Heterotopic heart transplantation: a single-centre experience

INTRODUCTION: Orthotopic heart transplantation (OHTx) represents the therapy of choice for end-stage heart disease not treatable with medical or conservative surgical approach. Heterotopic heart transplantation (HHTx) is a surgical procedure in which the graft is connected to the native heart in a parallel fashion and it was especially employed in precyclosporine era. The aim of this paper is to present our experience with HHTx. METHODS: From November 1985 till May 2003, 713 heart transplanted patients included 12 (1.7%) received HHTx. Eleven were male, mean age was 50.7 +/- 5.8 years. Five patients suffered from dilated cardiomyopathy and seven from ischemic cardiomyopathy. Indication for HHTx was: a body size mismatch in 11 cases and availability of a marginal organ in one case. RESULTS: Mean ischemic time was 149 +/- 48 minutes and mean cross-clamp time was 82.3 +/- 19.1 minutes. In four cases left ventricle aneurysm resection was associated with HHTx. Hospital mortality was 8.3% (one patient due to multiorgan failure). The actuarial survival rates were 92% and 64% at 1 and 5 years, respectively. The causes of death were: liver cancer, liver cirrosis, aortic dissection, cerebrovascular accident, and chronic rejection. CONCLUSIONS: In our experience, HHTx survival rate is comparable to OHTx. Because of the scarcity of donors, use of an undersized or marginal graft is a valid option to increase the number of transplanted patients. The major disadvantages of HHTx are the need for anticoagulant therapy, the more difficult hemodynamic and immunologic follow-up, and the presence of the diseased native heart.     

Liver transplantation from anti-hepatitis C virus-positive donors: our experience

Background

Hepatitis C (HCV) is among the most common causes of end-stage liver disease worldwide. The donor shortage leads us to consider alternative organ sources such as HCV-positive donors. The outcomes of these transplants must be evaluated thoroughly since there is universal recurrence of disease among HCV-positive liver transplant recipients.

Methods

From January 2005 to April 2011, we performed 143 liver transplants (OLT) to treat end-stage liver disease secondary to HCV infection. Thirteen patients (9,1%) received livers from HCV-positive donors. A control group consisted of 130 HCV-positive patients who underwent OLT during the same period with organs from HCV-negative donors. Donor HCV status was assessed by 2 tests: HCV antibodies and viral load. Not only recipient and graft survivals were analyzed, but also frequency, timing and severity of hepatitis recurrence.

Results

Among 143 transplants performed in HCV-positive recipients during a 6-year period from January 1, 2005, to April 30, 2011, 9.1% of patients received an organ from an anti-HCV-positive donor, 72.7% of whom showed a negative viral load. The vast majority (80%) of our patients suffered hepatitis during their follow-up, 22.4% of which were severe cases.

Conclusions

No significant difference in patient or graft survival was observed between the 2 groups. A high percentage of grafts with initial positive serology for HCV showed no viral replication. Grafts from HCV-positive donors can be considered to be a safe, effective source for liver donation.     

Survival after liver transplantation using hepatitis C virus-positive donor allografts: case-controlled analysis of the UNOS database

Background  

Numerous reports have documented reduced graft and patient survival after use of hepatitis C (HCV) seropositive allografts in liver transplantation (OLT). We aimed to examine if the use of a HCV+ liver allograft affects patient and graft survivals compared to HCV− donor allografts in a case-controlled analysis of the united network for organ sharing (UNOS) database.     

Late retransplantation of the liver: a single-centre experience

Liver retransplantation is considered to carry a higher risk than primary transplantation. The aim of this study was to analyse a single-center experience with late liver retransplantation. The overall rate of primary retransplantation was 11% (30 re-OLT out of 272 primary OLT). fiftten of these (50%) had retransplantation more than 3 months after the first transplant and were analyzed by reviewing their medical records. Causes of primary graft failure leading to retransplantation were chronic hepatic artery thrombosis in 6 cases (40%), HCV cirrhotic recurrence in 4 cases (28%), chronic rejection in 2 cases (14%), veno-occlusive disease, hepatic vein thrombosis and idiopathic graft failure in 1 case each (6%). UNOS status at re-OLT was 2A in all cases. All patients were hospitalised, and three of them were in intensive care. One- and two-year patient and graft survival rates were 80% and 66% and 66% and 59%, respectively. Death occurred in 5 patients, including 2 of the 3 admitted to the intensive care unit at the time of retransplantation, who died after a mean interval of 15 +/- 9 days from retransplantation. Retransplantation should be considered a very efficient way of saving lives, especially when the optimal timing for its execution is defined.     

