Iron overload in kidney transplants: prospective analysis of biochemical and genetic markers

BACKGROUND: The prevalence of iron overload and the influence of mutations in the HFE and TRF2 gene on biochemical markers of iron overload among renal transplant patients is unknown. METHODS: Serum iron, ferritin, transferrin saturation (TSAT), and liver function parameters were analyzed in a cohort of 438 renal transplants. In patients with iron overload, the time course of biochemical markers of iron status as well as the influence of iron loading mutations was investigated during a time period of 5 years. RESULTS: Of 438 renal transplant patients 41 (9.4%) presented with an iron loading phenotype (TSAT above 40% and/or ferritin above 800 ng/mL). Mutations in the HFE gene were present in 12 of 33 (36.3%) patients with iron overload. Among these one patient was homozygous for HFE C282Y, and two patients were compound heterozygous for HFE C282Y/H63D. No individual tested positive for nine other mutations in HFE as well as theTRF2 Y250X mutation. Over time we observed a decrease of mean iron and ferritin levels, and of mean TSAT in our study sample. In patients with mutations in HFE this decrease was less pronounced as compared to patients without mutations. We found an independent positive association between the presence of mutations in HFE and serum alanine-aminotransferase levels at follow-up (P= 0.003). CONCLUSION: Our study demonstrates that iron overload is frequently present in renal transplant patients and shows a continuous decrease over time. This decrease is possibly impaired by the HFE C282Y and HFE H63D mutations. Furthermore, mutations in HFE may influence liver function as reflected by increased alanine-aminotransferase concentrations.     

Long-term follow-up after liver transplantation in patients with hepatic iron overload.

Patients with hepatic iron overload who undergo orthotopic liver transplantation (OLT) have a worse 1-year survival than those who undergo transplantation for other indications; the long-term outcome in this population is unknown. The purpose of this study is to report long-term follow-up after OLT in a cohort of patients with hepatic iron overload. Five liver transplant centers in the United States reported follow-up data on 37 patients receiving a first liver transplant who had severe hepatic iron overload in their native livers. Kaplan-Meier 5-year survival among these patients was compared with survival data from all age-matched liver transplantations reported to the United Network for Organ Sharing (UNOS) over the same time period (1987 to 1993). The 5-year survival rate after OLT was 40% in the hepatic iron overload group compared with an overall survival rate of 62% for all patient groups from the UNOS registry (P =.0009). Although sepsis was the cause of 53% of all deaths occurring within the first year after OLT, cardiac complications accounted for 50% of the late mortality in patients with hepatic iron overload. In conclusion, long-term survival after OLT is significantly decreased in patients with hepatic iron overload. Infectious and cardiac complications are the most common causes of death in these patients. Further studies are needed to define the relationship between hepatic iron overload and mortality and to examine the effect of iron depletion on outcome after OLT in this patient population.     

Consequences of needle tract seeding of hepatocellular cancer after liver transplant

Although liver biopsy is a relatively safe procedure, needle tract seeding (NTS) of hepatocellular carcinoma (HCC) is described in up to 5% of patients after liver biopsy. The rate of NTS in patients with HCC who had liver transplantation is unknown. We performed a retrospective analysis of 759 HCC cases from August 1992 to August 2011. Demographics, ethnicities, risk factors, tumor characteristics, treatments, recurrence, and survival were collected. Patients who underwent percutaneous liver biopsy, resection, and transplant were identified. In all, 359 underwent biopsy to diagnose HCC and 42 patients underwent liver transplant. None of 171 patients who underwent radiofrequency ablation alone had seeding. None of the 11 patients who had biopsy and radiofrequency ablation performed in a single session developed NTS; however, two of 12 patients who had biopsy and radiofrequency ablation performed at separate sessions had NTS. Two patients underwent liver transplantation and subsequently developed needle tract seeding eventually died from HCC. Although the incidence of needle tract seeding was low in liver transplant patients, it can potentially change a curative therapy into a non‐curative one. Single‐session liver biopsy and radiofrequency ablation may reduce the risk of needle tract seeding of HCC.     

