Trajectories of Alcohol Consumption Following Liver Transplantation

Any use of alcohol in the years following liver transplantation (LTX) approaches 50% of patients transplanted for alcoholic liver disease (ALD). We collected detailed prospective data on alcohol consumption following LTX for ALD to investigate ongoing patterns of use. Using trajectory modeling we identified four distinct alcohol use trajectories. One group had minimal use over time. Two other groups developed early onset moderate‐to‐heavy consumption and one group developed late onset moderate use. These trajectories demonstrate that alcohol use varies based on timing of onset, quantity and duration. Using discriminant function analysis, we examine characteristics of recipient's pre‐LTX alcohol histories and early post‐LTX psychological stressors to identify the profile of those at risk for these specific trajectories. We discuss the relevance of these findings to clinical care and preliminarily to outcomes.     

Alcohol Use Disorders After Bariatric Surgery

Background

The increased incidence of alcohol use disorders (AUD) after bariatric surgery has been proposed despite limited empirical support. We sought to determine the prevalence of current and lifetime AUD and other Axis I diagnoses in patients who have undergone bariatric surgery, and to test the hypothesis that greater weight loss is associated with a higher incidence of AUD following surgery.

Methods

Individuals who underwent bariatric surgery between 2004 and 2007 were recruited for inclusion in the study. The diagnosis of current and lifetime AUD and other Axis I disorders was assessed using the Structured Clinical Interview for DSM-IV.

Results

A total of 51 individuals were included. The prevalence of lifetime and current AUD was 35.3% and 11.8%, respectively. No associations were found between weight loss following surgery and the development of an AUD or other Axis I diagnoses. Significantly more current AUD was reported in (1) individuals with a lifetime history of AUD compared to those without a lifetime AUD (p?p?Conclusions Individuals undergoing bariatric surgery were found to have a lifetime prevalence of AUD comparable to the general population. Although weight loss was not associated with the development of an AUD following surgery, individuals with a lifetime history of AUD may be at increased risk for relapsing to alcohol use after surgery. All instances of current AUD were identified in individuals undergoing RYGB as opposed to LAGB.     

Oxygen Consumption at Anaerobic Threshold Predicts Cardiac Events After Heart Transplantation

Objectives

The ventilatory efficiency and functional capacity measured by the cardiopulmonary exercise test (CPET) have been used as important prognostic variables in congestive heart failure. This study sought to identify whether these predictors before heart transplantation (HTX) play a key role in predicting adverse events in patients with heart failure after HTX.

Assessment of Donor Liver Pathology Predicts Survival After Liver Transplantation: A Retrospective Cohort Study

BackgroundThe aims of this study were to investigate the pathologic manifestation of pretransplant biopsy and to provide an accurate assessment method for liver graft of China Donation after Citizen's Death (CDCD).MethodsA retrospective analysis was performed based on clinical and biopsy data of 96 CDCD liver transplantations completed between January 2012 and December 2017. The pretransplant pathologic sections were semiquantitatively scored according to Banff Schema recommendations on liver allograft pathology. Graft overall survival (OS) and early allograft dysfunction (EAD) rates were observed.ResultsThe histologic analysis of the 96 CDCD liver graft biopsy specimens was summarized, including portal area neutrophilic infiltrate, macrovesicular steatosis, microvesicular steatosis, and hepatocellular swelling. Among these pathologic characteristics, only portal area neutrophilic infiltrate ≥20% was an independent risk factor for graft survival, although it has limited effect on the recipient's short-term prognosis.ConclusionsWe found that portal area neutrophilic infiltrate ≥20% was an independent risk factors for long-term graft survival. According to this criterion, we can identify liver transplant recipients at risk for poor prognosis and make timely interventions.     

Risk Factors of Cytomegalovirus Infection After Pediatric Liver Transplantation

PurposeCytomegalovirus (CMV) infection is known to be the most frequently viral infection among patients after liver transplantation. This is especially true in pediatric living-donor liver transplantation because the recipients have often not been infected with CMV and postoperative primary infection with CMV frequently occurs.Patients and MethodsOf 93 patients who underwent pediatric liver transplantation at our department, 33 patients (36.3%) were diagnosed with CMV infection using the antigenemia method (C7-HRP). Retrospective review and statistical analysis were conducted to confirm risk factors of post-transplantation CMV infection.ResultPositive lymphocytes were diagnosed between postoperative days 8 and 111 after transplantation. Ganciclovir or foscavir were administrated to 21 patients. The other 10 patients who had one positive lymphocyte were observed and the cell disappeared on follow-up examination. We did not observe any cases of positive lymphocytes with C7-HRP in patients who received a graft from a CMV antibody?negative donor. Independent predictors associated with CMV infection in the multivariable analysis were administration of OKT3 and grafts from CMV antibody?positive donors.ConclusionIn CMV infection after pediatric liver transplantation, cases with CMV antibody?positive donors and with OKT3 administration for acute rejection are considered high risk, and cases with CMV antibody?negative donors are considered low risk.     

