The antifracture efficacy of vitamin D in adults - are we assessing it reliably? A systematic review

INTRODUCTION

The antifracture efficacy of vitamin D is still controversial. The aim of this systematic review was to examine if the vitamin D trials were designed adequately to reliably assess its antifracture activity.

MATERIAL AND METHODS

The electronic databases PubMed, Medline, Embase, Web of Science, and Cochrane Library were searched to identify clinical trials evaluating the antifracture efficacy of vitamin D in adults. We compared the protocols of the trials against the opinions of the American Society for Bone and Mineral Research (ASBMR), International Society for Clinical Densitometry (ISCD), National Osteoporosis Foundation (NOF), European Medicines Agency (EMEA) experts, and the consensus statement from the 2nd International Conference on Controversies in Vitamin D, and against the protocols of the trials of the medications with proven antifracture efficacy (bisphosphonates, teriparatide, abaloparatide, raloxifene, denosumab, romosozumab). We assessed the prospective character, study design, group description, number of patients, study duration, and vitamin D (serum examination and dosage) supplementation. A description of the desired characteristics of the study protocol was presented.

RESULTS

Thirteen eligible trials were identified. All but 2 were conducted in the elderly population only. Nine trials were included in the final analysis. Serum 25-hydroxy vitamin D (25OHD) was not measured in a representative number of subjects before (except in 2 studies), during, or after treatment in any study.

CONCLUSIONS

The analysed studies did not conclusively assess the vitamin D antifracture efficacy in patients with prestudy low serum vitamin levels, due to the lack of assessment of whether sufficient doses of vitamin D were used. They informed about the relevant doses and preparations of vitamin D in particular groups (specific fracture risk, age, place of residence) only.

Kidney Function After Liver Transplantation in a Single Center

Background

Renal dysfunction in the peri-transplant period appears to complicate both short- and long-term outcome of liver transplantation (LT). The aim of this study was to analyze the impact of selected clinical features in the peri-liver transplant period, as well calcineurin inhibitor, particularly tacrolimus given after LT, on kidney function in a single liver transplant center’s experience.

Material/Methods

A total 125 consecutive liver-grafted individuals (82 M, 43 F), mean age 50±13 y (with alcohol-related liver disease in 48 (38%) patients) were included into the study. Their clinical data were collected in the database until 46 months of follow-up, and the Python packages Pandas (version 0.22.0) and scikit-learn (version 0.21.3) were used for data analysis.

Results

More advanced liver disease as judged by Child-Pugh class and MELD score differed significantly patients with preserved (serum creatinine SCr <1.5 mg/dL) and impaired (SCr ≥1.5 mg/dL) kidney function before LT. Older age and higher SCr pre-LT were associated with higher levels of SCr after LT in 2 time-points. SCr before LT was correlated with delta SCr for the highest and last recorded value (P<0.0001). Higher amounts of transfused colloids during surgery were associated with increased delta SCr for the highest value (P=0.019) after grafting in logistic regression analysis. There were no associations between SCr after LT and duration of anhepatic phase, urine output ≤100 mL/h, or post-reperfusion syndrome during transplantation (all P>0.05). There were no associations between SCr after LT and tacrolimus trough levels in analyses of correlations and linear regression analyses (all P>0.05).

Conclusions

We found that pretransplant serum creatinine was the only factor affecting kidney function after LT in our liver transplant center. The restricted fluid policy was safe and effective in terms of long-term renal function. The role of kidney-saving immunosuppressive protocols in preserving renal function long-term after LT was also confirmed.

THE IMPORTANCE OF MENTAL RESILIENCE AGAINST LONELINESS DURING THE COVID-19 PANDEMIC IN DIALYSIS PATIENTS

The pandemic crisis of COVID-19 has caused anxiety and depressive symptoms to increase in many people worldwide. Yet, difficult situations may not only lead to various types of disorders, fears, anxieties and feelings of loss. They can also lead to positive changes, even to development or growth after experienced trauma, to positive adaptation, to changes in self-perception, changes in interpersonal relations or philosophy of life. Patients with chronic kidney disease, especially those on renal replacement therapy, often experience severe psychological problems such as anxiety disorders, depressive disorders, or difficulties related to coping with excessive stress. The aim of our review is to disscus the appropriatness of mental health screening tools in patients with chronic kidney disease, including those on dialyses, during COVID-19 pandemic. Recently published studies indicate the limited available data evaluating the diagnostic accuracy of screening tools for mental status in patients with chronic kidney disease. This, it seems reasonable to stress the mental health associations with situational stress in this group of patients during the SARS-CoV-2 pandemic. It is also worth pointing out the need to research the impact of the mental disorders in this population on morbidity and mortality, taking into account other organ complications and the quality of life of patients not only during the SARS-CoV-2 pandemic. It is worth to to make every effort to reduce the severity of the anxiety and feelings of hopelessness in dialysis patients, to cope with the pandemic.

Clinical Relevance of Kidney Biopsy in Patients Qualified for Liver Transplantation and After This Procedure in the Model for End-stage Liver Disease (MELD) Era: Where Are We Today?

