of culture-negative neutrocytic ascites in febrile cirrhotic patients warrants consideration of cryptococcal peritonitis.

Impact of evolving trends in recipient and donor characteristics on cytomegalovirus infection in liver transplant recipients

BACKGROUND

This study determines whether the recipient and donor characteristics that influence the cytomegalovirus (CMV) infection rate after liver transplantation have changed.

METHODS

The recipient and donor characteristics that may affect the rate of CMV infection were assessed in 232 liver transplant recipients at our institution during a 14-year period (1989-2003).

RESULTS

Since 1989, the age of recipients (P=0.0001) and donors (P=0.0001) has increased significantly. Pretransplant CMV seropositivity in recipients has decreased significantly (P=0.0001, 86.4% [1989-1992] to 53.7% [2000-2003]), whereas donor CMV seropositivity has remained unchanged (P>0.20). As a result, there has been a significant increase in the proportion of high-risk (CMV recipient-/donor+) patients (P=0.012); 10.6% of recipients from 1989 to 1992 versus 24.1% of recipients from 2000 to 2003 were CMV recipient-/donor+. The Child-Pugh scores of recipients have remained unchanged over time. However, the proportion of patients undergoing transplantation while being cared for in the intensive care unit has decreased significantly over time (P=0.0002). Despite an increase in the rate of CMV infection (P=0.09), the incidence of CMV disease has decreased significantly (P=0.0004).

CONCLUSIONS

The proportion of high-risk patients (CMV recipient-/donor+) has increased significantly over time, attributable largely to a declining rate of CMV seropositivity in recipients before transplantation. These data have implications for guiding prophylactic practices and resource use after liver transplantation.

Changing epidemiology and predictors of mortality in patients with spontaneous bacterial peritonitis at a liver transplant unit

OBJECTIVES

To determine whether antimicrobial resistance in pathogens and outcome in patients with spontaneous bacterial peritonitis (SBP) has evolved over time.

METHODS

Sixty-one consecutive episodes of SBP were studied in patients with end-stage liver disease undergoing evaluation for liver transplantation between 1991 and 2001. Patients were dichotomized into a cohort between 1991 and 1995 (the earlier cohort) and 1996-2001 (the later cohort).

RESULTS

Overall, 19% of all bacteria were multiply-antibiotic resistant. The frequency of multiple-antibiotic resistance in bacteria increased from 8.3% to 38.5% in the earlier as compared to the later cohort (P = 0.07). Overall, mortality at 30 days in the study patients was 26% and had remained unchanged between the two cohorts. The mortality rate was significantly higher in patients with multiply-antibiotic-resistant bacteria than in those with other bacteria (P = 0.045). However, the Child-Pugh score (P = 0.003), and renal failure (P = 0.04) were the only independently significant predictors of mortality in patients with SBP.

CONCLUSIONS

Mortality in patients with end-stage liver disease who developed SBP has remained unchanged over the last decade. Although multiple-antibiotic resistance in bacteria causing SBP has increased over time, the severity of hepatic and renal dysfunction were the predominant determinants of outcome in these patients.

Lack of efficacy of mupirocin in the prevention of infections with Staphylococcus aureus in liver transplant recipients and candidates

BACKGROUND

Infections with Staphylococcus aureus are a significant problem in patients in liver transplant units. An association between prior nasal carriage with and subsequent infections has been documented previously in liver transplant recipients and patients with cirrhosis. However, the role of decolonization with mupirocin applied intranasally for the prevention of S. aureus infections in these patients has not been determined.

METHODS

S. aureus nasal carriage was prospectively sought in 70 consecutive liver transplant candidates. Mupirocin two times per day for 5 days was administered to the carriers. Follow-up nasal cultures to document decolonization were performed 5 days after the final application of mupirocin. The primary endpoint was the development of S. aureus infections.

RESULTS

Thirty-one of 70 patients (44%) were found to be nasal carriers and 27 of 31 nasal carriers (87%) were successfully decolonized. However, 12 of 27 patients (37%) successfully decolonized became recolonized with S. aureus, and an additional nine patients who were initially noncarriers became newly colonized with S. aureus during the study period. Despite the use of mupirocin, 16 of 70 patients (23%) developed an infection with S. aureus. No isolate was found to be mupirocin resistant.

CONCLUSION

Elimination of S. aureus nasal carriage by mupirocin did not prevent S. aureus infections in patients in our liver transplant unit.

Safety and efficacy of isoniazid chemoprophylaxis administered during liver transplant candidacy for the prevention of posttransplant tuberculosis

BACKGROUND

Optimal timing of initiation of isoniazid chemoprophylaxis in liver transplant recipients who test positive on the tuberculin skin test has not been defined. We sought to determine whether isoniazid prophylaxis administered during liver transplant candidacy was safe and effective for the prevention of posttransplantation tuberculosis.

METHODS

During a 9-year period, 18 liver transplant candidates with tuberculin skin test greater than 5 mm or recent conversion to positive tuberculin skin test were identified and received isoniazid chemoprophylaxis for 12 months. For each case, a control matched with the patient for underlying liver disease and age (within 5 years of the case) was included. Liver function tests were assessed monthly. The median follow-up was 55 months and ranged up to 107 months for the cases.

RESULTS

At baseline, the cases had a total bilirubin of 2.2 mg/dL, alanine aminotransferase of 106 IU/L, prothrombin time of 14.2 sec, and serum albumin of 2.9 gm/dL (mean values). Hepatic function tests did not differ significantly for the cases at 3, 6, 9, and 12 months when compared with those at baseline or between the cases and controls at each of the above time points. Discontinuation of prophylaxis was not required in any of the patients. The outcome (proportion of patients who underwent transplantation or were dead or alive at the last follow-up) and survival time for the cases did not differ significantly from those of the controls (P >0.20).

CONCLUSION

In liver transplant candidates at risk for infection after transplantation, isoniazid chemoprophylaxis used during candidacy was well tolerated and did not adversely effect hepatic function or outcome as compared with the control patients.

Voriconazole inhibition of the metabolism of tacrolimus in a liver transplant recipient and in human liver microsomes

The purpose of this study was to assess the effect of voriconazole on the blood tacrolimus concentration in a liver transplant recipient and to examine the interaction between voriconazole and tacrolimus by using human liver microsomes. Two subjects were enrolled in the clinical study: one received voriconazole, and the other received a placebo. Tacrolimus metabolism was evaluated in human liver microsomes at various concentrations in the absence and presence of various concentrations of voriconazole. Coadministration of voriconazole and tacrolimus resulted in elevated (nearly 10-fold-higher) trough tacrolimus blood concentrations in the liver transplant patient. In the in vitro study, voriconazole at a concentration of 10.4 +/- 4.3 micro g/ml inhibited the metabolism of tacrolimus by 50%. Clinically relevant concentrations of voriconazole inhibited the metabolism of tacrolimus in human liver microsomes. Close monitoring of the blood concentration and adjustment in the dose of tacrolimus are warranted in transplant recipients treated with voriconazole.