Lamivudine for hepatitis B in liver transplantation: a single-center experience

BACKGROUND: Liver transplantation for hepatitis B virus (HBV) has been associated with a high rate of reinfection and graft failure. Lamivudine, a potent inhibitor of HBV replication, has been shown to prevent viral recurrence after transplantation. METHODS: The effectiveness of lamivudine monotherapy for the management of HBV recurrence after liver transplantation was assessed. Lamivudine was used in three patient groups: (1) patients started before transplantation and continued after transplantation (n = 13); (2) patients treated after transplantation (n = 15); and (3) patients with de novo hepatitis B after transplantation (n = 4). RESULTS: Median follow-up on lamivudine was 24 months. Active viral replication (HBV-DNA+) was seen in 17 (53%) of 32 at treatment initiation. All lost HBV-DNA at a mean of 2.4+/-1.6 months after lamivudine initiation. Twenty-six (81%) patients remain free of viral recurrence. Six (19%) patients have evidence of breakthrough infection with the YMDD mutant of HBV, two of whom progressed to graft failure. All four patients in group 1 who developed breakthrough had evidence of hepatitis B surface antigen expression in the explanted liver by immunohistochemistry despite being serum HBV-DNA negative before transplantation. No difference was observed among the three groups in DNA clearance or breakthrough rates. CONCLUSIONS: Lamivudine achieves viral DNA clearance in almost all patients. Expression of viral antigens in the liver seems to identify patients at risk of developing HBV-DNA recurrence. Disease-free survival of 81% at 22 months is similar to data with hepatitis B immunoglobulin therapy. Given the safe clinical profile and high efficacy in the prevention of disease recurrence, lamivudine will favorably change the outlook of liver transplantation for HBV.     

Use of severely steatotic grafts in liver transplantation: a matched case-control study

BACKGROUND: Although there is a worldwide need to expand the pool of available liver grafts, cadaveric livers with severe steatosis (>60%) are discarded for orthotopic liver transplantation (OLT) by most centers. METHODS: We analyzed patients receiving liver grafts with severe steatosis between January 2002 and September 2006. These patients were matched 1:2 with control patients without severe steatosis according to status the waiting list, recipient age, recipient body mass index (BMI), and model for end-stage liver disease (MELD) score. Primary end points were the incidence of primary graft nonfunction (PNF), and graft and patient survival. Secondary end points included primary graft dysfunction (PDF), the incidence of postoperative complications, and histologic assessment of steatosis in follow-up biopsies. We also conducted a survey on the use of grafts with severe steatosis among leading European liver transplant centers. RESULTS: During the study period, 62 patients dropped out of the waiting list and 45 of them died due to progression of disease. Of 118 patients who received transplants 20 (17%) received a graft with severe steatosis during this period. The median degree of total liver steatosis was 90% (R = 65%-100%) for the steatotic group. The steatotic (n = 20) and matched control group (n = 40) were comparable in terms of recipient age, BMI, MELD score, and cold ischemia time. The steatotic group had a significantly higher rate of PDF and/or renal failure. Although the median intensive care unit (ICU) and hospital stay were not significantly different between both groups, the proportion of patients with long-term ICU (> or =21 days) and hospital (> or =40 days) stay was significantly higher for patients with a severely steatotic graft. Sixty-day mortality (5% vs. 5%) and 3-year patient survival rate (83% vs. 84%) were comparable between the control and severe steatosis group. Postoperative histologic assessment demonstrated that the median total amount of liver steatosis decreased significantly (median: 90% to 15%, P < 0.001). Our survey showed that all but one of the European centers currently reject liver grafts with severe steatosis for any recipient. CONCLUSION: Due to the urgent need of liver grafts, severely steatotic grafts should be no longer discarded for OLT. Maximal effort must be spent when dealing with these high-risk organs but the use of severely steatotic grafts may save the lives of many patients who would die on the waiting list.     

Nocardiosis following solid organ transplantation: a single-centre experience.

Nocardiosis is a localized or disseminated bacterial infection caused by aerobic Actinomyces that commonly affects immunocompromised hosts. The aim of this study was to retrospectively review clinical course and outcome of nocardiosis in solid organ recipients at our centre. Five cases of nocardiosis were identified in a series of more than 4000 consecutive solid organ transplants performed at Innsbruck university hospital during a 25-year period. Of the five patients with nocardiosis, two had undergone multivisceral, one liver, one kidney and one lung transplantation. Three patients with Nocardia asteroides infection were treated successfully and recovered from their infectious disease, however, one lost his renal graft following withdrawal of immunosuppression. The lung recipient recovered from nocardiosis but died later on from Pseudomonas pneumonia. One multivisceral recipient died from Nocardia farcinica-disseminated infection. Nocardiosis is a rare, difficult-to-diagnose-and-treat complication following solid organ transplantation. Intestinal recipients might be at increased risk to develop this infection.     