Chronic kidney disease (CKD) has been recognized as an increasingly common complication of liver transplantation (OLTx). Post-transplant renal dysfunction contributes to long-term morbidity and mortality following OLTx and is a very important issue in the management of liver transplant recipients. Its etiology is multifactorial and can be determined by kidney biopsy, which is too rarely done in this patient group. In the clinical context of patients with liver cirrhosis, accurate and reliable evaluation of the renal injury is crucial. We performed a review of kidney biopsies in patients with symptoms of CKD (proteinuria/hematuria/elevated creatinine) before and after liver transplantation in the published literature. Kidney biopsies were performed either before or after liver transplantation using percutaneous technique. There are few reports on transjugular kidney biopsy. Biopsy results prevented unnecessary modification of immunosuppressive therapy or selection of candidates for liver transplantation. In our opinion, kidney biopsy is a clinically relevant diagnostic approach to recognize kidney disease before and after liver transplantation, it also helps with the management of kidney disease in this population, and it is safe. Kidney biopsy should be offered more often in liver transplant patients to ensure appropriate therapy in concomitant CKD in this population. Our decisions today will impact clinical outcomes in the future.

Treatment of hepatitis C in selected clinical settings

This article aims to review the treatment strategy of Hepatitis C in compelling indications and provide the literature update, mainly discussing the EASL (European Association for the Study of the Liver) recommendations, which described the current optimal management of patients with acute and chronic HCV infections. The review will focus on HCV infection in selected clinical settings including patients with immune complex-mediated manifestations of chronic hepatitis C, patients with chronic kidney disease (CKD) or renal end-stage renal disease (ESRD), and solid organ transplant recipients.

Approach to a patient with hepatitis c: diagnosis and pretreatment assessment

Chronic infection with hepatitis virus C affects more than 70 million individuals worldwide. Hepatitis C infection is the leading cause of end-stage liver disease, hepatocellular carcinoma, and multiple extrahepatic manifestations associated with immune system disorders and chronic inflammation. In the era of interferon-free anti-HCV regimens, clinical care for patients with HCV-related liver disease and extrahepatic complications has advanced significantly because of improvements in therapy and prevention. The antiviral capacity of a new generation of direct-acting agents provide high rates of sustained virological response, and it is expected to improve clinical outcomes in these patient populations. The article aims to review published data on the treatment strategy of hepatitis C, including the EASL (European Association for the Study of the Liver) recommendations.

Pretransplant QT Interval: The Relationship with Severity and Etiology of Liver Disease and Prognostic Value After Liver Transplantation

BACKGROUND Prolonged QT interval is an integral part of the definition of cirrhotic cardiomyopathy. The aim of this study was to analyze the relationship between QT corrected (QTc) and the etiology and the severity of liver disease in relation to the complications of cirrhosis in candidates for orthotropic liver transplantation (OLTx). MATERIAL AND METHODS From 360 consecutive patients with end-stage liver disease (ESLD) consulted by a designated cardiologist, 160 patients underwent OLTx. The QTc was calculated according to 3 formulas in 151 ECG tracings with good quality. The severity of liver disease was assessed according to Child-Pugh classification and model for end-stage liver disease (MELD). This was a single-center study with register-based follow-up design. RESULTS Prolonged QTc over 440 ms was found in 51 subjects (33.8%), but none had prolonged QTc >500 ms. QTc corrected by Fridericia (F) formula was more suitable for patients with ESLD. We found no correlation between QTc interval and severity of liver disease. The QTc interval was higher in patients with alcoholic cirrhosis when compared to patients with viral hepatitis and ESLD of other etiologies. We observed a higher QTc interval in patients with gastroesophageal varices and encephalopathy. We did not notice any significant difference in the effect of the QTc interval on survival. CONCLUSIONS QTc interval might be associated with etiology and complication of ESLD. The prolonged QT interval is not associated with higher all-cause mortality after OLTx.

The Pre-Transplant Profile of Cardiovascular Risk Factors and Its Impact on Long-Term Mortality After Liver Transplantation

BACKGROUND Cardiovascular disease (CVD) is an important aggravating factor for orthotopic liver transplantation (OLT) outcomes. CVD still seems to be one of the most common cause of death in the long-term post-transplant period. Nevertheless, there are some limited data regarding the optimal strategy of risk assessment during OLT candidate evaluation. MATERIAL AND METHODS Routine pre-transplant cardiac workup in 360 patients with end stage liver disease (ESLD) included electrocardiogram, echocardiography, and exercise stress testing. The aim of this retrospective study was an analysis of the impact of cardiovascular risk profile on overall mortality in the 2-year follow-up of 160 patients who underwent liver transplantation. RESULTS Cardiovascular risk factors or a history of CVD were found in 23.1% of patients who received transplants. The cardiovascular risk factors most common in our group of transplant recipients with ESLD were: diabetes (26.3%), hypertension (25.6%), and hepatopulmonary syndrome (23.1%). Only 3.8% of patients had a positive exercise test. Coronary angiography revealed at least 50% stenosis in some epicardial arteries in 1.9% of patients. The risk of death in long-term follow-up of liver transplant recipients was most strongly associated with 3 cardiac variables: history of coronary artery disease (CAD), angiographically confirmed coronary stenosis, and reduced ejection fraction (EF). CONCLUSIONS Our study identified pre-transplant CAD with its consequences as a factor associated with increased risk of negative post-transplant outcomes.