Risk Factors of Mortality After Liver Transplantation in Uruguay

Introduction

Identification of predictive factors of mortality in a liver transplant (LT) program optimizes patient selection and allocation of organs.

Cardiovascular Risk Factors and Immunosuppressive Regimen After Liver Transplantation

Cardiovascular and metabolic diseases represent important long-term complications after liver transplantation (LT), impairing long-term and disease-free survivals. A few mechanisms underlie the development of those complications, but the role of immunosuppressive drugs is major. Although several patients develop temporary metabolic diseases, which normalize after a short postoperative period and do not need long-term drug therapy, the incidences of de novo long-lasting arterial hypertension, hyperlipidemia, and diabetes mellitus are high during the first year after LT. The aim of this retrospective study was to evaluate new-onset arterial hypertension, hyperlipidemia, or diabetes among 100 LT patients at a single institution. We used chi-square statistical analysis to compare incidences during tacrolimus versus cyclosporine therapy. Hypertension did not seem to be more strongly related to tacrolimus than to cyclosporine, nor did diabetes, whereas there was a difference for the development of hyperlipidemia.     

Pregnancy After Liver Transplantation

The first known posttransplantation pregnancy was in 1958 in a renal transplant recipient who had received a kidney from her identical twin sister. The first known posttransplantation pregnancy in a liver transplant recipient was in 1978. Information available from female kidney transplant recipients helped in the decision making involved in the management of this case, as well as those that followed. Over the last 20 years, issues specific to liver transplantation and pregnancy have been identified. Similar to the kidney transplant recipient population, when prepregnancy recipient graft function is stable and adequate, pregnancy appears to be well tolerated. Also similar to kidney transplant recipients, there has been no evidence of a specific malformation pattern among the children, and although prematurity and low birth weight occur, overall newborn outcomes have been favorable. Pregnancy in the setting of recurrent liver disease, such as recurrent hepatitis C, poses a potential problem among liver transplant recipients, as well as the possible adverse effects of immunosuppression on maternal kidney function. Also of significance, peripartum graft deterioration has more severe consequences in this transplant recipient population. Therefore, pregnancy must be considered carefully in this transplant recipient group. Since 1991, the National Transplantation Pregnancy Registry (NTPR) has studied the safety of pregnancy outcomes in solid-organ transplant recipients. The purpose of this review is to catalog studies in the literature, as well as to present current data from the registry with management guidelines. (Liver Transpl 2000;6:671-685.)     

Clinical Characteristics and Risk Factors of Early-Onset Tuberculosis After Liver Transplantation

BackgroundWe encountered some cases of early-onset tuberculosis (TB) after liver transplant (LT), leading to further transmission to other immunocompromised patients. Therefore, we investigated the clinical characteristics and risk factors of early-onset TB after LT.MethodsAll adult patients with TB after LT from 1996 to 2019 were retrospectively enrolled. Our hospital did not screen for latent TB infection (LTBI) in LT recipients because of concerns regarding the potential hepatotoxicity of anti-TB medication. Patients were categorized into 2 groups based on the TB onset time after LT: early-onset TB (≤2 months) and late-onset TB (>2 months).ResultsOf 4301 LT recipients, 91 patients developed TB after LT (2.1%). The median time from LT to TB development was 9.4 months. Of these 91 patients, 11 were classified as having early-onset TB (12.1%). Patients with early-onset TB had a greater pretransplant TB history than patients with late-onset TB (36.4% vs 11.3%, P = .048).ConclusionThis unusual early-onset TB was more common in patients with a pretransplant TB history, suggesting the possibility of missed TB or full manifestation of the indolent course of TB after LT. Therefore, LT recipients with a pretransplant TB history should undergo thorough screening for active TB and consider prophylaxis.     

