Decreasing incidence of cancer after liver transplantation—A Nordic population‐based study over 3 decades

Cancer remains one of the most serious long‐term complications after liver transplantation (LT). Data for all adult LT patients between 1982 and 2013 were extracted from the Nordic Liver Transplant Registry. Through linkage with respective national cancer‐registry data, we calculated standardized incidence ratios (SIRs) based on country, sex, calendar time, and age‐specific incidence rates. Altogether 461 cancers were observed in 424 individuals of the 4246 LT patients during a mean 6.6‐year follow‐up. The overall SIR was 2.22 (95% confidence interval [CI], 2.02‐2.43). SIRs were especially increased for colorectal cancer in recipients with primary sclerosing cholangitis (4.04) and for lung cancer in recipients with alcoholic liver disease (4.96). A decrease in the SIR for cancers occurring within 10 years post‐LT was observed from the 1980s: 4.53 (95%CI, 2.47‐7.60), the 1990s: 3.17 (95%CI, 2.70‐3.71), to the 2000s: 1.76 (95%CI, 1.51‐2.05). This was observed across age‐ and indication‐groups. The sequential decrease for the SIR of non‐Hodgkin lymphoma was 25.0‐12.9‐7.53, and for nonmelanoma skin cancer 80.0‐29.7‐10.4. Cancer risk after LT was found to be decreasing over time, especially for those cancers that are strongly associated with immunosuppression. Whether immunosuppression minimization contributed to this decrease merits further study.     

Non-invasive diagnosis of liver cirrhosis: Magnetic resonance imaging presents special features

Objective Liver cirrhosis and its complications constitute a daily clinical challenge. The diagnosis of cirrhosis is traditionally established with the invasive method of liver biopsy. We undertook the present study in order to investigate the sensitivity and specificity of magnetic resonance imaging (MRI) in diagnosing cirrhosis. Material and methods A total of 56 patients were included in our retrospective study. The liver cirrhosis group comprised 30 patients and the control group 26 patients. All cases were histologically verified. A 1.5T MRI unit was used. Twelve radiological features of cirrhosis (enlargement of segment one, narrowing of hepatic veins, enlargement of spleen, fibrosis, nodular liver surface, ascites, regenerative nodules, enlargement of hilar periportal space, atrophy of right lobe, portosystemic collaterals, expanded gallbladder fossa, iron depositions) and tumour-load were evaluated by consensus reading. The ratio between segment one and right lobe was measured and the livers were classified as cirrhotic or non-cirrhotic. The χ²-test and t-test were used to indicate statistical difference. Results The sensitivity of MRI in diagnosing liver cirrhosis was 87% and the specificity 92%. The most characteristic MRI features were enlargement of segment one (83%), narrowing of hepatic veins (83%), signs of portal hypertension (77%), fibrosis (77%), and nodular liver margin (67%). There were statistical differences in all MRI signs between the cirrhosis and control groups. The ratio between segment one and right lobe also showed statistical significance between the two groups. All occult hepatocellular carcinomas were detected in the cirrhosis group. Conclusion MRI has high sensitivity and specificity in the diagnosis of liver cirrhosis.     

Expression of activation markers,HLA class II and IL-2R in acute vascular rejection of human renal allografts

We analyzed the expression of class II antigens on graft tubular cells and the expression of IL-2R on lymphoid cells in 314 prospective aspiration biopsies taken from 30 consecutive patients with histologically verified acute vascular rejection (AVR). Based on histology, two main groups were seen: 11 grafts had features of AVR only and 19 grafts had a combination of AVR and acute cellular rejection (ACR). The AVR findings were also predominant in the latter group. In the grafts with a combination of AVR and ACR, patterns similar to ordinary ACR were seen in class II and IL-2R expression. On the contrary, no class II or IL-2R induction could be seen in the grafts with pure AVR and irreversible rejection. This pattern, demonstrated by immunocytology, suggested that AVR is a heterogenous group of rejections, where different cellular and molecular mechanisms are operating. Humoral mechanisms might be involved in these rejections.     

Efficacy of sequential use of superparamagnetic iron oxide and gadolinium in liver MR imaging

Purpose: To evaluate the efficacy of combined (double contrast) use of superparamagnetic iron particles (SPIOs) and gadolinium (Gd) in liver MR imaging.Material and Methods: Unenhanced, Gd-enhanced, SPIO-enhanced, and both SPIO- and Gd-enhanced images were acquired at 1.5 T. Twenty patients with previously detected liver lesions were included. Fast SE-STIR, and breath-hold true FISP, fat-suppressed T1- and T2-weighted sequences were obtained with all techniques. Lesion count was assessed by consensus reading.Results: Collective evaluation of all MR sequences revealed 61 lesions in 16 patients; SPIO-enhanced MR detected lesions with a sensitivity of 95% (n=58). The sensitivity of unenhanced MR imaging was 90% (n=55). There was no statistical difference between SPIO-enhanced and unenhanced MR images. From single sequences, the greatest number of lesions was detected with the SPIO-enhanced fast SE-STIR sequence (n=56, sensitivity 92%). By using the fat-suppressed T1-weighted sequence, Gd-enhanced and both SPIO- and Gd-enhanced MR images demonstrated sensitivities of 77% (n=47) and 80% (n=49), respectively. Despite the combined use of both contrast media, this sequence was significantly less sensitive in lesion detection when compared to SPIO-enhanced imaging.Conclusion: SPIO-enhanced MR imaging was the most sensitive method in lesion detection. The benefit of the combined use of SPIO and Gd was negligible.     