Good outcome following liver transplantation using pericardial-peritoneum window for hepato-atrial anastomosis to overcome advanced hepatic alveolar echinococcosis and secondary Budd-Chiari Syndrome - a case report

BACKGROUND

This report presents a case of a 57- year old female with advanced Hepatic Alveolar Echinococcosis causing a secondary Budd-Chiari Syndrome due to infiltration of the suprahepatic inferior vena cava treated successfully by liver transplantation.

CASE PRESENTATION

A temporary veno-venous bypass was introduced, but a typical end to end cavo-caval anastomosis wasn't possible in this case. In order to access a disease free part of the inferior vena cava, an oval window of the diaphragm was excised, providing communication between the peritoneum and pericardium. A vascular clamp was placed onto the right atrium which allowed for an atrial-caval anastomosis. The remainder of hepatectomy was performed in a conventional manner. In the post-operative period and during the 18 month follow-up there were no complications. The patient remains in good general condition with optimal graft function.

CONCLUSIONS

A hepato-atrial anastomosis with a pericardial-peritoneum window during liver transplantation is feasible and extends the curability potential for patients with advanced Hepatic Alveolar Echinococcosis considered for liver transplantation.

Generalized Posttransplant Kaposi Sarcoma without Mucocutaneous Manifestations in the First Liver Transplantation in an HIV-Positive Patient in Poland: A Case Report and Review of Literature

BACKGROUND Kaposi sarcoma (KS) is the most frequent skin cancer in solid organ recipients, and also a typical malignancy in HIV-infected persons. CASE REPORT We describe here a rare case of primary nodal KS without mucocutaneous manifestations, diagnosed in a 20-year-old HIV/HBV co-infected patient 12 months after liver transplantation (LT), the first one performed in a HIV-positive patient in Poland. The course of the disease was very aggressive; the patient died four weeks after general lymphadenopathy appearance. In the autopsy, KS infiltration was found in numerous lymph nodes and in the lung' apexes without skin or other organs' involvement. CONCLUSIONS In conclusion, posttransplant KS may present as general lymphadenopathy without mucocutaneous manifestations, thus mimicking posttransplant lymphoproliferative disorder, which is often the first clinical suspicion. Lymph node histopathological examination is necessary to make the right diagnosis.

Evolution Of The Results Of 1500 Liver Transplantations Performed In The Department Of General, Transplant And Liver Surgery Medical University Of Warsaw

Liver transplantation is a well-established treatment of patients with end-stage liver disease and selected liver tumors. Remarkable progress has been made over the last years concerning nearly all of its aspects. The aim of this study was to evaluate the evolution of long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery (Medical University of Warsaw).

MATERIAL AND METHODS

Data of 1500 liver transplantations performed between 1989 and 2014 were retrospectively analyzed. Transplantations were divided into 3 groups: group 1 including first 500 operations, group 2 including subsequent 500, and group 3 comprising the most recent 500. Five year overall and graft survival were set as outcome measures.

RESULTS

Increased number of transplantations performed at the site was associated with increased age of the recipients (p<0.001) and donors (p<0.001), increased rate of male recipients (p<0.001), and increased rate of piggyback operations (p<0.001), and decreased MELD (p<0.001), as well as decreased blood (p=0.006) and plasma (p<0.001) transfusions. Overall survival was 71.6% at 5 years in group 1, 74.5% at 5 years in group 2, and 85% at 2.9 years in group 3 (p=0.008). Improvement of overall survival was particularly observed for primary transplantations (p=0.004). Increased graft survival rates did not reach the level of significance (p=0.136).

CONCLUSIONS

Long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery are comparable to those achieved in the largest transplant centers worldwide and are continuously improving despite increasing recipient age and wider utilization of organs procured from older donors.

Acetaminophen (Paracetamol) induced acute liver failure - A social problem in an era of increasing tendency to self-treatment

INTRODUCTION

The widespread availability of medication without prescription, so-called over the counter (OTC), and the rapid development of health consciousness of Poles is associated with broad access to medical information in the mass media. This causes patients to recognize their own disease, cancel doctor's appointments, and begin self-treatment. This time and money-saving behavior, often signaled by pain, usually leads to the treatment of symptoms alone, without seeking the cause of the disease.The aim of the study was to present life-threatening paracetamol poisoning, and the treatment of acute liver failure.

MATERIAL AND METHODS

In 2002-2014, 35 patients were hospitalized due to acute paracetamol poisoning: 17 female and 18 male patients aged between 17-59 (mean 32.3 years). Patients were treated in the surgical intensive care unit, where their parameters of liver and renal function were continuously monitored. If there was no improvement in the liver function, patients underwent albumin dialysis with the Prometheus system and were qualified for liver transplantation (LTx).

RESULTS

26 patients were treated pharmacologically and 7 out of 9 patients who underwent LTx were dialyzed. Overall, 11 patients had 26 albumin dialysis in total; 4 patients died - 1 post-transplant and 3 pre-transplant.

CONCLUSIONS

Paracetamol is the cause of many poisonings resulting from the lack of public awareness about toxic interactions with alcohol, and suicide attempts. Acetaminophen-induced acute liver failure concerns a small percentage of patients but can be successfully treated with albumin dialysis, and in extreme cases by liver transplantation.

