Journal of Liver Transplantation最新文献

Introduction

This study presents our experience with Epstein Barr virus (EBV) and Cytomegalovirus (CMV) infections in the pediatric liver transplant population and their potential association with the development of the post-transplant lymphoproliferative syndrome (PTLD).

Patients and methods

This retrospective descriptive study covers the period from 2014 to 2017 and includes pediatric liver transplanted recipients who underwent viral load monitoring for EVB and CMV during the first-year post-transplant.

Results

A total of 89 patients were included in the study, with a median age of 0.68 years (RIQ 0.31–0.96) (10.8 months RIQ 8.4–25.2). The most common underlying pathology leading to transplantation was biliary atresia, observed in 55 (61.6 %) cases. Regarding EBV viral loads, values exceeding 10,000 copies/ml were observed in 9 (8 %) patients at 3 months, 33 (29.3 %) at 6 months, 31 (27.6 %) at 9 months and 25 (22.3 %) at 12 months post-transplantation. The probability of developing EBV infection within one-year post-transplantation was 81.3 %, while the probability of CMV infection was 29 %. A total of 8 (8.9 %) biopsy-confirmed graft rejections occurred, only 1 was EBV and CMV-negative. The likelihood of graft rejection in patients with EBV infection was 21.5 %, and for CMV it was 20.8 %. Importantly, only one case of PTLD was documented during 12 months follow-up.

Conclusion

Characterizing this pediatric liver transplant population and monitoring EBV and CMV viral loads enables timely interventions, potentially reducing the risk of PTLD and graft rejection.

Introduction

In pediatric patients undergoing liver transplantation, infections are one of the primary complications. The etiology varies depending on the time elapsed post-transplant, with early presentations of bacterial and fungal infections, followed by viral and parasitic infections. There is limited literature describing the prevalence of infectious complications in this group of patients in Colombia.

Objective

To describe infectious complications in patients undergoing liver transplantation within the first 3 months post-procedure at the Fundación Valle del Lili, Cali, Colombia.

Methods

A case series of 165 pediatric liver transplant patients during the period 2011–2017. A descriptive analysis of all entered data was conducted. Survival analysis using the Kaplan-Meier method was performed, with an exploratory analysis comparing patient survival based on the presence of infection, censored for death related to postoperative complications.

Results

The primary diagnosis at the time of transplantation was biliary atresia in 65% of cases. A total of 215 infectious episodes were recorded in 92 pediatric liver transplants. The most frequent microorganisms were Klebsiella pneumoniae (21%), Cytomegalovirus (CMV) (7%), Pseudomonas aeruginosa (7%), Escherichia coli (6%), and Epstein Barr Virus (EBV) (6%). Three-month patient survival was 92% for infection-related mortality.

Discussion

Infectious complications within the first three months post-pediatric liver transplantation were predominantly bacterial in origin. Bacterial and fungal infections manifested earlier, while viral infections appeared later. Infectious complications did not impact the three-month patient survival in this group.

The diagnosis of arterial complications in children after Liver Transplantation (LT) urges prompt diagnosis and treatment. This study aims to determine whether hepatic artery Doppler Ultrasound (DUS) parameters can predict arterial complications in the immediate period after LT in children.

A retrospective review of the pediatric liver database at our tertiary-care pediatric hospital was performed. The study included 70 pediatric patients who underwent a liver transplantation from 2016 to 2021. Clinical, laboratory and Doppler findings were recorded daily the first 5 days after transplantation, with special attention given to post-anastomotic Peak Systolic Velocity (PSV) and Resistive Index (RI).

Patients with hepatic artery complications, including acute thrombosis and stenosis, had lower PSV values after surgery compared to the group with non-complications, with a statistical significance (< 0.001). Receiver operating characteristic (ROC) curve analysis determined an optimal cut-off value of PSV less than 29 cm/s the 2nd day after LT, 25.2 cm/s the 3rd day, 28.5 cm/s the 4th day and 29.4 cm/s the 5th day, to discriminate children with and without hepatic arterial complications. Notably, these cut-off values are lower than those proposed in adults.

Optimal PSV cutt-off values in children in the immediate period after LT are presented. Knowledge of these cutt-off values improves the interpretation of DUS measurements and thereby, may help to accurately guide the clinical management.

Light Chain Deposition Disease (LCDD) is a rare monoclonal gammopathy characterized by deposition of light chains along the basement membranes of various organs, leading to progressive dysfunction (1,2). It has histological features that differ from amyloidosis and is most often characterized by the overproduction of kappa light chains (2). The kidney is usually the most affected organ and is responsible for the initial clinical manifestations, whereas liver dysfunction is less common and generally less severe than kidney involvement (1,3). We present a case of LCDD in a patient with renal dysfunction associated with secondary sclerosing cholangitis (SSC) and severe liver and kidney involvement, efficiently treated with autologous stem cell transplantation followed by double liver-kidney transplantation.

Pediatric liver transplantation has evolved since the first transplant was performed by Dr. Starzl more than 50 years ago. Innovations in surgical techniques, immunosuppression, and infection control have significantly improved patient outcomes, graft survival, and quality of life. However, further progress depends not only on the discovery of new treatment option but should rely upon the identification of the factors in the perioperative care which contribute to successful outcomes and guide our decision-making process.

Indications for pediatric liver transplantation can be divided into three major groups: cholestatic liver conditions, liver based metabolic disorders, and others represented by acute liver failure of different etiologies, tumors, inherited autoimmune diseases, and multiple infectious causes.

Many of these conditions manifest themselves with multi organ pathologic expression, requiring earlier interventions to treat acute liver failure or chronic cholestasis leading to failure to thrive. Containment of patient pathology and maintenance of optimal neurologic and extra-hepatic visceral organ function is paramount during the pre - transplant period.

Multidisciplinary management of comorbid conditions in complex pediatric liver transplant candidates during the perioperative period with the emphases on optimization and patient selection has never been summarized in the literature. Thant is why this review focuses on a comprehensive, multidisciplinary preoperative evaluation of pediatric patients in whom progressive liver disfunction manifests early in life and eventually requires liver transplantation. We will address multi-organ system involvement, preoperative optimization in anticipation of the complexity of intraoperative care, as well as short- and long-term postoperative management.

Antibody-mediated rejection (AMR) following liver transplantation is a significant clinical challenge, with donor-specific antibodies (DSAs) playing a pivotal role. Understanding the mechanisms and impact of DSAs is crucial for improving transplant outcomes and patient care. This review provides an in-depth analysis of the pathogenesis, diagnosis, and management of AMR in liver transplantation, focusing on the role of DSAs. AMR in liver transplants, though less common than in other organ transplants, presents unique diagnostic and therapeutic challenges. The review explores the latest diagnostic criteria, including serum DSAs, C4d staining, and liver biopsy findings. It delves into the pathogenesis of AMR, emphasizing the role of both preformed and de novo DSAs in causing graft injury and rejection. The review also discusses current therapeutic strategies, such as the use of immunosuppressants, plasmapheresis, intravenous immunoglobulin, and proteasome inhibitors, highlighting their efficacy and limitations. Furthermore, it examines the unique aspects of liver immunology that contribute to the organ's relative resistance to DSA-mediated injury. Emerging research, particularly on gene expression changes in renal allografts during simultaneous liver-kidney transplantation, is also discussed, offering insights into future directions. This review is instrumental for clinicians and researchers in understanding the complexities of AMR in liver transplantation and in developing more effective management strategies.