Chances and limitations of non‐invasive tests in the assessment of liver fibrosis in liver transplant patients

Kamphues C, Lotz K, Röcken C, Berg T, Eurich D, Pratschke J, Neuhaus P, Neumann UP. Chances and limitations of non‐invasive tests in the assessment of liver fibrosis in liver transplant patients.
Clin Transplant 2009 DOI:10.1111/j.1399‐0012.2009.01152.x
© 2009 John Wiley & Sons A/S. Abstract: Because fibrosis progression resulting in liver cirrhosis represents the main reason for graft lost in patients after liver transplantation, an early detection of liver fibrosis is crucial. In recent years, several non‐invasive tests for the assessment of liver fibrosis have been developed. We prospectively assessed the stage of liver fibrosis of 135 liver transplant patients (94 hepatitis C virus [HCV], 41 alcoholic cirrhosis) using liver biopsy, transient elastography, and serum markers. In the HCV group, the area under the receiver operating characteristic curve (AUROC) for diagnosis of significant fibrosis (F ≥ 2) and cirrhosis (F = 4) was 0.81 (negative predictive value [NPV] = 0.58, positive predictive value [PPV] = 0.9) and 0.87 (NPV = 0.94, PPV = 0.56), respectively. In the alcoholic cirrhosis group, significant fibrosis (F ≥ 2) was diagnosed with an AUROC of 0.83 (NPV = 1.00, PPV = 0.23). In both groups, higher AUROC values were reached in patients with a body mass index of <25 kg/m², and both serum markers showed no significant correlation to liver fibrosis. The transient elastography is a reliable test for exclusion of liver cirrhosis in HCV transplant and significant liver fibrosis in alcoholic transplant patients. For the diagnosis of significant liver fibrosis in HCV transplant patients, the transient elastography reaches good results but cannot replace liver biopsy. Both serum markers AST‐to‐platelet ratio index and FIB‐4 are not feasible to assess liver fibrosis in liver transplant patients.     

Rare cause of weight loss in a kidney transplant recipient: iron overload

Various reasons such as malignancies and chronic infections may cause weight loss in kidney transplant patients. In this report, iron overload as a rare cause of weight loss in a kidney transplant patient is presented. Forty-seven-year-old male patient who transplanted from a deceased donor 5 years ago was hospitalized because of 20?kg of weight loss. In medical history, he had history of hemodialysis for 89 months and received 100–300?mg of intravenous iron therapy per week before transplantation and transfused eight units of blood. In physical examination, weight and height were 45?kg and 185?cm, respectively. Respiratory and cardiac auscultation was normal. Laboratory results revealed as follow: glucose 76?mg/dL, urea 60?mg/dL, creatinine 1.35?mg/dL, aspartate aminotransferase 74?U/L, alanine aminotransferase 77?U/L, C-reactive protein 2.59?mg/dL, albumin 3.3?g/dL, globulin 3.4?g/dL, white blood cells 3200/mm³, hemoglobin 13.1?g/dL and platelets 190,000/mm³. Chest and abdominal tomography didn’t reveal any pathology. Portal Doppler ultrasound showed signs of early cirrhosis. Viral and autoimmune hepatitis markers were negative. Ferritin was 5300?ng/mL and transferrin saturation was 82%. In liver biopsy, hemosiderosis was diagnosed and heterozygous H63D gene mutation was detected. Totally, 19 units of phlebotomy were performed. Liver function tests and serum ferritin decreased gradually. At outpatient follow-up in 6 months, he returned to former weight. In conclusion, there can be several causes of weight loss in kidney transplant patients. Iron overload can come across as a rare cause of weight loss. In these patients, ferritin levels should be checked and diagnosis should be clarified by liver biopsy and gene mutation analysis.     