Treatment of pruritus with Prometheus dialysis and absorption system in a patient with benign recurrent intrahepatic cholestasis

Benign recurrent intrahepatic cholestasis (BRIC) is an autosomal recessive liver disorder characterized by recurrent episodes of jaundice and itching. Episodes of cholestasis last variously from 1 week to several months, may start at any age and usually resolve spontaneously. No effective treatment has been found as yet. We report a case of genetically proven BRIC in a male patient who developed three episodes of pruritus and jaundice at the age of 14, 16 and 19 years. During the third episode, he did not respond to pharmacological medical therapy, and fractionated plasma separation and absorption (FPSA, Prometheus) was performed to manage intractable pruritus. The treatment immediately alleviated pruritus, lowered serum bilirubin concentration and induced sustained remission in the 5-year follow up. FPSA seems to be a safe and effective way of treatment for BRIC in patients with severe pruritus and prolonged jaundice.

Heterozygous α1‑antitrypsin deficiency in liver transplant candidates

INTRODUCTION

It is estimated that in about 1% of all liver transplant candidates liver cirrhosis is caused by hereditary homozygous α1‑antitrypsin (AAT) deficiency.

OBJECTIVES

The aim of the study was to evaluate the role of heterozygous AAT deficiency in the development of liver cirrhosis leading to liver transplantation.

PATIENTS AND METHODS

In the years 2009-2011, we conducted a prospective study of 304 consecutive patients (men, 57%) scheduled for orthotopic liver transplantation. AAT phenotyping and the clinical assessment of hepatic and cardiopulmonary functions were performed in all subjects. 

RESULTS

The most common causes of liver cirrhosis were viral hepatitis (21%) and alcohol abuse (12%). Normal protease inhibitor (Pi) MM phenotype was observed in 284 patients. The PiMZ phenotype was detected in 11 subjects (4%), which indicates its higher prevalence in patients with liver cirrhosis compared with the general population (2%). PiMS phenotype was found in 6 patients (2%), and this value was similar to that observed in the Polish population. In 3 patients, less common phenotypes were observed: MP, IM, and MX.

CONCLUSIONS

The PiMZ phenotype may be an independent risk factor for the development of liver cirrhosis along with the most common causes, namely, viral hepatitis and alcohol abuse.

Results of liver transplantation in the Department of General, Transplant and Liver Surgery at the Medical University of Warsaw in patients with chronic hepatitis B and C viruses infection

INTRODUCTION

Cirrhosis related to hepatitis C virus (HCV) and hepatitis B virus (HBV) infection is the most frequent indication for liver transplantation worldwide. Progress in prophylaxis of posttransplant HBV recurrence has led to major improvements in long-term outcomes of patients after liver transplantation. Conversely, impaired posttransplant survival of patients with HCV infection was reported in several studies, mainly due to recurrence of viral infection. The purpose of this study was to compare long-term results of liver transplantation between patients with HBV monoinfection, HCV monoinfection and HBV/HCV coinfection.

MATERIAL AND METHODS

A total of 1090 liver transplantations were performed in the Department of General, Transplant and Liver Surgery in cooperation with the Department of Immunology, Internal Medicine, and Transplantology at the Transplantation Institute Medical University of Warsaw between December 1994 and May 2012. After exclusion of patients with cirrhosis of non-viral etiology, patients with malignant tumors, and patients with acute liver failure, the final study cohort comprised 209 patients with HBV (HBV+/HCV- subgroup; n = 56) or HCV (HBV-/HCV+ subgroup; n = 119) monoinfection or HBV/HCV coinfection (HBV+/HCV+; n = 34). These subgroups of patients were compared in terms of long-term results of transplantations, defined by 5-year patient and 5-year graft survival estimates.

RESULTS

Overall and graft survival rates after 5-years for the whole study cohort were 74.5% and 72.6%, respectively. Five-year overall survival was 70.4% for patients within the HBV+/HCV- subgroup, 77.8% for patients within the HBV-/HCV+ subgroup, and 68.5% for patients within the HBV+/HCV+ subgroup. The corresponding rates of graft survival were 67.0%, 76.3%, and 68.5% for patients within the HBV+/HCV-, HBV-/ HCV+, and HBV+/HCV+ subgroups, respectively. Observed differences were non-significant, both in terms of overall (p = 0.472) and graft (p = 0.461) survival rates.

CONCLUSIONS

Both overall and graft survival rates after liver transplantations performed in the Department of General, Transplant and Liver Surgery in cooperation with the Department of Immunology, Internal Medicine, and Transplantology at the Transplantation Institute Medical University of Warsaw in patients with HBV and HCV infection are comparable to those reported by other European and American centers. In contrast to other studies, obtained results do not confirm the negative impact of HCV infection on long-term outcomes of patients.

Prevalence and predictors of acute renal injury in liver transplant recipients

Renal failure is a major factor impacting liver transplant outcomes. Renal functional impairment predicts decreased survival, leading to increased morbidity and mortality. The aim of this study was to estimate the incidence, risk factors, and resolution of acute kidney injury (AKI) among liver transplant recipients during the operative hospital stay. We analyzed data from 99 orthotopic liver transplantations (OLT) performed at our center in 2008. Posttransplantation occurrence of AKI was defined as an increase in serum creatinine (SCr) concentration of 0.3 mg/dL or more, namely, 1.5-fold from baseline. AKI was observed among 31.31% of liver transplant recipients (n = 31). The mean increase in SCr was 2.49 +/- 0.78-fold from baseline. The mean posttransplant SCr level was 2.59 +/- 0.92 mg/dL. Renal replacement therapy was introduced to 16.12% (n = 5) liver recipients developing AKI. Among them, 2 subjects (6.45%) died. The mean SCr level at the time of discharge from the hospital was 1.17 +/- 0.57 mg/dL among the AKI group compared with 0.77 +/- 0.32 mg/dL among the group without AKI. Pretransplant renal impairment expressed by an elevated SCr concentration (relative risk [RR] = 1.25; P = .0386) and treatment with exogenous vasoconstrictors during the operation (RR = 2.27; P = .016) were identified as risk factors for developing AKI after liver transplantation.

