Transplantation Reports最新文献

Belatacept is a novel fusion protein that blocks signal two of T cell activation. Belatacept was approved in 2015 for the prevention of acute rejection in kidney transplant recipients. Results from a 2014 phase II clinical trial in liver transplant recipients was terminated early due to an increased risk of death and graft loss, leading to a black box warning for its use in liver transplant recipients. Here we describe the clinical course of a 55 year old male patient who underwent a liver transplant for cholestatic liver disease. His post-transplant course was complicated by multiple episodes of severe acute cellular rejection as well as multiple complications from maintenance immunosuppression including chronic kidney disease (CKD), steroid-induced diabetes, mycophenolate-associated colitis, and mammalian target of rapamycin (mTOR) inhibitor-induced lung injury. Belatacept was initiated 5 years post-transplant as a last-line option for maintenance immunosuppression. Six months post-initiation, the patient has had stabilization of his CKD, improvement in lung function, and remains without evidence of acute or chronic rejection.

Purpose

Outcome of pediatric liver transplant patients is affected by various factors, including critical care management in the early phase following surgery. This article focuses on early recognition of complications in pediatric liver transplant patients in Pediatric Intensive Care Unit (PICU). In particular, this article highlights the common problem in post-liver transplant pediatric patients in Indonesia, and the strategies to optimize recovery and minimize complications.

Summary

Almost every system organ is affected by the surgery and medications given intra- and post-operatively. Careful monitoring and appropriate management are needed to ensure long-term success of surgery and prevent both early and late complications. Early extubation is recommended, however some may need PEEP titration to obtain optimal oxygenation. Advanced hemodynamic monitoring paired with clinical signs is recommended for optimal perfusion and ventriculo-arterial coupling. Routine electrolytes examination and neurological assessment are needed. Infection control and immunosuppression have to be optimized. Early enteral nutrition, nutritional support for recovery is needed, however should be gradually administered in malnourished patients.

Conclusion

Early detection of post-transplant complications must be identified to ensure appropriate management is given as soon as possible. The ultimate goal is to retain graft acceptance as long as possible and the reduction of morbidity and mortality post-transplantation.

Today, bariatric surgery has become the main therapeutic means to fight against the escalating increase in obesity, worldwide. Besides that, non-alcoholic steatohepatitis has inflated its indication for liver transplantation. Liver transplant surgeons are prone to face more and more patients with such background. Here, we described the first case of liver transplantation for hepatocellular carcinoma in a patient with previous history of biliopancreatic diversion with duodenal switch. Biliopancreatic diversion with duodenal switch is nowadays an uncommon bariatric surgery but use to be a second stage surgery following sleeve gastrectomy. Liver transplantation can be challenging as such bariatric procedure reshape the digestive anatomy and can also be responsible for malnutrition. Without such complication and in a center specialized in bariatric surgery and liver transplantation, such cases can be successful and should not alarm liver transplant surgeons. In our case, the bariatric anatomy was conserved, and the liver transplantation was successful, without difficulty of the post-operative immunosuppressive treatment. However, long term follow-up showed an exacerbation of the sarcopenia level and establish even more the need for an association of a well-planned physical and nutritional rehabilitation in the peri-operative period in such candidate.

Immunoglobulin A (IgA) Nephropathy (IgAN) is one of the most common recurrent glomerulopathies associated with graft loss and patient survival after kidney transplantation (KT). Steroid withdrawal regimens in KT have been associated with improvements of patient outcomes. The Scripps Center for Organ Transplantation (SCOT) utilizes a rapid low-dose steroid withdrawal immunosuppression (IS) protocol for KT maintenance. We assessed the impact of our protocol on IgAN recurrence over a 10-year period to reassess our steroid withdrawal and IS protocols to see if outcomes diverged from available UNOS data. Therefore, we used IS and induction matched retrospective data from UNOS to investigate patient and graft survival for IgAN. SCOT recurrence rates for IgAN was 13.6%. Overall outcomes of graft failure and recipient death did not differ between SCOT patients and data obtained from steroid free transplants from UNOS. Our results differ from earlier studies showing IgAN was associated with a higher risk of graft loss, perhaps due to selection of a SCOT IS matched dataset. Based on our analysis, we believe that it is safe to continue the steroid avoidance protocols at SCOT and think that it may be beneficial, given the adverse effects and toxicities associated with steroid use.