Single‐center outcomes of combined heart and liver transplantation in the failing Fontan

Long‐term outcomes of the Fontan operation include Fontan failure and liver disease. Combined heart‐liver transplantation (CHLT) is an option for select patients although limited data exist on this strategy. A retrospective review of Fontan patients 18 years or older referred for cardiac transplant evaluation between 2000 and 2013 at the Hospital of the University of Pennsylvania was performed. All patients were considered for potential CHLT. Clinical variables such as demographics, perioperative factors, and short‐term outcomes were reviewed. Of 17 referrals for cardiac transplantation, seven Fontan patients underwent CHLT. All patients who underwent CHLT had either advanced fibrosis or cirrhosis on liver biopsy. There were no perioperative deaths. The most common postoperative morbidity was acute kidney injury. Short‐term complications include one episode of acute liver rejection but no cardiac rejection greater than 1R. CHLT is an acceptable therapeutic option for patients with failing Fontan physiology who exhibit concomitant advanced liver fibrosis. However, optimal patient selection is currently undefined, and long‐term outcomes are not known.     

Efficacy of hepatic computed tomography to detect iron overload in chronic hemodialysis

The diagnostic efficacy of hepatic computed tomography density (HCTD) in comparison with serum ferritin for the detection of iron overload was investigated in uremic patients on maintenance hemodialysis (HD) and in patients with idiopathic hemochromatosis (IHC). Ten IHC patients, 38 HD patients and 40 healthy subjects underwent the CT scanning of the liver and determination of percent saturation of transferrin, serum ferritin concentration and HLA typing. Liver iron content was determined by histochemical grading and direct measurement of liver iron concentration either in IHC patients or in HD patients. Nineteen HD patients were considered to have iron overload on the basis of liver iron concentration exceeding 3.6 mumol/100 mg dry weight. The mean +/- SD values of HCTD in healthy subjects, IHC patients, HD patients with iron overload and without iron overload were 60.2 +/- 5.6, 79 +/- 5.6, 71.4 +/- 3.6, 58 +/- 3.8 Hounsfield units, respectively. HCTD showed positive correlations with liver iron concentration and serum ferritin either in IHC patients or in HD patients. The analysis of the diagnostic efficacy of HCTD in comparison with serum ferritin for the detection of excessive hepatic iron in HD patients demonstrated that HCTD had higher sensitivity, specificity, positive and negative predictive values. Cut-off points were arbitrarily fixed to 66 Hounsfield units for HCTD, 400 micrograms/liter for serum ferritin and 3.6 mumol/100 mg dry weight for liver iron concentration. Seventeen HD patients who possessed the histocompatibility antigens associated with IHC, namely HLA-A3 and/or HLA-B7 and/or HLA-B14, had liver iron concentration, serum ferritin and HCTD values higher than those of the HD patients without these "hemochromatosis alleles".(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of Preoperative Iron Deficiency on Transfusion Requirements in Liver Transplantation Recipients: A Prospective Observational Study

The aims of this study were to determine the frequency of preoperative iron deficiency in adult living donor liver transplantation patients and to investigate its relationship with the need for intraoperative transfusion. Between September 1, 2011, and June 1, 2012, 103 patients scheduled for liver transplantation were included in this prospective study. Patients were divided into 2 groups according to baseline iron status: an iron-deficient group and a non deficient (normal iron profile) group. Iron deficiency was assessed on the basis of several parameters, including transferrin saturation, levels of ferritin, soluble transferrin receptor, C-reactive protein, and peripheral blood smear. Preoperative iron deficiency was diagnosed in 62 patients. Preoperative iron deficiency was associated with low preoperative hemoglobin levels (P = .01) and a high rate of intraoperative transfusion (P < .0001). Preoperative iron deficiency is prognostic factor for predicting intraoperative transfusion requirements. These findings have important implications for transfusion practices for liver transplant recipients.     