Bleeding complications precipitated by unrecognized Gingko biloba use after liver transplantation

Because of its neurocognitive enhancing effects, Gingko biloba has emerged as amongst the most commonly used herbal products. We report a liver transplant recipient with potentially life-threatening toxicity resulting from Gingko biloba use. Seven days after a second liver transplantation for recurrent hepatitisB virus infection, subphrenic hematoma was documented in a 59-year-old Korean patient. Failure to control bleeding with CT-guided drainage necessitated exploratory laparotomy for the evacuation of a large subphrenic hematoma. Three weeks later, an episode of vitreous hemorrhage was documented. Unbeknownst to his care providers, the patient had been consuming Gingko biloba throughout the postoperative period. No further bleeding episodes occurred after the cessation of Gingko biloba use. Unrecognized use of herbal products may be associated with serious side effects and adverse clinical sequelae in transplant recipients. Given their increasing popularity, the use of herbal products should be routinely sought as part of the history in transplant recipients.

Persistent lack of human herpesvirus-6 specific T-helper cell response in liver transplant recipients

BACKGROUND

Specific immunologic defects predisposing to human herpesvirus-6 (HHV-6), e.g. the role of HHV-6 specific T-helper cell memory response in liver transplant recipients, have not been assessed.

METHODS

T-helper function (mitogen ConA response) as a marker of overall immunocompetence and T-helper response (memory response) specific to HHV-6 and cytomegalovirus (CMV) were assessed in 15 liver transplant recipients and compared with 25 healthy subjects. Samples were tested pretransplant, at 2 weeks, 1 month, 2-3 months, and 1 year posttransplantation. Stimulation index (SI) >3 was considered a positive response.

RESULTS

Seven percent (1/15) of the transplant recipients at any time posttransplantation, as compared to 64% (16/25) of the healthy subjects, had a positive HHV-6 memory response (P = 0.00065). HHV-6-specific memory response in transplant recipients at 2 weeks (SI 1.43), 1 month (SI 1.1), and 2-3 months (SI 1.3) was significantly more suppressed than in healthy subjects (SI 17.5, P = 0.0001). Although transplant recipients as compared to healthy subjects also had a lower CMV-specific memory response posttransplant (P = 0.0439), CMV-specific memory response recovered significantly at 1 month (P = 0.03) and at 2-3 months (P = 0.027) as compared to that at 2 weeks. However, HHV-6 memory response was persistently absent up to 2-3 months with partial recovery at 1 year; 7% of the patients at 2-3 months, but 25% at 1 year had a positive HHV-6 specific memory response. Forty percent (6/15) of the patients developed HHV-6 viremia a mean of 4 weeks posttransplant. Patients with HHV-6 viremia had greater suppression of HHV-6 memory response at 1 month than those without viremia (mean SI, 0.96 vs. 1.3, P = 0.08). All but one of the patients had a positive ConA response.

CONCLUSION

Prolonged suppression of HHV-6 memory response, but not overall T-helper cell function was documented and may play a role in the pathogenesis of HHV-6 infection in liver transplant recipients. Memory response to CMV after liver transplantation was significantly more robust than to HHV-6.

Pharmacokinetics of cefoperazone and sulbactam in liver transplant patients

The authors evaluated the pharmacokinetics of cefoperazone and sulbactam in 9 liver transplant patients. Cefoperazone and sulbactam were administered as an intravenous infusion over 30 minutes every 12 hours for six doses, and multiple blood samples were collected immediately after the first dose (administered during the surgery) and after the last dose. The concentrations of cefoperazone and sulbactam in serum and, when possible, in urine and bile collected over one dosing interval were measured by high-pressure liquid chromatography. The concentration of cefaperazone ranged from 436 to 4118 microg/ml, and sulbactam ranged from 3.3 to 8.7 microg/ml in the bile samples. The intraoperative clearance of cefoperazone (0.53+/-0.18 ml/min/kg) was significantly higher than the postoperative clearance (0.21+/-0.23 ml/min/kg). The half-life of cefaperazone, although not statistically significantly different, was prolonged in all patients during the postoperative period. The clearance of sulbactam (1.51+/-0.51 ml/min/kg) was lower than what is reported in patients with normal renal function but was comparable to what has been reported in patients with renal impairment and in critically ill patients. There were no significant differences in any of the pharmacokinetic parameters of sulbactam during and after surgery. The pharmacokinetic parameters of cefoperazone and sulbactam were significantly altered in liver transplant patients compared to what has been reported in normal subjects but were similar to what has been reported in patients with liver and renal impairment. There was a significant impairment in the biliary excretion of cefoperazone during the postoperative period in liver transplant patients. Although the percentage of the dose of cefoperazone excreted in the bile was drastically reduced, the biliary concentrations were generally high and above the MIC for most organisms. Given that both renal and hepatic elimination of cefoperazone is decreased, leading to a lower clearance and longer half-life in liver transplant patients, lower doses (1-2 g per day) of cefoperazone may be sufficient in liver transplant patients during the immediate postoperative period.

Impact of human herpesvirus-6 on the frequency and severity of recurrent hepatitis C virus hepatitis in liver transplant recipients

A role of tumor necrosis factor-alpha (TNF-alpha) In the immunopathogenesis of hepatitis C virus (HCV) infection has been proposed. The novel herpes virus, human herpes virus-6 (HHV-6), is amongst the most potent inducers of cytokines, including TNF-alpha. The impact of HHV-6 viremia on the progression of recurrent HCV hepatitis was assessed in 51 HCV-positive liver transplant recipients. The frequency of recurrent HCV hepatitis did not differ between patients with HCV viremia (47.6%, 10/21) as compared with those without HCV viremia (46.7%, 14/30, p = 0.9). However, the patients with HHV-6 viremia had a significantly higher fibrosis score upon HCV recurrence than those without HHV-6 viremia (mean 1.5 vs. 0.3, p = 0.01). An association between cytomegalovirus (CMV) viremia and HCV recurrence was not documented; 50% (15/30) of the patients with CMV viremia and 42.8% (9/21) of those without CMV viremia had recurrent HCV hepatitis (p > 0.5). Receipt of ganciclovir (administered upon the detection of CMV viremia) was associated with lower total Knodell score (mean 5.2 vs. 6.9, p = 0.05) and a trend towards lower fibrosis score (mean 0.44 vs. 1.00, p = 0.12) in patients with recurrent HCV hepatitis. Thus, HHV-6 viremia in HCV-positive liver transplant recipients identified a subgroup of patients at increased risk for early fibrosis upon HCV recurrence.