Causes of early acute graft failure after liver transplantation: analysis of a 17-year single-centre experience

Despite satisfactory overall results reported, early post-operative period after liver transplantation (LT) still represents a critical time with persistently high rate of graft loss. We retrospectively reviewed our experience of 17 yr in LT, analysing the impact on grafts and patient survivals of the acute complications affecting the graft in the early period following LT. To evaluate the changes that occurred over the years in case of early acute graft failure (EAGF), the study population was divided into three equal groups of 223 patients corresponding to three different periods. Ninety (13.5%) experienced an EAGF. Causes of EAGF were hepatic artery thrombosis (HAT) in 32 cases (4.8%), primary graft non-function in 29 cases (4.3%), caval stenosis in 19 (2.8%), early irreversible acute rejection in 6 (0.9%) and portal vein thrombosis in 4 (0.6%). The use of elderly donors and the introduction of the piggyback technique proved to be associated with a higher incidence of HAT and caval stenosis, respectively. Female recipients of male donors were independently associated with Primary graft non-function. Of 90 patients with EAGF, 20 (22.2%) died within the first month after LT, 34 (37.8%) underwent retransplantation (ReLT) and 36 (40%) received conservative treatment. Conservative treatments increased from 3.6% in the first group to 47.0 and 66.8% in the second and third one (p = 0.000). One-year graft and patient survival of patients with EAGF significantly improved over the three eras analysed. The incidence of EAGF remains consistent. Nevertheless, a better understanding of the clinical situations and changes in treatment strategies have led to significant improvements in terms of graft and patient survival rates, now close to the survival rate of EAGF-free patients.     

Renal transplantation in the elderly: a long-term, single-centre experience.

BACKGROUND: End-stage renal failure increases with advancing age and renal transplantation should be considered in end-stage renal failure patients older than 60 years. However, there is a paucity of data on long-term patient and graft survival in this population. METHODS: From October 1983 to March 1999, 310 renal transplantations were performed at Geneva University Hospital in 283 patients, of which 49 were done in 48 patients older than 60 years (mean age 65.6+/-4.1 years). The following data were analysed at 1, 5, and 10 years, and compared between the patients >60 years and <60 years old: actuarial patient and graft survival, serum creatinine, causes of graft loss, and patient death. RESULTS: Patient survival at 10 years was 81% for patients <60 years and 44% for patients >60 years. Graft survival at 10 years was 59% for patients <60 years and 32% for patients >60 years. Graft survival at 10 years censored for death with functioning graft was 65% for patients <60 years and 81% for patients >60 years. Main causes of mortality in the older patients were related to cardiovascular events (47%), neoplasia (41%), and sepsis (18%). Overall, recipient and donor age were not predictive factors for graft survival, as shown by multiple logistic regression. CONCLUSIONS: Renal transplantation should be considered in patients older than 60 years, since graft survival is excellent in this population. Although these patients have a shorter life expectancy, they benefit from renal transplantation similarly to younger kidney transplant recipients.     

Critical use of extended criteria donor liver grafts in adult-to-adult whole liver transplantation: a single-center experience.

This study presents our experience with the use of extended criteria donor (ECD) liver grafts. One hundred fifteen liver transplants were divided into 2 groups: standard (S) and nonstandard (NS). Fifty-eight patients in group S received a liver procured from an ideal donor, whereas 57 patients in group NS received an organ from an ECD. On the basis of the number of risk factors, patients were divided into 3 subgroups: the S group with 58 receiving a standard graft, the NS1 group with 44 receiving a graft with 1 or 2 risk factors, and the NS2 group with 13 receiving a graft with 3 to 4 risk factors. Patient survival was not different at 6, 12, and 24 months (P > 0.05), whereas graft survival was different (P = 0.0079). Both patient survival and graft survival were influenced by the cumulative number of risk factors. The univariate analysis of the donor risk factors detected hemodynamic factors as predictive of graft failure (P = 0.024) and death (P = 0.018). In the multivariate analysis, which was adjusted for recipient age and donor and recipient gender, hemodynamic risk factors and Model for End-Stage Liver. Disease score in the recipient were the only variables independently associated with graft failure (P = 0.006, P = 0.012, negatively). Finally, we observed a reduction of dropout from the list to 9% from 14.1% (P = 0.04) and of mortality on the list to 32.55% from 41.01% (P = 0.11). Critical use of ECD liver grafts allowed recipients in the waiting list to have a greater chance of being transplanted.     