Iron Overload After Pediatric Liver Transplantation: A Case Report

Iron is an essential nutrient for living cells; however, an excessive accumulation of iron leads to organ damage and directly affects systemic immunity. Iron overload is clinically classified as hereditary or secondary. Most of secondary iron overload is caused by frequent blood transfusions because there is no active mechanism to excrete iron from the body. As recommended in various guidelines, chelation therapy is effective for reducing iron burden and improving organ function. There have been few reports on iron overload through blood transfusion during the perioperative period of liver transplantation. This report presents a case of iron overload due to repeated transfusions after pediatric liver transplantation managed by chelation therapy. The patient, an 11-month-old female with biliary atresia, underwent living donor liver transplantation. She revealed refractory anemia and required frequent blood transfusion. Both serum ferritin and transferrin saturation tended to increase after repeated transfusions, leading to secondary iron overload. Iron chelation therapy was started to prevent progression to organ failure and infection due to iron overload, and yielded a favorable outcome. It is crucial to consider the possibility of secondary iron overload and to achieve early detection and treatment to avoid progression to irreversible organ damage.     

Risk factors and consequences of post‐transplant diabetes mellitus

Demirci MS, Toz H, Y?lmaz F, Ertilav M, Asci G, Ozkahya M, Zeytinoglu A, Nart D, Ok E. Risk factors and consequences of post‐transplant diabetes mellitus.
Clin Transplant 2010 DOI: 10.1111/j.1399‐0012.2010.01247.x.
© 2010 John Wiley & Sons A/S. Abstract: Background: The aim of this study is to investigate the clinical course as well as risk factors and prognosis of post‐transplant diabetes mellitus (PTDM). Methods: Five hundred fifty‐five kidney transplant recipients were retrospectively evaluated. PTDM was defined as fasting blood glucose ≥140 mg/dL on at least two consecutive measurements or requirement of oral antidiabetic drug or insulin. Patients with PTDM were divided into subgroups according to time of onset (early; <90 d vs. late, ≥90 d) and duration of diabetes (transient, <90 d vs. sustained ≥90 d). Results: The frequency of PTDM was 18.3%. In multivariate analysis age (p < 0.001), hepatitis C virus (HCV) infection (p < 0.05) and tacrolimus use (p < 0.001) were independent risk factors. Among 220 HCV+ patients, liver biopsy was performed in 158, the histological grade (3.3 ± 2.8 vs. 4.4 ± 3.1) and stage (0.9 ± 1.1 vs. 1.4 ± 1.2) were significantly more severe in patients with PTDM than in non‐diabetics. Incidence of PTDM in patients with severe fibrosis was 46.7%; 19.2% in nil or mild fibrosis (p < 0.05). Patient and graft survival were significantly worse, and cardiovascular events and life‐threatening infection episodes were more frequent in PTDM. Half of the patients had early PTDM, while 30.3% of patients with PTDM showed transient nature. Five‐ and 10‐yr death censored graft survival rates were worse in transient subgroup compared with sustained patients with diabetes (log rank 0.025) whereas there was no difference in outcome between early and late subgroups. Conclusions: Age, tacrolimus, and HCV are independent risk factors for PTDM. PTDM has a negative impact on both patient and graft survival, irrespective of the time of onset and duration of diabetes.     

The effect of coronary angiography on renal function in preemptive renal transplant candidates

Lorenz EC, Stegall MD, Cosio FG, Gloor JM, Larson TS, Taler SJ. The effect of coronary angiography on renal function in preemptive renal transplant candidates.
Clin Transplant 2011: 25: 594–599. © 2010 John Wiley & Sons A/S. Abstract: Background: Increasing numbers of patients undergo preemptive renal transplantation. Obtaining cardiac catheterizations prior to transplantation to screen for coronary artery disease is controversial because of the perceived risk of inducing contrast nephropathy and the need for dialysis in patients with marginal renal function. We sought to examine the true impact of cardiac catheterization on time to dialysis in a cohort of preemptive renal transplant candidates. Methods: From a cohort of 376 transplant candidates evaluated preemptively at our program between 2/2001 and 4/2005, 34 patients had positive dobutamine stress echocardiograms. We reviewed the subsequent need for dialysis in these patients. Results: Among candidates undergoing angiography, 8.7% required dialysis within 14 d of contrast administration and 26% eventually needed dialysis prior to transplantation at 5.3 ± 3.7 months after their pre‐transplant evaluation. Among patients who did not undergo angiography, 27% needed dialysis prior to transplantation at 2.4 ± 1.8 months after pre‐transplant evaluation. Conclusions: Our results demonstrate a low risk of hastening the need for dialysis after coronary angiography in preemptive renal transplant candidates. Undergoing angiography had no effect on the ultimate need for or timing of dialysis initiation. These findings support completion of full cardiac evaluation as indicated for high‐risk preemptive renal transplant candidates.     