[Role of the pathomorphologist in diagnostic process concerning problems of ortothopic liver transplantation in adults]

In this paper are presented main tasks of the pathologist dealing with liver diagnosis concerning problems of its transplantation in adults. They include: pretransplant diagnosis of recipient's liver, examination of explanted liver, evaluation of donor liver (pretransplant biopsies and performed during the operation), posttransplant assessment of the graft. On the basis of our own experience, the most frequent problems in patologist's work and basic information concerning the diagnostic process in liver transplantation with posibillities and limits of the histopathological method are described. Because of the popularity of transplantation as the method of treatment of advanced liver diseases, the group of transplanted patients continously enlarges and may lead to visit to doctors of different specialties. That is why presentation of this issue seems to be very valuable.

Prevention of hepatitis B recurrence after liver transplantation using lamivudine and hepatitis B immune globulin

BACKGROUND

Patients undergoing liver transplantation (ltx) for hepatitis B-related liver disease are prone to recurrence. Historically, ltx has been associated with aggressive reinfection and poor survival results. The mainstay of prophylaxis has been passive immunotherapy with hepatitis B immune globulin(HBIG). Antiviral prophylaxis with lamivudine appears to reduce hepatitis B virus (HBV)infection after liver transplantation. However, HBV recurrence remains common. This study retrospectively evaluated a single center's experience with cohort of patients who underwent ltx for HBV-related chronic and acute liver disease. We examined the effect of a combined of intravenous HBIG and lamivudine viral prophylactic therapy on HBV recurrence and the outcome of ltx.

MATERIAL/METHODS

Eighteen patients underwent transplantation for HBV liver disease at our center. Before ltx all patients were HBsAg positive and 3 were HBV DNA positive. HBV recurrence was defined by HBsAg seropositivity after ltx. HBIG monotherapy was used in 2 (15%) patients, lamivudine monotherapy in 4 (31%), and lamivudine and HBIG combination in 7 (54%). Hepatocellular carcinoma was present in 1 patients. Maintenance immunosuppression regimens consisted of either a cyclosporine- or tacrolimus-based drug regimen.

RESULTS

Overall 1-year and 3-years patient survival rates were 60% and 60%, respectively, and 1-year and 3-years graft survival was 60% and 60% respectively. Among 7 patients receiving receiving combination HBIG and lamivudine, one patient died. He was retransplanted 9 months after first transplantation secondary to biliary complication caused by late hepatic artery thrombosis. Of the 6 surviving patients, 4 patients currently have normal allograft function. Allograft dysfunction developed in two patients because of ischemic biliary strictures. Among seven patients, who received HBIG and lamivudine, one did not receive proper administration of the prophylactic regimen and graft became infected. Serologic HBV recurrence was diagnosed after 9 months after transplantation.

CONCLUSIONS

Liver transplantation for HBV under combination viral prophylaxis results in good survival rates. A good outcome is possible after liver transplantation for HBV liver disease using HBIG dosed by pharmacokinetic parameters in combination with lamivudine. Viral prophylactic therapy has effectively reduced HBV recurrence and prolonged survival outcome.

Safety and efficacy of hormonal therapy in menopausal kidney-allograft recipients

AIM

A higher risk of premature menopause and osteoporosis has been observed in female kidney-allograft recipients, providing particular indications for hormonal therapy. We have summarized our 10-year-experience with hormonal therapy in menopausal kidney transplant recipients.

MATERIALS AND METHODS

From 1995 to 2004, hormonal therapy was administered to 54 kidney transplant recipients. At onset of therapy the ages of the women ranged from 31 to 52 years, and the period from transplantation from 3 months to 13 years. The mean time on therapy was 4.2 years. All patients received transdermal estradiol (E(2)) in combination with oral progestin.

RESULTS

Total regression of climacteric symptoms was reported in 75% of patients. After 3 months of the therapy follicle stimulating hormone (FSH) and E(2) levels normalized: FSH from 129 +/- 30.1 IU/L to 38.3 +/- 26.1 IU/L and E(2) from 18.5 +/- 5.8 pg/mL to 98.6 +/- 33.2 pg/mL. No significant change was noted in serum creatinine. Eleven patients developed abnormal uterine bleeding but none had premalignant or malignant lesions of the uterus on endometrial curettage. No incidence of breast cancer was noted during mean treatment period of 5.2 years. Seventeen patients discontinued therapy for medical indications: one for profound thrombophlebitis and 16 for significant deterioration of liver function. Twelve women made their own decision to discontinue therapy.

CONCLUSION

Hormonal replacement therapy was effective with no negative impact either on graft function or sex organs among kidney transplant recipients. Liver parameter monitoring seemed to be essential for safe continuation of treatment.

