Successful treatment of disseminated Nocardia farcinica infection in a living-donor liver transplantation recipient

Nocardiosis is a serious infection with high mortality. We report a case of subcutaneous and neural lesions due to Nocardia farcinica infection after living-donor liver transplantation. The neural lesion was cured with antibiotics without drainage.     

Pseudomonas aeruginosa infection after living-donor liver transplantation in adults

Objectives. Pseudomonas aeruginosa infection is a major cause of bacterial infection after deceased-donor liver transplantation. The incidence and risk factors of P. aeruginosa infection after living-donor liver transplantation (LDLT), however, are not known.
Methods. We retrospectively reviewed the data from 170 adult patients who underwent LDLT at the University of Tokyo Hospital. The microbiologic and medical records of the patients from admission to 3 months after LDLT were reviewed. Uni- and multivariate analyses were performed to identify the independent risk factors for postoperative P. aeruginosa infection.
Result. Preoperative P. aeruginosa carriage was identified in 15 (9%) patients. Only 2 of the 15 patients later presented with postoperative P. aeruginosa infection. Postoperative P. aeruginosa infection occurred in 27 (16%) of 170 patients by median postoperative day 38. Among those 27 patients, surgical site infections were recorded in 8 (30%) and intra-abdominal infections in 14 (52%). In 5 of the 27 (19%) patients, P. aeruginosa isolates were multiple antimicrobial resistant. Postoperative bile leakage independently predicted postoperative P. aeruginosa infection.
Conclusion. P. aeruginosa infections were frequently detected after LDLT, including those by multiple antimicrobial-resistant isolates. Postoperative bile leakage predisposed patients to P. aeruginosa infection. Surveillance culture should be checked periodically after LDLT to ensure that appropriate antimicrobials can be administered for postoperative infection.     

Methicillin-resistant Staphylococcus aureus infection after living-donor liver transplantation in adults

Background. Methicillin-resistant Staphylococcus aureus (MRSA) infection frequently complicates the postoperative course in deceased-donor liver transplantation. The incidence and risk factors of MRSA infection after Living-donor Liver transplantation (LDLT), however, are unclear.
Methods. We retrospectively reviewed the data from 242 adult patients who underwent LDLT at the University of Tokyo Hospital. The microbiologic and medical records of the patients from admission to 3 months after LDLT were reviewed. Uni- and multivariate analyses were performed to identify the independent risk factors for postoperative MRSA infection.
Results. Postoperative MRSA infection occurred in 25 of 242 patients by median postoperative day 23. Preoperative MRSA colonization, preoperative use of antimicrobials, operation time (≥16 h), and postoperative apheresis independently predicted postoperative MRSA infection.
Conclusion. Surveillance culture should be checked periodically after admission to identify patients at high risk for MRSA infection and to administer appropriate antimicrobials for perioperative infection. Postoperative apheresis, suggesting postoperative liver dysfunction, predisposed patients to MRSA infection.     

Massive Polycystic Liver with a Poor Performance Status Successfully Treated by ABO-incompatible Adult Living-donor Liver Transplantation While Overcoming Complications

We encountered a 47-year-old woman with polycystic liver disease (PLD) and severe malnutrition successfully treated by living-donor liver transplantation (LDLT). Her PLD became symptomatic with abdominal distension and appetite loss. Transcatheter arterial embolization and percutaneous cyst drainage failed to improve her symptoms. ABO-incompatible LDLT from her husband was performed after rituximab administration and mycophenolate mofetil introduction. Although she showed severe postoperative complications, she ultimately regained the ability to walk and was discharged. Because advanced PLD cases are difficult to treat conservatively or with surgery, like fenestration and hepatectomy, liver transplantation should be considered before it becomes too late.     