Serum ferritin and survival of renal transplant recipients: a prospective 10-year cohort study

Increased serum ferritin is frequent in renal transplant recipients. This reflects iron overload due to blood transfusions given to treat renal anaemia. Previous studies suggested excess mortality in non-renal transplant recipients with iron overload. We hypothesized that serum ferritin levels above 1100 ng/ml may be associated with increased long-term mortality in renal transplant recipients. Twenty consecutive renal transplant recipients with high levels of serum ferritin and 20 renal transplant recipients with normal serum ferritin levels, matched for age and gender, were prospectively studied for 10 years. Nine patients (45%) with increased serum ferritin died during follow-up, compared to four controls (20%). Univariate and multivariate analysis identified multiple blood transfusions (>40 units) prior to transplantation as being associated with higher mortality in renal transplant recipients (risk ratio (RR): 3.1, confidence interval (CI): 1.1-9.2; P=0.03). These data suggest that serum ferritin levels above 1100 ng/ml due to multiple blood transfusions causing iron overload is a relevant factor that increases mortality.     

Massive ascites after living donor liver transplantation with a right lobe graft larger than 0.8% of the recipient’s body weight

Shirouzu Y, Ohya Y, Suda H, Asonuma K, Inomata Y. Massive ascites after living donor liver transplantation with a right lobe graft larger than 0.8% of the recipient’s body weight.
Clin Transplant 2010: 24: 520–527.
© 2009 John Wiley & Sons A/S. Abstract: Background: There are only limited data on post‐transplant ascites unrelated to small‐sized grafts in living donor liver transplantation (LDLT). Methods: The subjects were 59 adult patients who had received right lobe LDLT with a graft weight‐to‐recipient weight ratio (GRWR) > 0.8%. Patients were divided into either Group 1 (n = 14, massive ascites, defined as the production of ascitic fluid > 1000 mL/d that lasted longer than 14 d after LDLT) or Group 2 (n = 45, no development of massive ascites). Patients were followed for a median period of 3.0 yr (range, 0.5–7.5 yr). Results: Group 1 had both higher Model for End‐Stage Liver Disease score and Child‐Pugh score than Group 2. Portal venous flow volume just after reperfusion was significantly greater in Group 1 than Group 2 (307.8 ± 268.8 vs. 176.2 ± 75.0 mL/min/100 g graft weight, respectively; p < 0.05). Post‐transplant infectious complications including ascites infection developed more frequently within the first post‐transplant month in Group 1. Massive ascites was significantly associated with early graft loss (p < 0.05). Conclusion: Post‐transplant massive ascites associated with portal over‐perfusion into the graft liver can develop in patients with a GRWR over 0.8%. Recipients with post‐transplant massive ascites require careful management to prevent infection.     

Patent foramen ovale does not have a negative impact on early outcomes in patients undergoing liver transplantation

Alba AC, Verocai Flaman F, Granton J, Delgado DH. Patent foramen ovale does not have a negative impact on early outcomes in patients undergoing liver transplantation.
Clin Transplant 2011: 25: 151–155. © 2010 John Wiley & Sons A/S. Abstract: Objective: To identify the impact of the presence of patent foramen ovale (PFO) in patients undergoing liver transplantation. Methods: Twenty‐seven pre‐liver transplant patients who had a PFO (PFO group) were identified and compared with 61 patients without PFO (NoPFO group). Patients were matched according to age, gender and cause of liver disease. The diagnosis of PFO was made by transthoracic echocardiography prior to liver transplantation. Patient baseline characteristics and complications during the early post‐transplant period were analyzed. Results: The mean age in the PFO group was 47 ± 14 (range 18–68) yr and 50 ± 11 (range 12–65) yr in the NoPFO group. The PFO group had a mean model for end‐stage liver disease (MELD) score of 15 ± 10 whereas in the NoPFO group the MELD score was 19 ± 10 (p = 0.08). There were non‐significant differences in echocardiographic parameters between groups. Duration of mechanical ventilation and the incidence of neurological complications were similar. Thirty‐day mortality rate was similar in both groups; only one patient in the NoPFO group died within the first 30 days post‐transplantation. Conclusions: The presence of PFO in patients with end‐stage liver disease undergoing liver transplantation does not appear to affect patient outcomes during the peri‐operative period.     