Rapid progressive hepatitis C after liver transplantation: a case report

A 56-year-old man on hemodialysis for 3 years because of chronic renal failure underwent living related donor liver transplantation (LRDLT) and splenectomy using the right hepatic lobe for liver cirrhosis type C (genotype 1b) with hepatocellular carcinoma. At 69 postoperative days (POD), he displayed a high fever and his blood transaminase and total bilirubin were increased. Based on finding in his liver biopsy, we diagnosed rapid recurrence of progressive hepatitis C after LRDLT, so we administered IFNβ. Thereafter his liver function returned to normal and his HCV-mRNA decreased to 1200 kcopy/mL. We inferred that hemodialysis and splenectomy decreased his immunity, allowing rapidly progressive hepatitis C recurrence after LRDLT.     

Asunaprevir and daclatasvir for recurrent hepatitis C after liver transplantation: A Japanese multicenter experience

The safety and efficacy of an IFN‐free regimen using asunaprevir (ASV) and daclatasvir (DCV) for recurrent hepatitis C virus (HCV) infection after liver transplantation (LT) have not been evaluated in Japan. A multicenter study of LT recipients (n = 74) with recurrent HCV genotype 1b infection treated with ASV‐DCV for 24 weeks was performed. Medical history was positive for pegylated interferon and ribavirin (Peg‐IFN/RBV) in 40 (54.1%) patients, and for simeprevir (SMV) with Peg‐IFN/RBV in 12 (16.2%) patients. Resistance‐associated variants (RAVs) were positive at D168 (n = 1) in the NS3, and at L31 (n = 4), Y93 (n = 4), and L31/Y93 (n = 1) in the NS5A region of the HCV genome. Sixty‐one (82.4%) patients completed the 24‐week treatment protocol. Although sustained viral response (SVR) was achieved in 49 (80.3%) patients, it was achieved in only two (16.7%) patients among those with histories of receiving SMV (n = 12). Univariate analysis showed that a history of SMV (P < .01) and the presence of mutations in NS5A (P = .02) were the significant factors for no‐SVR. By excluding the patients with either a history of SMV‐based treatment or RAVs in NS3/NS5A, the SVR rate was 96.4%. By excluding the patients with a history of SMV and those with RAVs in NS3/NS5A, viral clearance of ASV‐DCV was favorable, with a high SVR rate.     

Single-center experience with liver transplantation from controlled non-heartbeating donors: a viable source of grafts

BACKGROUND: To increase the number of livers available for transplantation a non-heartbeating donor (NHBD) liver transplant program was started after obtaining hospital ethical committee approval. METHODS: Controlled donors with a warm ischemia of <30 minutes were considered. A 5-minute stand-off period was observed from asystole to skin incision. A super-rapid technique was used for the retrieval. Methods used to assess the suitability for transplantation included liver function tests, morphologic and histologic assessment, and hepatocyte viability testing. RESULTS: Sixty livers were retrieved from NHBDs. Of these, 33 were judged suitable for transplantation. Of these one was exported and transplanted, and one could not be matched to a suitable recipient. A further 27 were not used because of liver appearance in 21, prolonged hypoxia and hypotension in 4, poor perfusion in 1, and donor malignancy in 1. Mean donor age was 39.4 years (range, 0.75-67 years). Causes of death were head trauma in 10 donors, intracranial bleed in 24, and anoxic/ischemic brain injury in 26. Mean warm ischemia time was 14.7 minutes (range, 7-40 minutes). Thirty-two patients were transplanted (one split liver), and the mean age of the recipients was 38.4 years (range, 0.7-72 years). All grafts had good early function except one right lobe split. There were 4 deaths resulting from ischemic brain injury, chronic rejection, biliary sepsis, and multiorgan failure following retransplantation for primary nonfunction. Overall patient and graft survival is 87% and 84%, respectively, at a median follow-up of 15 months. CONCLUSIONS: Early results suggest that controlled NHBDs are a significant new source of grafts, but careful donor selection and short cold ischemia are mandatory.     

Macroglobulinemia and membranoproliferative glomerulonephritis in a hepatitis C virus-positive patient

A 72-year-old female was admitted to our hospital for massive proteinuria. She had previously been diagnosed with hepatitis C virus (HCV) infection and macroglobulinemia. Renal histological examination demonstrated membranoproliferative glomerulonephritis (MPGN), and type 2 cryoglobulinemia was positive in her serum. It is generally recognized that MPGN is the most common nephritis associated with HCV infection and cryoglobulinemia, but this is the first report of an HCV-infected patient with macroglobulinemia associated with MPGN. After treatment with prednisolone and melphalan, proteinuria disappeared, but macroglobulinemia and cryoglobulinemia were not improved.