Beneficial effects of living-donor liver transplantation on esophageal varices

Background  Liver transplantation (LT) is known to improve bleeding esophageal varices (EVs) and portal hypertension. However, many issues related to EVs after LT remain unresolved, such as whether LT reduces blood supply to EVs, improves the diameter of unruptured EVs, or improves or worsens EVs. The aim of this retrospective study was to determine the effects of living-donor liver transplantation (LDLT) in patients with hepatic failure on EVs and inflow vessels to EVs and the factors associated with deterioration of EVs after LDLT. Methods  The study subjects were 35 patients with cirrhosis who underwent LDLT. Endoscopy and multidetector helical computed tomography (MDCT) were performed before and after LDLT. The diameter of the inflow vessel of EVs was measured by MDCT before and after LDLT, together with the LDLT-related reduction rate of the diameter of the gastric vein (RRGV). Results  Endoscopic examination showed improvement of EVs in 30 of 35 (86%) patients. RRGV improved in 17/35 (49%) patients, did not change in 13/35 (37%), and deteriorated in 5/35 (14%). The cause of RRGV deterioration seemed to be either the complication of portal vein or graft failure. In patients examined endoscopically at >1 year after LDLT, improvement of EVs was associated with significant changes in the rate of reduction of the major inflow vessel diameter and Child-Pugh score, compared with those who showed no improvement. Conclusions  LDLT results in improvement of EVs. EVs improved in 86% of the patients. Measurement of RRGV with MDCT is a good tool for prediction of EV improvement after LDLT.     

Helicobacter cinaedi bacteremia with cellulitis after ABO-incompatible living-donor liver transplantation: Case report

Helicobacter cinaedi (H. cinaedi), a Gram-negative spiral-shaped bacterium, is an enterohepatic non-Helicobacter pylori Helicobacter species. We report the first case of H. cinaedi bacteremia with cellulitis after liver transplantation. A 48-year-old male, who had been a dog breeder for 15 years, underwent ABO-incompatible living-donor liver transplantation for hepatitis C virus-induced decompensated cirrhosis using an anti-hepatitis B core antibody-positive graft. The patient was preoperatively administered rituximab and underwent plasma exchange twice to overcome blood type incompatibility. After discharge, he had been doing well with immunosuppression therapy comprising cyclosporine, mycophenolate mofetil, and steroid according to the ABO-incompatible protocol of our institution. However, 7 mo after transplantation, he was admitted to our hospital with a diagnosis of recurrent cellulitis on the left lower extremity, and H. cinaedi was detected by both blood culture and polymerase chain reaction analysis. Antibiotics improved his symptoms, and he was discharged at day 30 after admission. Clinicians should be more aware of H. cinaedi in immunocompromised patients, such as ABO-incompatible transplant recipients.     

Graft size and donor age are independent factors for graft loss in adult-to-adult living-donor liver transplantation using the left liver

Background/purpose

Graft survival is affected by various factors, such as preoperative state and the ages of the recipient and donor, as well as graft size. The objective of this study was to analyze the risk factors for graft survival.

Methods

From September 1997 to July 2005, 24 patients who had undergone living-donor liver transplantation (LDLT) were retrospectively analyzed. Sixteen patients survived and the eight graft-loss cases were classified into two groups according to the cause of graft loss: graft dysfunction without major post-transplantation complications (graft dysfunction group; n = 3), and graft dysfunction with such complications (secondary graft dysfunction group; n = 5). Various factors were compared between these groups and the survival group.

Results

Mean donor age was 31.9 years in the survival group and 49.2 years in the secondary graft dysfunction group (P = 0.024). Graft weight/recipient standard liver volume ratios (G/SLVs) were 36.7% in the survival group, and 26.2% in the graft dysfunction group (P = 0.037). The postoperative mean PT% for 1 week was 48.6% in the survival group and 38.1% in the secondary graft dysfunction group (P = 0.05).

Conclusions

Our surgical results demonstrated that G/SLV and donor age were independent factors that affected graft survival rates.     

Secondary non-resectable liver tumors: A single-center living-donor and deceased-donor liver transplantation case series