Trends in invasive fungal infections in liver transplant recipients: correlation with evolution in transplantation practices

BACKGROUND

The incidence of invasive fungal infections, particularly invasive candidiasis, after liver transplantation is strongly influenced by surgical factors and technical complexity of the surgery. We assessed the temporal trends in invasive fungal infections in the context of evolution in liver transplantation practices, technical developments, and other risk factors.

METHODS

Demographic and clinical characteristics of the patients, transplantation-related variables, and rates of infection were longitudinally analyzed over the last 10 years in 190 consecutive liver transplant recipients at our institution. Trends for categorical data were evaluated using the Cochran-Armitage trend test and for continuous variables using analysis of variance with linear contrast.

RESULTS

A decrease in the length of operation (P=0.03), intraoperative transfusion requirements (P=0.0001), cold ischemic time (P<0.0001), use of roux-en-Y biliary anastomosis (P=0.0015), rate of biopsy proven rejection (P<0.0001), and retransplantation (P=0.056) was documented over the successive years. A significant decline in Child-Pugh score (P=0.02) and in the proportion of patients transplanted as UNOS 2a occurred (P=0.0001). Although the incidence of cytomegalovirus infection remained unchanged, a significant increase in the frequency of primary cytomegalovirus infection (P=0.045), and a decrease in cytomegalovirus disease (P=0.0006) was documented. Over the same time period, a significant decrease in the incidence of invasive candidiasis (P=0.015), and an insignificant increase in the rate of invasive aspergillosis (P=0.20) occurred.

CONCLUSION

Notable technical developments in liver transplantation practices and risk profiles of patients have occurred over the decade. These variables may have a role in influencing the evolving trends in invasive fungal infections in liver transplant recipients.

Seasonal pattern of early mortality and infectious complications in liver transplant recipients

Seasonal variation has been documented in the frequency and attributable mortality of a number of medical illnesses and infections in the nontransplantation setting. Whether similar trends exist in transplant recipients is not known. Seasonal rates of overall and early mortality and contributory variables stratified by season were assessed in 190 consecutive liver transplant recipients who underwent transplantation over a 10-year period. The frequency of infectious complications and rejection was also assessed and stratified by season of transplantation. Early (deaths occurring in the first year posttransplantation), but not overall, mortality correlated significantly with seasonality. Of patients with early mortality, 43% (13 of 30 patients) died in winter; 23% (7 of 30 patients), in spring; 13% (4 of 30 patients), in summer; and 20% (6 of 30 patients), in fall. The frequency of deaths in winter was significantly greater than for all other seasons (P = .022). The high wintertime mortality could not be explained by previously recognized risk factors portending a poor outcome, e.g., United Network for Organ Sharing status, Child-Pugh score, surgical time, blood loss, pretransplantation and posttransplantation dialysis, infections, rejection, or increased immunosuppression. Strong trends toward a higher rate of cytomegalovirus disease in patients who underwent transplantation in fall (P = .09) and bacterial infections in those who underwent transplantation in winter were documented (P = .09). There was no correlation between seasonality and rejection. Early mortality in winter in liver transplant recipients was significantly greater than if the deaths were totally random. Whether the seasonal clustering of deaths and infections is triggered by respiratory viruses, yet unrecognized viruses, or unknown exogenous factors remains to be determined.

PREEMPTIVE PROPHYLAXIS WITH A LIPID PREPARATION OF AMPHOTERICIN B FOR INVASIVE FUNGAL INFECTIONS IN LIVER TRANSPLANT RECIPIENTS REQUIRING RENAL REPLACEMENT THERAPY1

BACKGROUND

Posttransplant renal replacement therapy has been shown to be an independently significant risk factor for invasive fungal infections after liver transplantation. We assessed the efficacy of a lipid preparation of amphotericin B as prophylaxis for invasive fungal infections, directed toward liver transplant recipients requiring renal replacement therapy.

METHODS

A total of 148 patients transplanted between 1990 and 1997 received no antifungal prophylaxis. Since 1997, 38 patients underwent liver transplantation; antifungal prophylaxis with a lipid preparation of amphotericin B was used in patients requiring renal replacement therapy.

RESULTS

Fifteen percent (22 of 148) of the patients transplanted before 1997 required renal replacement therapy. In this cohort, the incidence of invasive fungal infections (36% vs. 7%, P=0.0007) and invasive aspergillosis (14% vs. 2%, P=0.02) was significantly higher in patients who required renal replacement therapy compared with those who did not. Since 1997, 29% (11 of 38) of the patients required renal replacement therapy and received antifungal prophylaxis. Invasive fungal infections occurred in 36% (8 of 22) of the patients who received no prophylaxis (patients before 1997), and 0% (0 of 11, P=0.03) in those who received antifungal prophylaxis (since 1997). Antifungal prophylaxis was independently associated with protection from fungal infection (P=0.017). No reduction in mortality with antifungal prophylaxis was documented.

CONCLUSION

Prophylaxis with a lipid preparation of amphotericin B was associated with a significant reduction in invasive fungal infections in high-risk liver transplant recipients, i.e., those requiring renal replacement therapy. However, no beneficial effect on survival could be documented.

Posttransplantation dialysis-associated infections: morbidity and impact on outcome in liver transplant recipients

The aim of this study is to assess the predictors, impact on infectious morbidity, and outcome of posttransplantation dialysis in liver transplant recipients and to compare the results with data from patients who did not require dialysis after transplantation. The study sample included 176 consecutive patients undergoing liver transplantation; the median follow-up was 4.3 years. All patients were administered tacrolimus as primary immunosuppression. Overall, 16% (28 of 176 patients) of the patients required dialysis after transplantation. Patients requiring dialysis had significantly greater pretransplantation creatinine levels (2.4 v 1.2 mg/dL; P =.009), were more likely to require pretransplantation dialysis (21% v 1%; P =.0001), and had a greater rate of biopsy-proven rejection episodes (50%, 14 of 28 episodes v 20%, 30 of 148 episodes; P =.0009) and longer posttransplantation intensive care unit lengths of stay (P =.0001). The incidence of infections (91% v 41%; P =.0001) and episodes of infection per patient (2.4 v 0.7 episodes; P =.0001) were significantly greater in patients undergoing dialysis compared with those not undergoing dialysis. There was no difference in the frequency of cytomegalovirus (CMV) infection or disease; however, bacterial infections (87% v 31%; P =.0001) and invasive fungal infections (39% v 7%; P =.0001) were significantly more likely to occur in patients requiring dialysis. In logistic regression, dialysis (P =.0006) and CMV infection (P =.007) were independent significant predictors of major infections. Overall survival (assessed by Kaplan-Meier probability) was less in patients undergoing dialysis compared with those not undergoing dialysis (P =.0001). Among dialyzed patients, only 10% of those who survived had an invasive fungal infection compared with 46% of those who died (P =.08); 5 of 6 patients died within 1 month of the fungal infection. The need for dialysis portended a grave outcome in liver transplant recipients and identified a subgroup of patients at a significantly greater risk for major infections, particularly fungal infections, after liver transplantation.