Donor haptoglobin phenotype determines outcome following liver transplantation

Haptoglobin (Hp) is a polymorphic plasma protein with multiple functions defined by three major phenotypes (Hp 1‐1, Hp 2‐1, and Hp 2‐2). In this article, the effects of the donor Hp phenotype (determined by starch gel electrophoresis) on the outcome and the iron status after liver transplantation were investigated. A total of 450 liver transplant patients were enrolled in this study with a median follow‐up of 37 months. Kaplan–Meier and Cox regression survival analyses showed a significantly worse graft survival for liver transplantation cases with an Hp 2‐2 donor phenotype, which was associated with an increased mortality rate in this group. In male patients, the Hp 2‐2 phenotype was associated with higher serum ferritin concentrations, which may be linked to the significantly increased likelihood of infectious complications in this phenotype. Liver transplant patients with Hp 1‐1 and Hp 2‐1 grafts had a better outcome probability than recipients of an Hp 2‐2 graft, which may be explained by differences in iron metabolism induced by the Hp genotype of the graft.     

Should heart,lung, and liver transplant recipients receive immunosuppression induction for kidney transplantation?

Ranney DN, Englesbe MJ, Muhammad W, Al‐Holou SN, Park JM, Pelletier SJ, Punch JD, Lynch RJ. Should heart, lung, and liver transplant recipients receive immunosuppression induction for kidney transplantation?
Clin Transplant 2010: 24: 67–72. © 2009 John Wiley & Sons A/S. Abstract: As the outcomes of heart, liver, and lung transplantation continue to improve, more patients will present for subsequent renal transplantation. It remains unclear whether these patients benefit from induction immunosuppression. We retrospectively reviewed induction on solid organ graft recipients who underwent renal transplant at our center from January 1, 1995 to March 30, 2007. Induction and the non‐induction groups were compared by univariate and Kaplan–Meier analyses. There were 21 patients in each group, with mean follow‐up of 4.5–6.0 years. Forty‐seven percent of patients receiving induction had a severe post‐operative infection, compared with 28.6% in the non‐induction group (p = NS). The one yr rejection rate in the induction group was 9.5% compared with 14.3% for non‐induction (p = NS). One‐yr graft survival was 81.0% and 95.2% in the induction and non‐induction group (p = NS). In summary, there is a trend toward lower patient and graft survival among patients undergoing induction. These trends could relate to selection bias in the decision to prescribe induction immunosuppression, but further study is needed to better define the risks and benefits of antibody‐induction regimens in this population.     