Recurrence of primary sclerosing cholangitis in patients after liver transplantation

BACKGROUND

Primary sclerosing cholangitis (PSC) is a chronic cholestatic disease that progresses to end-stage liver disease. There are several specific problems related to the posttransplantation period in these patients. The aim of this study was to analyze a single center experience with 17 orthotopic liver transplantations (OLT) due to PSC.

PATIENTS AND METHODS

Seventeen patients were included (10 men, 7 women). Actuarial patient and graft survival rates and the incidence of recurrent sclerosing cholangitis were determined at 1, 5, and 7 years.

RESULTS

Fifteen patients received single grafts, whereas two patients required retransplants. Patients received either cyclosporine (n = 7) or tacrolimus (n = 10) based immunosuppression. The 1-, 5-, and 7-year patient survival rates were 80%, 60%, and 60%, respectively, whereas the graft survival rates were 88%, 65%, and 65%, respectively. Two patients had cholangiocarcinomas (CCA) diagnosed during OLT; both recurred within 6 months and had a fatal outcome. Two patients (12%) developed recurrent sclerosing cholangitis, as assessed by liver histology and imaging of biliary tree.

CONCLUSIONS

Liver transplantation provides good patient and graft survival rates in cases affected with PSC. CCA is associated with poor recipient survival. Recurrent PSC occurs in approximately 12% of cases but does not significantly affect patient survival.

Candida-Associated Denture Stomatitis in Patients After Immunosuppression Therapy

Patients who undergo kidney or liver transplantation receive long-lasting immunosuppressive therapy. The resultant unfavorable symptoms result from immune deficiency and the side effects of the medications. The aim of this study was to establish the frequency and intensity of denture stomatitis and oral candidiasis among denture-wearing patients who were treated with immunosuppressive drugs. The study was performed in the group of denture wearers with a transplanted kidney or liver who had been treated with immunosuppressive medications. The control group included healthy people wearing dentures. We made physical and clinical examinations in both groups. The history covered nonobjective symptoms in the oral cavity, hygienic habits in the mouth, and the time span during which the dentures had been used. We also evaluated the conditions of the oral mucosal membrane, angular cheilitis, as well as denture stabilization. In both groups mycological investigations were performed by inoculating a direct swab from the oral mucosa and the denture surface on Soborauda agar. The results of our study suggest that patients with immunosuppression were more frequently subject to Candida albicans infections and stomatitis.

Morphologic Features of Hepatitis C Recurrence in Patients After Orthotopic Liver Transplantation-Preliminary Analysis of our Case Observations

INTRODUCTION

Hepatitis C virus (HCV) recurrence is almost universal in patients after liver transplantation. The diagnosis of reinfection is more difficult than that of a primary process, as shown by our pathomorphologic analysis of cases of HCV recurrence.

MATERIAL

During 5.5 years, 240 liver biopsies included 54 obtained from liver transplant recipients with primary HCV infections, among whom 26 (56.5%) had clinical signs and symptoms of hepatitis. Nineteen patients from this population underwent 30 liver biopsies. In addition, seven biopsies were performed in five patients without clinical signs of reinfection.

RESULTS

In 44.2% of patients with HCV recurrence and 15% without reinfection, the intensity of the primary process in the native livers was assessed as high. Reinfection was found in all patients with liver carcinoma and 67% with hepatocyte dysplasia. Histologic signs of infection were estimated as minimal (n = 4), mild (n = 19), or moderate (n = 4). In five patients with reinfections and one without recurrence, histologic manifestations of acute rejection were also observed. In conclusion, HCV was the indication for liver transplantation in 22.4% cases. Clinical manifestation of recurrence was found in 56.5% of the patients, who tended to be older than those without disease recurrence. Upon microscopy, lobular lesions predominated over the portal changes. Factors predisposing to HCV recurrence were coexistence of other liver disorders, a high intensity of the inflammatory process, hepatocyte dysplasia, and/or hepatocellular carcinoma in the native liver and acute rejection episodes.

Posttransplant Lymphoproliferative Disorder: Morphological Picture and Diagnostic Difficulties

Posttransplant lymphoproliferative disorder (PTLD) is a well-known complication of both solid organ and bone marrow transplantation. It includes a wide spectrum of proliferative changes ranging from reactive hyperplasia, borderline lesions to malignant lymphomas. PTLD develops in 1% to 10% of transplant recipients. We present 10 cases of PTLD. Five developed after renal, four after liver, and one after heart transplantation. Among the early lesions, we diagnosed two reactive plasmacytic hyperplasias; one infectious mononucleosis-like PTLD; one polymorphic lesion; and one "mixed" case of plasmacytic hyperplasia in one tonsil with a polymorphic PTLD in the second one. Among the lymphomas, we observed three diffuse large B-cell lymphoma (DLBCL); one mantle lymphoma; and one Hodgkin lymphoma-like PTLD. The morphological pictures of six PTLD cases were typical and posed no diagnostic problems. In the one case of plasmacytic hyperplasia, the lymph node morphology was atypical with atrophy of lymphoid components accompanying plasma cell proliferation. Contrary to a good prognosis of early, reactive PTLD, this patient experienced a rapid course and succumbed to sepsis. The most difficult case was a rare Hodgkin lymphoma-like PTLD, which was diagnosed only by a bone marrow biopsy. Because of its noncharacteristic immunophenotype, it was primarily diagnosed as an anaplastic lymphoma of the T-cell type. After additional immunohistochemical studies (BOB and OCT2), we established the final diagnosis of Hodgkin lymphoma-like PTLD. Due to the increasing number of organ transplantations, doctors of various specialties may encounter PTLD.