Evolving trends in multiple-antibiotic-resistant bacteria in liver transplant recipients: a longitudinal study of antimicrobial susceptibility patterns

The incidence, sources, impact on outcome, and temporal trends in multiple-antibiotic-resistant bacteria in liver transplant recipients over the last decade (from 1990 through 1999) were assessed. Of 165 consecutive patients who underwent transplantation, 31% (51 of 165 patients) had at least 1 infection caused by multiple-antibiotic-resistant bacteria. Overall, 69% (66 of 96 infections) of all bacterial infections were multiple-antibiotic resistant. Ninety-one percent (45 of 49 isolates) of the Staphylococcus aureus isolates, 50% (6 of 12 isolates) of the enterococci, and 54% of the gram-negative bacteria (47%; 7 of 15 Pseudomonas aeruginosa, and 60%; 12 of 20 Enterobacteriaceae) were multiple-antibiotic resistant. A significant trend toward an increase in infections caused by multiple-antibiotic-resistant bacteria (P =.003), largely caused by an increase in gram-positive infections, was documented through the decade. There was a significant increase in infections caused by methicillin-resistant S aureus (P =.0001) and vancomycin-resistant enterococci (P =.04) over time. The proportion of gram-negative isolates that were multiple-antibiotic resistant (P =.447) did not increase significantly over time. However, a strikingly high frequency of resistance to piperacillin or ceftazidime suggests that extended-spectrum beta-lactamase production in our Enterobacteriaceae may have been more prevalent than realized. Mortality at 1 year was significantly greater in patients with multiple-antibiotic resistant bacteria compared with all other patients (P =.001). These longitudinal trends have implications not only for guiding therapeutic practices, but ultimately for devising strategies to curtail multiple-antibiotic resistance in liver transplant recipients.

Long-term survival after liver transplantation in 4,000 consecutive patients at a single center

OBJECTIVE

To evaluate the long-term survival outcomes of a large cohort of liver transplant recipients and to identify static and changing factors that influenced these outcomes over time.

SUMMARY BACKGROUND DATA

Liver transplantation has been accepted as a therapeutic option for patients with end-stage liver disease since 1983, with continual improvements in patient survival as a result of advances in immunosuppression and medical management, technical achievements, and improvements in procurement and preservation. Although many reports, including registry data, have delineated short-term factors that influence survival, few reports have examined factors that affect long-term survival after liver transplantation.

METHODS

Four thousand consecutive patients who underwent liver transplantation between February 1981 and April 1998 were included in this analysis and were followed up to March 2000. The effect of donor and recipient age at the time of transplantation, recipient gender, diagnosis, and year of transplantation were compared. Rates of retransplantation, causes of retransplantation, and cause of death were also examined.

RESULTS

The overall patient survival for the entire cohort was 59%; the actuarial 18-year survival was 48%. Patient survival was significantly better in children, in female recipients, and in patients who received transplants after 1990. The rates of retransplantation for acute or chronic rejection were significantly lower with tacrolimus-based immunosuppression. The risk of graft failure and death was relatively stable after the first year, with recurrence of disease, malignancies, and age-related complications being the major factors for loss.

CONCLUSION

Significantly improved patient and graft survival has been observed over time, and graft loss from acute or chronic rejection has emerged as a rarity. Age-related and disease-related causes of graft loss represent the greatest threat to long-term survival.

Cytomegalovirus antigenemia directed pre-emptive prophylaxis with oral versus I.V. ganciclovir for the prevention of cytomegalovirus disease in liver transplant recipients: a randomized, controlled trial

BACKGROUND

The efficacy of pre-emptively administered oral ganciclovir in preventing cytomegalovirus (CMV) disease has not been documented in liver transplant recipients. We sought to compare the efficacy of pre-emptive oral ganciclovir with that of i.v. ganciclovir for the prevention of CMV disease after liver transplantation, and to determine whether withholding prophylaxis in the absence of CMV antigenemia, reliably identified patients in whom no prophylaxis was necessary.

METHODS

Surveillance cultures for CMV pp65 antigenemia were performed in all patients at weeks 2, 4, 6, 8, 12, and 16. Patients with CMV antigenemia were randomized into two study groups. The experimental group received oral ganciclovir for 6 weeks (2 g t.i.d. for 2 weeks, then 1 g t.i.d. for 4 weeks), and the control group received i.v. ganciclovir (5 mg/kg q 12 hr) for 7 days.

RESULTS

Of 72 consecutive liver transplant recipients studied, CMV antigenemia occurred in 31% (22 of 72). Twenty-two patients with asymptomatic antigenemia were randomized to two study groups. CMV disease (viral syndrome) occurred in 9% (1 of 11) of the patients in the i.v. ganciclovir group and in 0% (0 of 11) of the patients in the oral ganciclovir group. None of the study patients developed tissue invasive CMV disease. The median reduction in antigenemia level with oral ganciclovir was 55% at week 1, and 100% at week 2. Overall, 64% of the patients by week 1, 93% by week 2, and 100% by week 4 had antigenemia levels below the baseline after oral ganciclovir. Of 50 patients without CMV antigenemia, none developed CMV disease.

CONCLUSIONS

Pre-emptive prophylaxis based on CMV antigenemia can effectively target the patients for CMV prophylaxis; 69% of the patients never received antiviral prophylaxis and did not develop CMV disease. Antiviral therapy instituted upon detection of antigenemia prevented tissue invasive CMV in both ganciclovir groups. Pre-emptively administered oral ganciclovir was effective as prophylaxis for CMV disease after liver transplantation.

Human herpesvirus-6 in liver transplant recipients: role in pathogenesis of fungal infections, neurologic complications, and outcome

BACKGROUND

The clinical impact and relevance of human herpesvirus-6 (HHV-6) infection in liver transplant recipients, has not been fully discerned.

METHODS

A prospective study of 80 consecutive liver transplant recipients was performed using surveillance cultures for HHV-6 at weeks 2, 3, 4, and 6 after transplantation. Viral isolation was used for the detection of HHV-6.

RESULTS

HHV-6 infection occurred in 39% (31 of 80) of the patients. Patients with HHV-6 infection were more likely to have hepatocellular carcinoma as underlying liver disease (P=.09). Mental status changes of unidentifiable etiology were significantly more likely to occur in patients with HHV-6 compared with those without (26%, 9 of 31 vs. 6%, 3 of 49, P=.008). HHV-6 infection was an independent predictor of invasive fungal infections (odds ratio 8.3, 95% confidence interval, 1.2-58.0, P=.03). A significant association between HHV-6 infection and CMV infection after transplantation, CMV recipient and donor serostatus, rejection, or fever of unknown origin, could not be documented. Mortality at last follow-up in patients with HHV-6 infection (29%, 9 of 31) was significantly greater than those without HHV-6 (6%, 3 of 49, P=.008).