Background: During the last decades, deceased-donor liver transplantation(DDLT) has gained a place in the therapeutic algorithm of well-selected patients harbouring non-resectable secondary liver tumors. Living-donor LT(LDLT) might represent a valuable means to further expand this indication for LT. Methods: Between 1985 and 2016, twenty-two adults were transplanted because of neuroendocrine( n = 18, 82%) and colorectal metastases( n = 4, 18%); 50% received DDLT and 50% LDLT. In LDLT, 4(36%) right and 7(64%) left grafts were used; the median graft-to-recipient-weight ratios(GRWR) were 1.03%(IQR 0.86%-1.30%) and 0.59%(IQR 0.51%-0.91%), respectively. Median post-LT follow-up was 64 months(IQR 17–107) in the DDLT group and 40 months(IQR 35–116) in the LDLT group. DDLT and LDLT recipients were compared in terms of overall survival, graft survival, postoperative complications and recurrence. Results: The 1-and 5-year actuarial patient survivals were 82% and 55% after DDLT, 100% and 100% after LDLT, respectively( P 0.01). One-and 5-year actuarial graft survivals were 73% and 36% after DDLT, 91% and 91% after LDLT( P 0.01). The outcomes of right or left LDLT were comparable. Donor hepatectomy proved safe, and one donor experienced a Clavien IIIb complication. Bilirubin peak was significantly lower after left hepatectomy compared with that after right hepatectomy [1.3(IQR 1.2–2.2) vs. 3.3(IQR 2.3–5.2) mg/d L; P = 0.02]. Conclusions: The more recent LDLT series compared favorably to our DDLT series in the treatment of secondary liver malignancies. The absence of portal hypertension and the use of smaller left grafts make recipient and donor surgeries safe. The safety of the procedures and lack of interference with the scarce allograft pool are expected to lead to a more frequent use of LDLT in the field of transplant oncology.     

Liver transplantation for hepatocellular carcinoma in the world: the Taiwan experience

Liver transplantation (LT) has been regarded as “potentially curative” in a cirrhotic patient with hepatocellular carcinoma (HCC) because it removes the cancer and eradicates the cirrhosis. In Taiwan, HCC ranks first among the leading causes of cancer mortality in males and 4th in females. The most common causes are chronic hepatitis B virus-related cirrhosis, hepatitis C virus-related cirrhosis, and combined hepatitis B and C virus-related cirrhosis. The aggregate lifetime cost of hepatitis and HCC constitutes a significant burden on the Taiwanese health-care system. The reported overall (living-donor LT and deceased donor LT) 1- and 3-year survival rates for HCC after LT in Taiwan ranged from 86 to 98% and 61 to 96%, respectively. Microscopic vascular invasion did not influence the outcome of patients, but high alpha-fetoprotein levels >200 ng/ml may be a risk factor for HCC recurrence after transplant.     

Cryptococcosis after living donor liver transplantation: report of three cases

Cryptococcosis is the third most common invasive fungal infection in solid organ transplantation, which usually occurs more than 6 months after the primary operation. In our series of 180 consecutive adult living-donor liver transplantation recipients, three (1.5%) had cryptococcosis and one of these patients died. The serum cryptococcal antigen examination was positive in all three patients who suffered from cryptococcosis. The serum cryptococcal antigen test might contribute to the early detection and treatment of cryptococcosis.     

Liver transplantation for hepatocellular carcinoma: Korean experience

Hepatocellular carcinoma (HCC) is the second most common cause of male cancer death in Korea, where the major etiology, chronic hepatitis B virus infection, is endemic. With a high incidence of unresectable HCCs and a low cadaveric organ donation rate, the number of adult living-donor liver transplantations (LDLTs) has increased rapidly, by tenfold, over the past 10 years, as an alternative to deceased-donor liver transplantation (DDLT) in Asia, including Korea. Currently, HCC accounts for more than 40% of the indications for adult LDLT as the associated decompensation cirrhosis or unresectable HCC with 2.8% perioperative mortality at our institute. In determining eligibility for LDLT, the Milan criteria, which have a major aim of reducing the wastage of cadaveric liver grafts, still remain the gold standard. Our published results with 168 adult LDLTs show no difference from the results with DDLT for HCC that meets the Milan criteria. However, since a substantial proportion of adult LDLT patients not fulfilling the Milan criteria have been found to survive for longer than expected, and because a live donor organ is a private gift, most LDLT programs in Korea accept HCC patients beyond the Milan criteria, and the reported 3-year survival rates for such patients are approximately 63%. Our new proposal for expanded criteria (Asan criteria; tumor diameter ≤5 cm, number of lesions ≤6, no gross vascular invasion) in LDLT has focused on extending the number limits but keeping the maximum tumor size at 5 cm, because even modest expansion of tumor size limits beyond the Milan criteria adversely affected survival. The overall 5-year patient survival rates were 76.3 and only 18.9% within and beyond the Asan criteria, respectively; these criteria broaden the indications for patient selection and can more accurately identify patients who will benefit from LDLT than the conventional Milan criteria and the University of California at San Francisco criteria. In Asia, where the option for DDLT is minimal or negligible, LDLT with the modest expanded selection criteria will continue to provide a chance of long-term survival for some patients with advanced HCC.     