Pemphigoid-Like Ocular Lesions in Patients With Graft-Versus-Host Disease Following Allogeneic Bone Marrow Transplantation

We present two patients who developed keratitis sicca and pemphigoid-like symptoms following allogeneic bone marrow transplantation (BMT). The diagnosis of ocular graft-versus-host disease (GvHD) was considerably delayed in both. They were admitted to the reference ophthalmology and posttransplant care departments years after allogeneic BMT, when skin biopsy revealed changes typical for chronic GvHD. In both cases either systemic or local immunosuppressive treatment led to improvement of the clinical condition but did not significantly change patients' quality of life.

Pathomorphological Features of Acute Rejection in Patients After Orthotopic Liver Transplantation: Own Experience

INTRODUCTION

Acute hepatic allograft rejection remains an important problem following liver transplantation. Liver biopsy specimens show a combination of characteristic changes, first observed by Snover as a diagnostic triad: portal inflammation, bile duct damage, and central or portal vein endothelial inflammation (endothelitis or endothelialitis). The aim of this study was to describe our histopathological assessment of liver transplants.

MATERIALS AND METHODS

In the period between September 2000 and June 2004, we evaluated 150 liver biopsy specimens from 105 liver recipients.

RESULTS

Acute rejection was diagnosed in 26.6% of liver biopsies taken from 31.4% patients who demonstrated clinical symptoms of liver damage. In 90% of cases the rejection was described as minimal or mild, and in 10% as moderate. There was no episode of severe acute rejection. Only four biopsies (10%) showed nothing but Snover triad changes. In 9 (22.5%) cases only acute rejection was diagnosed; the remaining showed in addition to acute rejection the possibility of other concomitant pathologies: viral infection in 15 cases (37.5%), biliary flow obstruction in 11 cases (28.5%), functional cholestasis in two cases (5%), and ischemic complications in three cases (7.5%).

CONCLUSIONS

Histologically confirmed acute rejection episodes were diagnosed in 14.9% liver recipients. Liver biopsy specimens, aside from Snover triad features, often showed other unspecific morphological changes. Differentiation of acute rejection from other accompanying diseases is sometimes difficult, requiring precise clinical data and pathologist experience.

Successful Reversal of Acute Vascular Rejection and Cyclosporine-Associated Nephrotoxicity in Renal Allograft With Combined Sirolimus and Mycophenolate Mofetil as Immunotherapy

Cyclosporine (CsA) has substantially improved patient and graft survival rates in solid organ transplantation. In clinical studies, sirolimus has been shown to be as effective as CsA to maintain survival of renal and cardiac allografts without causing nephrotoxicity. Herein we describe a patient with biopsy-proven CsA-associated nephrotoxicity and refractory renal allograft rejection who was converted from steroids, CsA, and azathioprine to steroids, sirolimus (RAPA), and low-dose mycophenolate mofetil (MMF). The follow-up period was 60 months. We observed substantial improvement, even normalization in renal function. Our patient did not give consent to repeat biopsy after conversion. We also observed a beneficial effect of CsA withdrawal on blood pressure control. The spectrum of adverse events induced by sirolimus seemed to be mild relative to the potency of the immunosuppressive effect. The excellent response to combined RAPA and MMF in this patient was probably due to "concerted actions" of these agents on both B- and T-cell functions. The combination enhanced therapeutic efficacy while minimizing the toxicity of individual drugs used in the regimen. These findings suggest that sirolimus, when used as a base therapy in combination with low-dose MMF in a renal allograft recipient, may be an alternative to CsA-based therapy, providing potent immunosuppression of a renal allograft. Sirolimus administration facilitated steroids dose reduction.

Outcome of Four High-Risk Pregnancies in Female Liver Transplant Recipients on Tacrolimus Immunosuppression

Pregnancies in women after liver transplantation are considered high risk due to the greater rate of complications observed in immunosuppressed graft recipients. We report successful outcomes of four high-risk pregnancies in female liver transplant recipients on tacrolimus-based immunosuppression. The patients, aged 23 to 32 years, at the time of conception were 12 to 59 months from transplantation (mean 30 months). Preterm labor was the most important pregnancy complication observed in these patients. One episode of acute graft rejection was observed. A variable demand for tacrolimus was noted during pregnancy. Despite complications all four pregnancies were successful. The mean gestational age at delivery was 34.4 weeks. The birth weight of the newborns varied from 1410 to 3490 g (mean 2303 g) and the mean Apgar score was 8. No structural malformations or early complications were observed in the newborns. Excluding the patient with acute rejection, the remaining three cases showed all liver parameters to remain stable.