CONCLUSIONS

Central nervous system complications of unknown etiology after liver transplantation may be related to HHV-6 infection. HHV-6 viremia was an independently significant predictor of invasive fungal infections and was associated with late mortality in liver transplantation recipients.

Late-onset renal failure after liver transplantation: role of posttransplant alcohol use

BACKGROUND

Late-onset renal failure is being increasingly recognized as a complication in patients undergoing liver transplantation for hepatitis C virus (HCV). However, its precise incidence, predisposing risk factors, and impact on outcome after liver transplantation, have not been defined.

METHODS

The development of late-onset renal failure (defined as serum creatinine persistently >2.0 mg/dl, occurring more than 6 months posttransplant) was assessed in 120 consecutive liver transplant recipients who survived at least 6 months after transplantation. Fifty-seven percent (68/120) of the patients had undergone transplantation for liver disease due to HCV. The median follow-up was 5 years.

RESULTS

Late-onset renal failure developed in 28% (33/120)of the patients. Posttransplant alcohol use (P=0.0001), posttransplant diabetes (P=0.0042), and recurrent HCV hepatitis (P=0.019) were significantly associated with late onset renal failure. In multivariate analysis, alcohol use (O.R. 10.7, 95%; CI 2.4-35.9, P=0.001) and diabetes (O.R. 2.1, 95%; CI 1.1-9.9, P=.03) were independently significant predictors of late onset renal failure. When only patients transplanted for HCV were analyzed, posttransplant alcohol use (P=0.004) was the only significant independent predictor of late-onset renal failure. HCV genotype 1b, as compared with other HCV genotypes, was associated with a higher rate of late-onset renal failure in patients with HCV; 70% of the patients with genotype 1b versus 32% of those with 1a and 33% of those with 2b, developed late onset renal failure (P=0.03). At a median follow up of 5 years, mortality in patients with HCV with late-onset renal failure was 52% as compared with 2% in those without renal failure (P=.0001).

CONCLUSION

Late-onset renal failure in patients with HCV portended a grave outcome. Alcohol use was an independent predictor of late-onset renal failure in patients with HCV and represents a potentially modifiable risk factor for late-onset renal failure in these patients.

Quality of life in long-term survivors after liver transplantation: impact of recurrent viral hepatitis C virus hepatitis

Post liver transplant recurrence of infection with hepatitis C virus (HCV) occurs in approximately 50% of patients transplanted because of HCV-related liver disease. The aim of this study was to assess long-term quality of life, psychologic distress, and coping in patients with recurrent HCV after liver transplantation in comparison to patients transplanted for other etiologies of underlying liver disease. All liver transplant recipients transplanted at a University affiliated Veterans Affairs Medical Center who had greater than 6 months follow-up were sent a questionnaire investigating quality of life (assessed by Medical Outcomes study health survey SF-36), depression (assessed by Beck Depression Inventory), total mood disturbance (assessed by Profile of Mood States scale), coping (assessed by Billing and Moos Inventory of coping with illnesses), and employment status. Lower Beck Depression Inventory score (p = 0.001), lower mood disturbance score (p = 0.0001), overall satisfaction with present work (p = 0.0001), and lesser use of avoidant coping (p = 0.06) were predictors of better quality of life in long-term survivors of liver transplantation. At a mean follow-up of 4 yr after liver transplantation, patients with histopathologically diagnosed recurrent viral HCV hepatitis had significantly lower global quality of life score (mean score of 76.4 versus 86.2, p = 0.011) and physical functioning score (mean score 20 versus 25, p = 0.015), as compared to all other patients. In summary, quality of life and physical functioning were significantly impaired in liver transplant recipients with histopathologically diagnosed recurrent HCV hepatitis, as compared to those whose HCV hepatitis had not recurred or those transplanted for other reasons.

Methicillin-resistant Staphylococcus aureus: the other emerging resistant gram-positive coccus among liver transplant recipients

We undertook a study of the characteristics and clinical impact of infections due to methicillin-resistant Staphylococcus aureus (MRSA) after liver transplantation. Of 165 patients who received liver transplants at our institution from 1990 through 1998, 38 (23%) developed MRSA infections. The predominant sources of infection were vascular catheters (39%; n=15), wound (18%; n=7), abdomen (18%; n=7), and lung (13%; n=5). A significant increase in MRSA infections (as a percentage of transplant patients infected per year) occurred over time (P=.0001). This increase was greater among intensive care unit patients (P=.001) than among nonintensive care unit hospital patients (P=.17). Cytomegalovirus seronegativity (P=.01) and primary cytomegalovirus infection were significantly associated with MRSA infections (P=.005). Thirty-day mortality among patients with MRSA infections was 21% (8/38). Mortality was 86% in patients with bacteremic MRSA pneumonia or abdominal infection and 6% in those with catheter-related bacteremia (P=.004). Thus the incidence of MRSA infection has increased exponentially among our liver transplant recipients since 1990. These infections have unique risk factors, time of onset, and a significant difference in site-specific mortality; deep-seated bacteremic infections, in particular, portend a grave outcome.

Thrombocytopenia in liver transplant recipients: predictors, impact on fungal infections, and role of endogenous thrombopoietin

BACKGROUND

Thrombocytopenia is a frequent and potentially serious complication in liver transplant recipients. The role of endogenous thrombopoietin level in posttransplant thrombocytopenia, has not been fully defined in liver transplant recipients. Additionally, there is accumulating evidence to suggest that platelets play a important role in antimicrobial host defense.

METHODS

There were 50 consecutive liver transplant recipients studied. Variables predictive of thrombocytopenia, its impact on infectious morbidity and outcome, and serial thrombopoietin (TPO) serum concentration were assessed.