Thrombotic microangiopathy-like disorder after living-donor liver transplantation: a single-center experience in Japan

AIM:To investigate thrombotic microangiopathy (TMA)in liver transplantion,because TMA is an infrequent but life-threatening complication in the transplantation field. METHODS:A total of 206 patients who underwent living-donor liver transplantation (LDLT) were evaluated,and the TMA-like disorder (TMALD) occurred in seven recipients. RESULTS:These TMALD recipients showed poor outcomes in comparison with other 199 recipients. Although two TMALD recipients successfully recovered,the other five recipients finall...     

Effect of rituximab dose on induction therapy in ABO-incompatible living kidney transplantation: A network meta-analysis

Background:Rituximab is an induction immunosuppressant essential for ABO-incompatible kidney transplantation (ABOi KT). However, studies on its dosing, which differs among countries and transplant centers, are lacking. Therefore, we retrospectively investigated the effectiveness of the induction dose of rituximab against patient mortality, graft failure, and adverse events.Methods:We included the studies referring to at least 2 of eligible induction doses (200 mg, 200–500 mg, or 500 mg) of rituximab during ABOi KT and relevant outcomes such as patient survival, graft failure, and bacterial and viral infections. We performed direct and indirect network meta-analyses using Bayesian models and ranked different rituximab doses using generation mixed treatment comparison. Publications were retrieved using CENTRAL, MEDLINE, EMBASE, and Science Citation Index Expanded databases from 1970 to February 2020 and analyzed. The GRADE of network meta-analysis approach specified 4 levels of certainty for a given result: high, moderate, low, and very low.Results:Among the 4256 patients from 21 trials, glomerular filtration rate, graft loss, antibody-mediated rejection, T-cell mediated rejection, fungal infection, bacterial infection, and CMV infection did not differ among ABOi groups treated with different rituximab doses. The effect on mortality was significantly higher in rituximab 200 to 500 mg, and rituximab 500 mg groups (odds ratios [OR] 3.5, 95% CrI: 1.3–9.8, and OR 3.0, 95% CrI 1.1–9.8), but not in rituximab 20 mg group (OR 0.45, 95% CrI 0.036–2.5). The incidence of BK virus was significantly lower in the rituximab 200-mg group than in the other groups.Discussion:In ABO-incompatible kidney transplantation, low-dose rituximab is more efficacious than higher doses and reduces serious infection risks. Additional randomized controlled trials might be needed to confirm these findings due to small sample size.     

Subcapsular hematoma after right-lobe living-donor liver transplantation

Because right-lobe living-donor liver transplantation was introduced in adult-to-adult liver transplantation to mitigate the problems of small-for-size grafts, some technical controversies have been reported. This report describes a case of graft subcapsular hematoma due to parenchymal injury. A 53-year-old woman underwent a right-lobe living-donor liver transplantation for acute-on-chronic liver failure due to primary biliary cirrhosis. A huge subcapsular hematoma was discovered by routine Doppler echogram examination on the first posttransplantation day. Relaparotomy findings revealed that rotation of the graft for the hemostasis procedure during the transplant operation had induced a compression injury to the graft by the xiphoid process. It was speculated that a small laceration in the graft parenchyma led to the major subcapsular hematoma. This experience suggests that the graft liver must be handled with special care to prevent potential mechanical injury.     

Graft-versus-host disease and survival after ABO-incompatible allogeneic bone marrow transplantation: a single-centre experience

The effect of ABO-incompatibility on graft versus host disease (GVHD) and survival was evaluated in 173 consecutive patients receiving allogeneic bone marrow transplantation (BMT). Thirty-four percent of the patients developed GVHD and univariate analysis suggested a higher incidence of GVHD in minor ABO-incompatibility than in ABO-identity (14/30, 47% versus 37/112, 33%; P = 0.02). However, using logistic regression adjusted for potential confounders, the GVHD risk did not differ significantly. During a mean follow-up time of 59 months, the mortality was 37% and survival was significantly dependent on ABO-compatibility (P = 0.004). In particular, patients with bidirectional ABO-incompatibility had an excess mortality rate (RR, 7.6; 95% CI, 2.5-23.2; P = 0.0004). Taken together, these results suggest that ABO-incompatibility may represent a risk factor in allogeneic BMT.