Incidence and Risk Factors of Deep Vein Thrombosis After Liver Transplantation

BackgroundDeep venous thrombosis (DVT) occurs in 0.1% of persons per year, affecting 15%–40% of general surgical procedures without prophylaxis. Thromboembolic prophylaxis is not commonly used after orthotopic liver transplantation (LT) owing to the risks of bleeding and coagulopathy. Cirrhosis and the association with the coagulation cascade, before and after transplantation, are not well understood. The purpose of this study was to determine the incidence of DVT and its risk factors after LT.MethodsWe retrospectively reviewed LTs performed at our center from 2005 to 2012. We identified patients with Doppler examinations showing DVT after LT, platelet count, and international normalized ratio (INR) at time of DVT, associated symptoms, DVT prophylaxis, and perioperative risk factors. We determined the incidence of DVT, the odds ratio of each preoperative risk factor, the difference in platelet count and INR between those with and without a DVT, and the weighted risk of each factor in the development of DVT with the use of logistic regression modeling.ResultsOf 314 patients, the incidence of DVT was 8.6% (27/314). Between those with and without DVT there was no significant difference in age, sex, platelet count, INR, infection, hepatocellular cancer, use of venous bypass, and prior surgery. There was a significant difference in mobility, 67% vs 20% (P < .0001), and the use of factor VII, 11% vs 2% (P < .05). The estimated risk for of developing DVT for patients with neither of these factors was 4%; with factor VII the risk rose to 17%; with mobility difficulty the risk rose to 23%; and with both the risk was 62%. In our entire population, there were no cases of pulmonary embolism.ConclusionsThe risk of developing a DVT after LT is ≥9% even with mechanical DVT prophylaxis. Consideration should be given to using both mechanical and chemical prophylaxis after LT.     

Risk Factors for Development of Acute Renal Failure After Liver Transplantation

Background.?Acute renal failure (ARF) is a common complication after liver transplantation (LTx). Identification of risk factors may prevent the development and attenuate the impact of ARF on patients outcome after LTX. Methods.?Retrospective analysis of variables in the pre, intra, and postoperative periods of 92 patients submitted to LTx was performed in order to identify risk factors for development of ARF after LTx. ARF was defined as serum creatinine ≥2.0 mg/dL in the first 30 days after LTx. Univariate and multivariate analysis by logistic regression were performed. Results.?ARF group comprised 56 patients (61%). Preoperative serum creatinine was higher in ARF group. During the intraoperative period, ARF group required more blood transfusions, developed more episodes of hypotension and presented longer anesthesia time. In the postoperative period, ARF group presented higher serum bilirubin and more episodes of hypotension. Dialysis was required in 10 patients (11%). The identified risk factors for development of ARF were: preoperative serum creatinine >1.0 mg/dL, more than five blood transfusions in the intraoperative period, hypotension during intra and postoperative periods. The identified mortality risk factors were hypotension in the postoperative period and no recovery of renal function after 30 days. Conclusions.?Several factors are involved in the pathogenesis of ARF after LTx and may influence patients outcome and mortality. Pretransplant renal function and hemodynamic conditions in the operative and postoperative periods were identified as risk factors for development of ARF after LTx. Nonrenal function recovery and postoperative hypotension were identified as mortality risk factors after LTx.     

Preoperative Opiate Use Independently Predicts Narcotic Consumption and Complications After Total Joint Arthroplasty

Background

Multimodal pain protocols have reduced opioid requirements and decreased complications after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, these protocols are not universally effective. The purposes of this study are to determine the risk factors associated with increased opioid requirements and the impact of preoperative narcotic use on the length of stay and inhospital complications after THA or TKA.

Liver Stiffness 1 Year After Transplantation Predicts Clinical Outcomes in Patients With Recurrent Hepatitis C

The value of transient elastography (TE) to assess clinical outcomes in hepatitis C recurrence after liver transplantation (LT) has not been explored so far. We studied 144 hepatitis C–infected and 48 non–hepatitis C virus (HCV)‐infected LT recipients and evaluated the prognostic value of TE 1 year after transplantation to predict clinical decompensations and graft and patient survival. In HCV patients, cumulative probabilities of liver decompensation 5 years after LT were 8% for patients with liver stiffness measurement (LSM) <8.7 kilopascals (kPa) versus 47% for patients with LSM ≥ 8.7 kPa (p < 0.001). Five‐year graft and patient cumulative survival were 90% and 92% in patients with LSM < 8.7 kPa (p < 0.001) and 63% and 64% in patients with LSM ≥ 8.7 kPa, respectively (p < 0.001). Patients with low LSM 1 year after LT had excellent outcomes independently from receiving antiviral treatment or achieving sustained virological response (SVR). In contrast, graft survival significantly improved in patients with LSM ≥ 8.7 kPa who achieved SVR. No association between outcomes and LSM at 12 months was observed in non‐HCV patients. In conclusion, LSM 1 year after LT is a valuable tool to predict hepatitis C‐related outcomes in recurrent hepatitis C and can be used in clinical practice to identify the best candidates for antiviral therapy.     

Steroid-Free Immunosuppression After Liver Transplantation Does Not Increase the Risk of Graft Fibrosis

Background

Steroid-free immunosuppression after liver transplantation (OLT) is effective and safe in the short and mid terms. However, research has shown a higher risk for late fibrosis among pediatric liver transplant recipients who have steroids withdrawn. Our aim was to test this hypothesis in the adult population.