RESULTS

The median pretransplant platelet count was 67 x 10(3)/cmm. After the liver transplantation, the median nadir platelet count was 33 x 10(3)/cmm and was reached a mean of 6 days after the transplant. A lower pretransplant platelet count (r= +.068, P=.0001), lower serum albumin before the transplants (r=+0.39, P=.014), longer operation time (r=0.27, P=.05), higher intraoperative packed red cells (r=0.28, P=.049) and fresh frozen plasma transfusions (r=0.42, P=.004), higher bilirubin at Day 7 (r=-.386, P=.005), and higher serum creatinine at Day 7 after the transplants (r=-.031, P=.025) correlated significantly with a lower nadir in platelets after the transplant. Nadir in platelet count was significantly lower in nonsurvivors compared with survivors (16 vs. 36 x 10(3)/cmm, P=.0001). Forty-three percent (9 of 21) of the patients with nadir platelet counts of < or =30 x 10(3)/cmm had a major infection within 30 days of the transplant compared with 17% (5 of 29) with nadir platelet counts > 30 x 10(3)/cmm (P=.04). Fungal infections occurred in 14% of the patients with nadir platelet counts of < or =30 x 10(3)/cmm versus 0% in those with nadir platelet counts of > 30 x 10(3)/cmm (P=.06); all patients with fungal infections had nadir platelet counts of < or =30 x 10(3)/cmm before fungal infection. Nadir in platelet count preceded the first major infection by a median of 7 days. Pretransplant TPO level did not differ between survivors (mean 103 pg/ml) or nonsurvivors (mean 144 pg/ml). After the transplantation, TPO levels increased in both groups. TPO level peaked at Day 7 and subsequently declined in survivors. Nonsurvivors had persistent thrombocytopenia despite a progressive rise in TPO level; TPO level was significantly higher at Day 7 (P=.02), Day 9 (P=.0019), and Day 14 (P=.04) in nonsurvivors compared with survivors.

CONCLUSION

Persistent thrombocytopenia portended a poor outcome in liver transplant recipients and was not related to low TPO levels. Thrombocytopenia preceded infections and identified a subgroup of liver transplant patients susceptible to early major infections; its precise role in fungal infections warrants validation in larger studies.

Predicting bacteremia and bacteremic mortality in liver transplant recipients

Predictors of bacteremia and mortality in bacteremic liver transplant recipients were prospectively assessed. One hundred eleven consecutive episodes of fever or infections were documented in 59 patients over a 4-year period. Forty-nine percent (29 of 59 patients) of the patients had bacteremia, 39% (23 of 59 patients) had nonbacteremic infections, and 12% (7 of 59 patients) had fever of noninfectious cause. Primary (catheter-related) bacteremia (31%; 9 of 29 patients), pneumonia (24%; 7 of 29 patients), abdominal and/or biliary infections (14%; 4 of 29 patients), and wound infections (10%; 3 of 29 patients) were the predominant sources of bacteremia. Diabetes mellitus (odds ratio, 6.9; P =.03) and serum albumin level less than 3.0 mg/dL (odds ratio, 0.14; P =.02) were independently significant predictors of bacteremia compared with nonbacteremic infections. Mortality at 14 days was 28% (8 of 29 patients) in those with bacteremia compared with 4% (1 of 23 patients) in those with nonbacteremic infections and 0% (0 of 7) in patients with fever of noninfectious cause (P =.03). Intensive care unit stay at the time of bacteremia (100% v 47%; P =.005), absence of chills (0% v 53%; P =.005), lower temperature at the onset of bacteremia (99.2 degrees F v 101.5 degrees F; P =.009), lower maximum temperature during the course of bacteremia (99.3 degrees F v 102 degrees F, P =.008), greater serum bilirubin level (7.6 v 1.5 mg/dL; P =.024), presence of abnormal blood pressure (80% v 16%; P =. 0013), and greater prothrombin time (15.6 v 13.3 seconds; P =.013) were significantly predictive of greater mortality in the bacteremic patients. These data have implications for discerning the likelihood of bacteremia and initiation of empiric antibiotics pending cultures. Lack of febrile response in bacteremic liver transplant recipients portended a poorer outcome.

Clinical and virologic outcomes of hepatitis B and C viral coinfection after liver transplantation: effect of viral hepatitis D

Hepatitis B (HBV) and C viral (HCV) dual-infection-associated liver disease is an uncommon indication for liver transplantation. The clinical and virologic outcomes in such patients have not been well studied. We retrospectively studied 13 patients with hepatitis B surface antigen (HBsAg) and antibody to HCV positivity who underwent orthotopic liver transplantation (OLT) and survived at least 30 days post-OLT. Antibody to hepatitis delta virus (HDV) was negative in 8 patients (group I) and positive in 5 patients (group II). Eleven of the 13 patients received standard hepatitis B immune prophylaxis, and they all remained HBsAg negative. All group I patients were HCV RNA positive after transplantation; in contrast, all group II patients were HCV RNA negative. Serum alanine aminotransferase levels were elevated in 88% (7 of 8) of the patients in group I compared with 20% (1 of 5 patients) in group II. None of the patients had graft loss from chronic rejection or recurrent hepatitis. Three patients had unsuspected hepatocellular carcinoma in the explant. We conclude that among liver transplant recipients with HBV and HCV coinfection, HDV infection is associated with the suppression of HCV replication and mild inflammatory activity after OLT.

Fever in liver transplant recipients in the intensive care unit

Whether febrile illnesses in the intensive care unit (ICU) have unique spectrum, etiologies, and outcome has not been determined in liver transplant recipients. We studied 78 consecutive febrile patients over a 4-yr period; 49% (38/78) were in the ICU and 51% (40/78) were in the non-ICU setting. Of febrile patients in the ICU, 87% (33/38) had infection and 13% had non-infectious etiology for fever. Seventy-nine percent (26/33) of the infections associated with fever in the ICU were bacterial, 9% (3/33) were viral, and 9% (3/33) were fungal in etiology. Pneumonia (30%), catheter-related bacteremia (15%), and biliary tree (9%) were the predominant sources of infections associated with fever in the ICU. Bacteremia was documented in 45% of the patients with fever in the ICU. Fifty-three percent (20/38) of the febrile episodes in the ICU occurred during the initial post-transplant stay, and 47% (18/ 38) during a subsequent readmission. Pneumonia accounted for 41% of all febrile infections during the first 7 d of ICU stay, but only 14% of those after 7 d. Febrile patients in the ICU had higher APACHE II scores (p = 0.001), higher APS scores (p = 0.0001), higher bilirubin (p = 0.001), lower cholesterol (p = 0.019), higher prothrombin time (p = 0.001), were more tachycardiac (p = 0.002), and were more likely to have abnormal blood pressure (p = 0.001) than those in the non-ICU setting. Twenty-three percent of all infections in the ICU were unaccompanied by fever and 9% were accompanied by hypothermia. Mortality at 14 d (24 versus 0%, p = 0.001) and at 30 d (34 versus 5%, p = 0.001) was significantly higher in febrile patients in the ICU, as compared to the patients in the non-ICU setting. These data have implications for diagnostic evaluation and management of critically ill febrile liver transplant recipients.