Medical epidemiology of patients surviving ten years after liver transplantation

Simo KA, Sereika S, Bitner N, Newton KN, Gerber DA. Medical epidemiology of patients surviving ten years after liver transplantation.
Clin Transplant 2011: 25: 360–367. © 2010 John Wiley & Sons A/S. Abstract: The transition into extended long‐term follow‐up after liver transplantation raises a new series of issues with respect to continuing care of this population. A retrospective study was performed, analyzing patients who underwent orthotopic liver transplant (OLT) and survived ≥10 yr at a single institution. Long‐term comorbidities such as diabetes mellitus (DM), hypertension (HTN), chronic kidney disease (CKD), coronary artery disease (CAD), and obesity were identified and standardized prevalence ratios ([SPR]) utilized to compare with the general US population. There was an increased prevalence of HTN ([SPR] = 2.25 ± 0.61), DM ([SPR] = 2.67 ± 0.72), and CKD ([SPR] = 15.3 ± 4.04) but not CAD or obesity. In multivariate analysis, non‐viral etiology of end‐stage liver disease was associated with CKD (OR 3.42 CI 1.11–10.53), and an initial glomerular filtration rate (GFR) <60 mL/min per 1.73 m² (CKD stages III–V) was associated with HTN (OR 4.62 CI 1.14–18.73) after OLT. Creatinine ≥1.5 mg/dL at 10 yr was associated with an initial GFR <60 mL/min per 1.73 m² (p = 0.000) and CAD after OLT (p = 0.012). Patients, 10 yr after OLT, have a significantly higher prevalence of HTN, DM, and CKD than the general population, which is not confounded by obesity. Increased vigilance and proactive management are required to further improve long‐term outcomes.     

Preoperative dobutamine stress echocardiography, intraoperative events, and intraoperative myocardial injury in liver transplantation

INTRODUCTION: The appropriate method of screening for coronary artery disease in patients who present for liver transplantation is currently uncertain. METHODS: We assessed the utility of a screening protocol using dobutamine stress echocardiography (DSE) in 119 patients who underwent liver transplantation. Patients with cardiac risk factors had DSE performed, and those with positive results were referred for coronary angiography. Outcome was myocardial injury during liver transplantation determined by an elevation of cardiac troponin T measured after transplantation. RESULTS: Seventy-three patients had DSE performed; eight were reported as positive for inducible ischemia. Seven of these patients underwent coronary angiography, and one had significant coronary artery disease. Postoperative troponin elevation occurred in 14 patients. There was no significant difference in the prevalence of troponin elevation in those patients with positive DSE versus those with negative DSE. No significant difference was identified in the prevalence of troponin elevation when comparing those patients with cardiac risk factors who underwent DSE with those patients with no risk factors and no DSE performed. DSE had a sensitivity of 0.2 and a specificity of 0.9 for myocardial injury. The prevalence of intraoperative hemodynamic instability was significantly higher in patients who had evidence of myocardial injury, but hemodynamic instability was no more common in patients who had a positive DSE. CONCLUSION: When used in accordance with our protocol a positive DSE does not reliably identify patients at high cardiac risk during liver transplantation, but a negative DSE is strongly predictive of no myocardial injury.     

Effect of early EBV and/or CMV viremia on graft function and acute cellular rejection in pediatric liver transplantation

Indolfi G, Heaton N, Smith M, Mieli‐Vergani G, Zuckerman M. Effect of early EBV and/or CMV viremia on graft function and acute cellular rejection in pediatric liver transplantation.
Clin Transplant 2012: 26: E55–E61.
© 2011 John Wiley & Sons A/S. Abstract: Background: The clinical impact of Epstein–Barr virus (EBV) and cytomegalovirus (CMV) infections in the early post‐transplantation period are poorly documented. We investigated the prevalence and timing of EBV and CMV infections during the first 21 d post‐transplantation in relation to graft function and acute cellular rejection in a large cohort of pediatric liver transplantation recipients. Patients and methods: Clinical, biochemical, virological, and histopathological data of 62 consecutive children who received a liver transplant were reviewed retrospectively. Results: Seventeen patients (27%) developed EBV and 11 (18%) CMV viremia (mean interval from surgery: 7.6 d, SD 3.6 and 8.7 d, SD 6.4, respectively). EBV and CMV viremia were more common as a consequence of reactivation than of primary infection. EBV viremic recipients had more often abnormal bilirubin levels [p = 0.01; OR 5.8: 95% CI 1.3–25.5]. Acute rejection was diagnosed in 20 recipients (32.3%). No correlation was found between rejection and EBV and CMV serology before transplantation and viremia after transplantation (mean interval between the diagnosis of rejection and the detection of EBV DNA and CMV DNA: one d, SD 4.4 and five d, SD 9.2, respectively). Conclusion: EBV and CMV viremia occur at a very early‐stage post‐transplantation and do not appear to affect the short‐term outcome of the transplant.