Patients and Methods

The study involved 27 adults, 14 of whom were on a regimen of cyclosporine, azathioprine, and steroid (group A) and 13 cyclosporine and azathioprine steroid-free immunosuppression (group B). The main end point of the study was liver graft histology in the late stage after OLT, with emphasis on the evolution of fibrosis, which was scored according to Ishak. The secondary end points were patient and graft survivals, liver and kidney functions, rejection rates, infections, and tumors, as well as the incidences of cardiovascular and metabolic complications.

Results

After a mean follow-up of 89.3 ± 21 months, the mean fibrosis scores did not differ between the 2 groups (2.2 ± 1.5 vs 1.9 ± 1.2; P = NS). One group A patient developed a severe acute rejection episode. The 7-year patient and graft survivals, as well as liver and kidney functions, incidence of infections, and cardiovascular and metabolic complications were comparable. Patients receiving steroids showed a trend toward an higher rate of de novo malignancies.

Conclusion

Steroid-free immunosuppression did not increase the risk of graft fibrosis in the long term.     

肝移植术后患者口腔护理方法的探讨

目的探讨肝移植术后患者的口腔护理方法，有效预防口腔并发症。方法对11例肝移植术后患者，在气管插管拔除前、后及患者恢复期分别实施口腔冲洗、擦拭加含漱、刷牙加含漱的口腔护理方法。结果1例发生口腔霉菌感染，其余未发生感染及其他口腔并发症。结论肝移植术后在不同阶段根据患者的情况实施不同的口腔护理方法，可有效预防口腔并发症的发生。     

Long-term Complications After Liver Transplantation

Background

Along with an increased number of cases of liver transplantation (LT), perioperative mortality has decreased and short-term survival has improved. However, long-term complications have not been fully elucidated today.

Purpose

Chronic complications were analyzed individually to find risk factors and to improve long-term outcomes after LT.

Subjects

There were 63 cases of LT from our outpatient clinic that were included in this study. Among them, 58 were performed using living donor LT and 5 were performed using deceased donor LT. Original diseases mainly consisted of hepatitis C virus (HCV; 45.9%) and hepatitis B virus (23.0%).

Findings

The median follow-up was 5.4 ± 3.3 years (range, 0.1∼17 years). Overall survival at 2, 3, 5, and 10 years was 89.3%, 83.4%, 81.3%, and 81.3%, respectively. Long-term complications mainly consisted of renal dysfunction (62.7%), dyslipidemia (29.4%), diabetes mellitus (21.6%), and arterial hypertension (21.6%). In univariate analysis, HCV (P = .03) and elapsed years after LT (P = .02) were identified as predictive factors for arterial hypertension and recipient age >50 (P = .03), and elapsed years after LT for renal dysfunction (P = .03), respectively. In multivariate Cox regression analysis, HCV (odds ratio [OR] 5.25, 95% confidence interval [CI] 1.05–34.06, P = .04) was identified as a predictive factor for arterial hypertension, and recipient age older than 50 years for renal dysfunction (OR 5.67, 95% CI 1.34–28.88, P = .02). The number of elapsed years after transplantation was also identified as a predictive factor for arterial hypertension/dyslipidemia/renal dysfunction (OR 13.88/14.15/4.10, 95% CI 1.91–298.26/2.18–290.78/1.09–18.03, P = .01/.003/.04). Fifty percent of the recipients developed renal dysfunction within 8 years after LT, and fluctuation of estimated glomerular filtration rate (eGFR) within 3 months after LT was successfully associated with an annual decrease of eGFR (r² value = 0.574, P < .0001).

Conclusion

Renal dysfunction is the most frequent chronic complication after LT. As chronic individual eGFR can be now accurately predicted with deterioration speed, recipient strata for renal protection strategies should be precisely targeted.     

Fungus Infections After Liver Transplantation

The problem of fungus infections after liver transplantation was studied. In 100 consecutive recipients of orthotopic liver homografts there were 10 and 8 examples, respectively, of localized and disseminated infections caused by Candida species. Candidemia was demonstrated in 8 of these 18 patients. One patient who had a localized Candida infection also had disseminated cryptococcosis. An additional 31 patients were infested in that Candida could be cultured from sites where it is not normally found, such as the blood (8 examples), urine (8), ascitic fluid (8), and wounds (22). This exorbitant incidence of monilial infections and infestations was associated with a high frequency of complications involving the homograft as well as the hosts' gastrointestinal tract during the post-transplantation period. The yeasts found in blood, urine, ascitic fluid and elsewhere were thought to have originated from the gut. Ten of the 100 patients had aspergillosis which was localized in 7 instances and disseminated in 3. The lung was the most frequently affected organ. The fungus infections played a contributory role in the downhill course of our patients but in the event of death more fundamental and more frequent causes of failure were technical complications involving the homografts, difficulties in controlling rejection with reasonable immunosuppressive doses and bacterial sepsis. Suggestions have been made for the better control of fungal infections in liver recipients.