Psychological characteristics of candidates for liver transplantation: differences according to history of substance abuse and UNOS listing. United Network for Organ Sharing

Liver transplantation for patients with a history of substance abuse remains controversial. Resumption of heavy alcohol use postoperatively is a threat to long-term survival, but recidivism among transplanted alcoholics is reportedly low. An argument against psychological evaluation prior to transplantation revolves around the speculation that candidates will attempt to portray themselves as more desirable prior to listing with UNOS (United Network for Organ Sharing). This study measured psychological distress, coping styles, optimism, selected personality features, and perception of family environment among 73 U.S. military veterans who were candidates for liver transplantation. Candidates with positive histories of substance abuse revealed significantly more distress, less adaptive coping styles, and more character pathology than their counterparts. The only significant difference according to UNOS listing was on one measure of family environment. Results support preoperative psychological assessment and intervention on a more extensive level for substance abusers and raise questions for future research.

Encephalopathy associated with human herpesvirus 6 in a liver transplant recipient

Recent reports have documented human herpesvirus 6 (HHV-6) as a cause of high fever, bone marrow depression, and rash in liver transplant recipients in the absence of another known pathogen. We describe a 49-year-old liver transplant recipient who developed confusion, occipital headache, and involuntary movements of the limbs 3 weeks after orthotopic liver transplantation. HHV-6 was detected in the peripheral blood using a rapid culture assay. Examination of cerebrospinal fluid by polymerase chain reaction for HHV-6 was also positive. No other pathogens were identified. The patient improved after commencement of intravenous ganciclovir therapy. This case suggests HHV-6 needs to be considered in the differential diagnosis of unexplained confusion in liver transplant recipients.

Pulmonary infiltrates in liver transplant recipients in the intensive care unit

BACKGROUND

A frequent dilemma is discerning the likelihood of pneumonia and the need for empiric antibiotic therapy in liver transplant recipients with pulmonary infiltrates in the intensive care unit (ICU).

METHODS

We performed a prospective, observational study of consecutive liver transplant recipients developing pulmonary infiltrates in the ICU.

RESULTS

Of 90 consecutive liver transplant patients in the ICU over a 3-year period, 44% (40) developed pulmonary infiltrates. The etiologies were pneumonia (38%, 15 of 40), pulmonary edema (40%, 16 of 40), atelectasis (10%, 4 of 40), adult respiratory distress syndrome (8%, 3 of 40), contusion (3%, 1 of 40), and unknown (3%, 1 of 40). Pneumonia was due to methicillin-resistant Staphylococcus aureus in 27% (4 of 15), Pseudomonas aeruginosa (27%, 4 of 15), invasive aspergillosis (20%, 3 of 15), and Enterobacter cloacae, Serratia marcescens, Pneumocystis carinii pneumonia, and unknown (7%, 1 of 15) in one each. None of the patients had cytomegalovirus or herpes simplex virus pneumonia. Seventy-five percent of methicillin-resistant Staphylococcus aureus and all Aspergillus pneumonias, but only 14% of the Gram-negative pneumonias, occurred within 30 days of transplantation. Twenty-seven percent of the pneumonias occurred >365 days after transplantation; all of these were in patients with recurrent viral hepatitis C virus or hepatitis B virus, disseminated posttransplant lymphoproliferative disorder, or late rejection. Of patients with pneumonia, 87% were ventilated and 40% had bacteremia. Clinical pulmonary infection score (Pugin score) >6 (73% vs. 6%, P = 0.0001), abnormal temperature (73% versus 28%, P = 0.005), and creatinine level >1.5 mg/dl (80% versus 50%, P = 0.05) were predictors of pneumonia versus other etiologies of pulmonary infiltrates. Overall mortality in patients with pulmonary infiltrates was 28% (11 of 40); pneumonia as etiology (P = 0.06), creatinine level >1.5 mg/dl (P = 0.028), higher blood urea nitrogen (P = 0.017), and worse APACHE neurological score (P = 0.04) were predictors of poor outcome.

CONCLUSIONS

Our data have implications not only for identifying pneumonia as a potential cause of pulmonary infiltrates, but for the likely etiology of the pneumonia and thus the selection of empiric antibiotic therapy in critically ill liver transplant recipients. Pugin score >6 in patients with pulmonary infiltrates warrants antimicrobial therapy. Early onset within 30 days after transplantation raises the spectra of aspergillosis.

Intraoperative hypothermia is an independent risk factor for early cytomegalovirus infection in liver transplant recipients

BACKGROUND

Early cytomegalovirus (CMV) reactivation infections have been found to be associated with a number of stress responses such as severe bacterial infection. Intraoperative hypothermia is known to be a significant physiological stressor. Hence, we sought to evaluate a relationship between intraoperative hypothermia during liver transplantation and early CMV infection.

METHODS

Relationships between intraoperative hypothermia and early CMV infection were assessed using univariate and multivariate analysis.

RESULTS

There were 11 of 100 patients who had CMV infection detected within the first 30 days after the transplant and 16 of 100 in the next 3 months after the transplant. The median intraoperative temperature (34.4 degrees C) of those who subsequently developed early CMV infection was significantly lower than that in patients who did not develop early CMV infection (35.3 degrees C; P = 0.032). Multivariate analysis showed that only hypothermia was an independent predictor of early CMV infection (odds ratio 2.8, 95% confidence intervals 1.2-6.4; P = 0.047).

CONCLUSIONS

Intraoperative hypothermia during liver transplantation increases the risk of CMV infection in the 1st month postoperatively and active warming seems to reduce this risk.

Quality of life, functional status, and depression in male liver transplant recipients with recurrent viral hepatitis C

BACKGROUND

The quality of life, psychologic sequelae, and functional status of liver transplant recipients with recurrent hepatitis C virus (HCV) hepatitis have not been well defined.

METHODS

Perceived quality of life, psychologic distress, depression, adaptive coping, and functional status were prospectively assessed in 59 liver transplant recipients at baseline (before transplantation) and 6 and 12 months after transplantation; comparisons were made between patients with recurrent HCV hepatitis and all other patients.

RESULTS

Recurrent HCV hepatitis developed in 41% (14/34) of the patients with HCV. At 6 months, the patients with recurrent HCV hepatitis had significantly lower functional status (P=0.013) and experienced less gain in physical functioning from baseline than other patients (P=0.02). Quality of life, depression, and psychologic distress were not different at 6 months for patients with recurrent HCV hepatitis compared with all other patients. At 12 months, the patients with recurrent HCV hepatitis had significantly lower quality of life (P=0.003), greater depression (P=0.045), higher psychologic distress (P=0.05), and lower physical functioning (P=0.008) than all other patients.

CONCLUSION

Recurrent HCV hepatitis in liver transplant recipients is associated with impairment in quality of life, functional status, and greater depression compared with patients who did not have HCV and those without HCV recurrence.