[The course of hepatitis C infection after liver transplantation]

HCV infection is an important health problem all over the world. Hepatitis C is the main reason for liver cirrhosis and liver failure which is one of most common indication for liver transplantation (OLT). HCV-associated liver cirrhosis appears at 20-25% of infected patients within 20 years. Recurrence of HVC infection nearly universally follows transplantation and may lead to graft loss. Acute hepatitis appeared in 75% of patients. The rate of HCV cirrhosis on the graft is variable from 8 to 25% at 5 years. Antiviral treatment with combination therapy interferon-ribavirin gave promising results. Attempts to introduce prophylactic post-transplant antiviral treatment are still under evaluation. This paper presents clinical and therapeutical issues of recurrent hepatitis C after liver transplantation.

[Ocular manifestations in bone marrow transplantation--case report]

We present two cases of patients who developed keratitis sicca (dry eyes) and pemphigoid-like symptoms after allogeneic bone marrow transplantation. Skin biopsy revealed changes typical of GVHD. In both cases immunosuppressive treatment, systemic and local, produced improvement of the clinical condition.

Results of liver transplantation according to indications for orthotopic liver transplantation

OBJECTIVE

This study assessed the results of liver transplantation in patients with a variety of different indications.

METHODS

From 1989 to April 2003, 209 orthotopic liver transplantations (OLTx) were performed on 196 patients, including 178 cases. The diagnoses were: PBC (n = 34); PSC (n = 13); elective postinflammatory cirrhosis in the course of hepatitis C (n = 29); hepatitis B (n = 16); postalcoholic cirrhosis (n = 23), autoimmune cirrhosis (n = 11); Wilson's disease (n = 6); cirrhosis of unknown etiology (n = 10); secondary biliary cirrhosis (n = 5); Budd-Chiari syndrome (n = 6); and benign liver neoplasms (n = 7).

RESULTS

The 3-year survival rate in the group of patients transplanted electively was 74.1%. In other groups it was: PBC, 91.4%; PSC, 69.2%; hepatitis C, 69.6%; hepatitis B, 55.5%; postalcoholic cirrhosis, 80%; autoimmune cirrhosis, 81.8%; Wilson's disease, 57.1%; secondary biliary cirrhosis, 40%; Budd-Chiari syndrome, 66.6%; hemochromatosis, 100%; benign neoplasms of the liver, 87.5%; and liver cysts, 100%.

CONCLUSIONS

Results of liver transplantation were closely related to the urgency of the procedure. Better results were achieved in patients operated upon routinely compared with in those operated upon emergently (74.1% vs 50%). The best results of liver transplantation were achieved in patients transplanted on a routine basis with a diagnosis of PBC (91.4%), autoimmunologic cirrhosis (81.1%), postalcoholic cirrhosis (80%), or hemochoromatosis (100%). Patients with liver insufficiency due to hepatitis B and Wilson's disease have an increased risk of graft destruction, and the rate of survival in these patients is significantly lower than in other patients.

The impact of experience of a transplantation center on the outcomes of orthotopic liver transplantation

The so-called learning factor has been disregarded for many years in analyzing the causes of surgical complications and post-operative mortality; it is also the case for OLT. In our center until April 2003, 209 OLT were performed in 196 patients. We evaluated the impact of experience of the transplantation team on the outcomes of liver transplantation. Thirty-four patients died (mortality rate, 16%) and 1-year survival rate, 64%. Mortality rates varied during different periods of observation due to increasing experience of the transplantation team. The causes of mortality were assessed for a series of 34 patients: it was 75% at the beginning of transplantation procedures while recent deaths have not recently exceeded 10% of cases.

High-resolution 1H nuclear magnetic resonance spectroscopy analysis of bile samples obtained from a patient after orthotopic liver transplantation: new perspectives

The liver is involved in many synthetic and metabolic functions. It takes part in the regulation of circulation, thermoregulation, and digestion. All liver functions are disturbed during harvesting, preservation, and transplantation. The assessment of graft function is still a matter of concern. Many methods including analysis of hepatic enzymes, ketone body ratio, and level of drug metabolites do not give complete and reliable information on graft function. Liver biopsy is still the best diagnostic tool, however, it is invasive, carrying the risk of complications. High-resolution proton spectroscopy of nuclear magnetic resonance was used for analysis of the bile sample obtained from a patient after orthotopic liver transplantation.

Biochemical assessment of the early liver graft function in relation to selected donor parameters

The aim of this study was to assess the usefulness of liver grafts procured from "marginal donors." Among 62 liver transplants in 2002, almost half were harvested from donors who were not deemed acceptable by other transplant units. The authors compared the data concerning the donor's status with the function of the transplanted liver. The relations between individual parameters were estimated, as well as the differences between two groups of recipients: those who received a graft from the "poorer" donors versus those who received "better" grafts. Regardless of the relations between particular parameters a statistical analysis revealed that differences of liver function that were detected during the first 5 days after transplantation disappeared thereafter.

[Evaluation of patients for liver transplantation]

The liver transplantation (ltx.) is currently the only efficient treatment of the diseases which lead to the end stage liver failure. The proper time to perform the operation and the evaluation of the survival time, with or without transplantation, are the most important aspects of qualifications to the liver transplantation. There are no specific criteria of patient qualification for liver transplantation and there are no objective quantitative liver function tests. There were created many prognostic models for evaluation patients with chronic liver diseases. Some of them, the most popular, are presented in this article. We assume, that probability of one year survival less than 90% is the indication for ltx. However, the most important is total evaluation of clinical condition of the patient with liver failure. Such a complicated problem like qualification patients for ltx. needs to be solved by a team of experts from different medical specializations.