Liver transplantation for primary sclerosing cholangitis; predictors and consequences of hepatobiliary malignancy

BACKGROUND/AIMS: Hepatobiliary malignancies are frequently seen in primary sclerosing cholangitis (PSC) and they complicate the evaluation of patients and timing of liver transplantation. METHODS: Data from all Nordic PSC patients listed for liver transplantation during 1990-2001 were recorded prospectively. Predictors of hepatobiliary malignancy and patient survival rates have been analysed. RESULTS: Hepatobiliary malignancy was found in 52/255 (20%) patients accepted to the waiting list. Recent diagnosis of PSC, no ursodeoxycholic acid (UDCA) treatment, clinical suspicion and previous colorectal-cancer were predictors of malignancy. Among 89 patients with a strong suspicion of malignancy prior to acceptance, 35 (39%) had confirmed malignancy. A clinical suspicion had been raised in 35/52 (67%) patients with malignancy. Malignancy was found in 31/223 patients who received a liver allograft. The 1-, 3- and 5-year patient survival rates following transplantation for patients with PSC and cholangiocarcinoma were 65, 35 and 35%, respectively. CONCLUSIONS: Hepatobiliary malignancy is suspected in 1/3 of the PSC patients and found in 1/5. Although cholangiocarcinoma is regarded as a contraindication to liver transplantation (LTX), PSC patients with cholangiocarcinoma had a 35% 5-year survival following transplantation.     

Can the failure of a below-knee amputation be predicted? Predictability of below-knee amputation healing

The predictability of below-knee amputation healing was evaluated in 69 patients with severe distal ischaemia with or without diabetes mellitus. A special attempt was made to find out predictors of amputation failure. Of 71 amputations performed 20 failed. Preoperative systolic blood pressures and skin perfusion pressures were significantly higher at the level of amputation in patients whose amputations healed than in those whose amputations failed, mean 69.5 (SD 33.4) mmHg and 55.9 (SD 27.0) mmHg vs. 41.5 (SD 31.6) mmHg (p less than 0.01) and 35.6 (SD 13.9) mmHg (p less than 0.05), respectively. There was, however, considerable overlapping and only if calf systolic blood pressure was unmeasurable did below-knee amputations always fail. PVR and skin perfusion pressure data were useful in disclosing falsely high calf systolic blood pressures apparently caused by mediasclerosis. When these patients with pseudohypertension were excluded the presence of diabetes did not affect the pressure readings. The blood viscosity as indicated in this study by pre- and postoperative haemoglobin levels did not affect amputation healing. The present results suggest that vascular laboratory data are useful as supplementary information in the assessment of below-knee amputation healing but it can predict amputation failure only when no Doppler signals are present at the ankle level.     

Highly urgent liver transplantation: possible impact of donor-recipient ABO matching on the outcome after transplantation

BACKGROUND: Survival after liver transplantation for fulminant hepatic failure has been reported to be less favorable than survival for patients with chronic liver diseases. METHODS: We have studied all patients (n=229) undergoing highly urgent liver transplantation from 1990 to 2001 in the Nordic countries. The impact of patient and donor characteristics, with emphasis on donor-recipient ABO matching (identical, compatible, incompatible), has been studied. RESULTS: One-year and 3-year patient survival rates were 73% and 70% for the total period and 86% and 78% for the last 4-year period. Patients receiving an ABO-compatible liver allograft had significantly lower patient survival rates than those receiving an ABO-identical donor organ (1-year patient survival rates 66% of vs. 79%, P=0.03). Graft survival rates varied less (1-year graft survival rates of 64% vs. 74%, P=0.09). Patients receiving an ABO-incompatible liver allograft had patient survival rates of 70% at 1 year and 60% at 3 years but low graft survival rates (40% and 30% at 1 and 3 years). In a multiple regression analysis, significant independent predictors of poor patient survival were early year of transplantation, ABO-compatible donor, high donor age, and waiting time more than 3 days and less than 9 days. CONCLUSION: Survival after highly urgent liver transplantation has improved and is comparable to that observed in patients receiving a liver allograft because of chronic liver disease. Patients receiving an ABO-identical donor organ had significantly higher patient survival rates compared with those receiving an ABO-compatible donor liver.     

Association of fatal aneurysmal subarachnoid hemorrhage with human leukocyte antigens in the Finnish population

Human leukocyte antigens (HLA) have been reported to associate with the risk of aneurysmal subarachnoid hemorrhage (SAH) and poor outcome after SAH. Our aim was to identify HLA antigens that associate with the risk of fatal SAH in the Finnish population. Medical records of 600 cadaveric organ donors were reviewed to find organ donors that succumbed to SAH (n = 232) or brain trauma (n = 151). HLA antigen frequencies in these groups were compared with HLA frequencies in a reference population of 10,000 bone marrow donors. Chi-Square test with Bonferroni correction and multiplicative logistic regression models were used and false positive result probabilities (FPRP) were calculated. Alpha-level was 0.01. HLA-A3 associated with fatal SAH (p = 0.0014, OR 1.3 and 95%CI 1.1-1.6) and HLA-DR7 inversely associated with fatal SAH (p = 0.0040, OR 0.3 and 95%CI 0.2-0.6). HLA-A3 but not HLA-DR7 showed also a positive trend in donors with brain trauma. FPRP was below 0.5 for HLA-A3, but clearly above 0.5 for HLA-DR7. HLA-A3 seems to associate with fatal SAH in the Finnish population. Further studies are needed to reveal the pathobiologic mechanisms for how HLA-A3 associates with the risk of fatal SAH in Finns.