Psychological characteristics of candidates for liver transplantation

This study examined depression, anxiety, coping styles, optimism, selected personality characteristics, and perception of family environment among candidates for liver transplantation (OLTX); the goal was to measure and empirically describe psychosocial factors reported to impact on the experience and outcome of transplantation. Subjects were 73 US military veterans being considered for OLTX at the VAMC-Pittsburgh (UD) from 1994 to 1996. Psychological evaluation consisted of chart review, consultation with the transplant team, clinical interview and administration of published, standardized, and readily available psychological tests. Candidates displayed above normal levels of situational anxiety and depression, mainly adaptive coping styles, mild optimism, and positive family environments. Factor analysis of the data identified two dimensions of psychological distress, five coping styles, and three types of family environment. The composite MMPI-2 profile for the sample shows marked elevations of the neurotic triad and moderate elevations of psychasthenia and schizophrenia scales. Psychological distress, psychopathology, coping styles, optimism, and perceptions of family environment correlate with each other in the directions suggested by the literature. These findings support previous research with empirical data; results encourage the development of consistent psychological protocols and procedures to evaluate and treat organ transplant candidates.

Infectious complications occurring in liver transplant recipients receiving mycophenolate mofetil

BACKGROUND

Mycophenolate mofetil (MMF) is a new immunosuppressive agent that is gaining widespread use in solid organ transplantation recipients. A comprehensive assessment of infectious complications after its use after liver transplantation has never been assessed.

METHODS

Bacterial, fungal, and viral infections occurring after transplantation were compared for a cohort of consecutive liver transplant recipients who received MMF (because of suspected tacrolimus-related nephrotoxicity or neurotoxicity) and a cohort who did not receive the drug. All patients received a tacrolimus-based primary immunosuppressive protocol.

RESULTS

Biopsy-proven acute rejection episodes within the first 6 months after transplant occurred in 6% of MMF-treated patients but in 30% of those who did not receive MMF (P=0.07). No significant differences were found in occurrence of cytomegalovirus infection or disease, Pneumocystis carinii, Aspergillus, or other fungal infection and hepatitis C virus recurrence between MMF-treated and untreated patients. Bacterial infections were more common in MMF-treated patients, but this cohort had a prolonged intensive care unit stay compared with patients who did not receive MMF. None of the MMF-treated patients with bacterial infection had leukopenia.

CONCLUSIONS

MMF use does not appear to be associated with an significantly increased risk of infection occurring after liver transplantation and is associated with fewer episodes of acute rejection.

Late onset cytomegalovirus disease in liver transplant recipients: de novo reactivation in recurrent hepatitis C virus hepatitis

Late onset cytomegalovirus (CMV) disease (occurring more than 1 year post-transplant] was documented in two liver transplant recipients with recurrent hepatitis C virus hepatitis in the absence of factors known to precipitate CMV disease, i.e., primary acquisition of CMV, allograft rejection, augmented immunosuppression, concomitant infections, or blood transfusions. Both patients had CMV enteritis (with CMV adrenalitis in one case]; however, other symptoms and signs of overt CMV infection, i.e., fever, leukopenia, or atypical lymphocytes, were lacking. Hepatitis C virus is an immunomodulatory virus; impaired CMV-specific T-cell responses may have accounted for the predisposition of our patients to unprovoked, late onset CMV disease. Given the high incidence of hepatitis C virus recurrence after liver transplantation, awareness of the occurrence and recognition of the unusual presentation of CMV disease in this setting is both clinically relevant and significant, particularly since CMV is treatable if recognized promptly.

Staphylococcus aureus nasal colonization and association with infections in liver transplant recipients

BACKGROUND

Staphylococcus aureus has emerged as a leading cause of bacterial infections after liver transplantation. However, the role of nasal colonization in the development of S aureus infections has never been explored in liver transplant recipients. The objectives of this study were to determine whether nasal carriage of S aureus was a risk factor for S aureus infections in liver transplant recipients.

METHODS

Over a 2-year period, 30 consecutive liver transplant recipients were studied. Beginning when the recipients were transplant candidates, nasal cultures were performed at each admission and monthly thereafter until discharge or death.

RESULTS

Overall, 67% (20/30) of the patients were nasal carriers, 70% of the carriers had methicillin-resistant S aureus (MRSA), 15% had methicillin-sensitive S aureus, and 15% had both MRSA and methicillin-sensitive S aureus. Infections were significantly associated with the carrier state; 100% (9/9) of the infected patients were carriers as compared with 50% (11/21) of the noninfected patients (P=0.01). All infections were a result of MRSA, and 56% (5/9) of the infections were bacteremia. Median time to the onset of S aureus infections was 16 days after transplant. Pulse field gel electrophoresis (with digestion of S aureus with SmaI restriction enzyme) in seven infected patients demonstrated that the isolates from the anterior nares matched the invasive isolates in all cases. A total of 43% (3/7) of these infected patients shared the same restriction pattern.

CONCLUSION

MRSA colonization of the anterior nares was a significant predictor of MRSA infections in liver transplant recipients. Infections occurred only in those colonized with MRSA and were a result of the endogenously colonizing S aureus strains in all cases.

Staphylococcus aureus nasal colonization in patients with cirrhosis: prospective assessment of association with infection

OBJECTIVE

To determine if Staphylococcus aureus colonization of the anterior nares was a risk factor for S aureus infection in patients with cirrhosis and to determine the predictors of S aureus infection in colonized patients.

DESIGN

Prospective cohort study.

PATIENTS

84 consecutive patients with cirrhosis admitted to the liver transplant unit of a university-affiliated Veterans' Affairs Medical Center.

RESULTS

Overall, 39 (46%) of the 84 patients were nasal carriers of S aureus, of which 24 (29%) were methicillin-resistant Staphylococcus aureus (MRSA) and 15 (18%) were methicillin-sensitive Staphylococcus aureus (MSSA). Only MRSA, but never MSSA, carriage was acquired in the hospital; all 15 of the MSSA versus 14 (58%) of the 24 MRSA carriers were nasal carriers on first (admission) culture (P=.001). Of the 10 (42%) of 24 MRSA carriers who were not colonized on admission, 3 became MRSA carriers within 1 month, and 7 acquired MRSA carriage more than a month later. Higher Child-Pugh score was independently associated with MRSA carriage (odds ratio [OR], 1.54; 95% confidence interval [CI95], 1.1-2.3). S aureus nasal carriers (9 [23%] of 39) were significantly more likely to develop S aureus infections than noncarriers (2 [4%] of 45; P=.02). Central venous catheter use was associated independently with S aureus infections in the carriers (OR, 4.1; CI95 2.8-6.1). Mortality was significantly higher in carriers who developed S aureus infections as compared to those who did not (57% vs 13%; P=.022); S aureus infection was an independent predictor of mortality in the carriers (OR, 8.7; CI95, 1.2-63.8).

CONCLUSIONS

Colonization of the anterior nares was a significant predictor of S aureus infection in patients with cirrhosis.