Background

Lymphocyte cross-matching (CDC) is considered as important screening test that is unfrequently performed preoperatively in heart transplantation procedures. This test is desired to identify the risk for hyper-acute rejection in immediate postoperative period.

Patient and method

There were 57 patients (51 men and 6 women) in mean age of 44 +/- 14 between 2010 and 2019 screened for CDC tests. All patients were low risk for rejection including negative panel reactive antibody preoperative test. Preoperative donor's blood samples and lymph nodes were obtained during retrieval. Recipients blood samples were collected before surgery. CDC test were obtained retrospectively. Endomyocardial biopsies including immunopathological staining were performed on 6th and 14th postoperative day.

Results

The results obtained from cross-match test revealed 4 patients with lymphocytic T and B incompatibility (positive for cellular and humoral hyper-acute rejection) and 3 more for Lymphocytes B hyper-acute rejection (humoral rejection). All patients were hemodynamically stable. Successful therapy including high doses of polyvalent immunoglobulins and steroids parenteral infusions were proven by endomyocardial biopsies samples.

Conclusion

The lymphocytic cross-match testing is useful as postoperative examination. It help to find high risk patients for hyper-acute rejection. It allows for introduction immediate immunosuppressive therapeutic adjustment.

Introduction

Liver transplantation is a standardized treatment for the management of chronic liver failure, as well as, in selected cases of unresectable tumors and acute liver failure. Transplant programs show improvements that impact in the whole survival, however, bile duct complications remain the main cause of morbidity and mortality in transplant programs worldwide.

Material and methods

For statistical purposes, the liver transplant program activity has been divided into 2 Phases, the first one from 2009 to 2017 and the second from 2018 to the present. The files of patients with at least 6 months of follow-up were included.

Results

Throughout the program there is a record of 22 transplants, according to the division mentioned in two Phases, with a total of 9 transplants in 9 years in Phase 1 and 12 transplants in 2 years in Phase 2. With 33% (3) of complications for Phase 1 and 25% (3) for Phase 2.In all patients the management was endoscopic.

Conclusions

Bile duct complications are associated with identifiable risk factors, however, the patient's evolution is multifactorial. Both the decrease in the frequency of complications and the effectiveness in their management show improvement according to the establishment of the multidisciplinary team of Liver Transplantation.

Objectives

A number of patients have developed liver failure after the Kasai operation for biliary atresia (BA), even after long-term postoperative course. We report our experience regarding four cases of biliary atresia required and treated with living donor liver transplantation (LDLT) during adulthood.

Methods

All four patients underwent Kasai operation for BA from 1974 to 1983 and had been followed-up for more than 30 years in our institute. Then, they developed liver failure and treated with LDLT. These four patients’ records were reviewed retrospectively. All data are described using the median value.

Results

Three female and one male were included. Kasai operation was performed at the age of 61 days. The type of biliary obstruction was type III-b1-ν in all. The survival period of the native liver was 440 months. The age at LDLT was 37 years. The reasons of deterioration of native liver were recurrent cholangitis in two and pregnancy and delivery in other two. The age of living donor was 40 years. Right liver grafts were used in all. Percentage of the real graft volume per standard liver volume was 47%. All patients were alive and overall graft survival rate was 100% at a follow-up period of 65 months after LDLT.

Conclusion

Even after more than 30 year-survival with native liver after Kasai operation, liver failure may be caused by recurrent cholangitis or pregnancy and delivery. LDLT may be effective treatment for those adult patients if an adequate living donor is available.

Objectives

Major haemorrhagic events, including perplexing condition, intracerebral haemorrhage (ICH) are associated with significant morbidity and mortality. Treatment is planned on individual basis. A major portion of the injurious processes take place during the hours following the development of haematoma.

Organ transplantation naturally has a critical postoperative period. The complications may involve various systems of the body. We aimed to find out the incidence of haemorrhage into different compartments of the intracranial cavity in liver, kidney and heart recipient patients. We searched for possible mechanisms leading to this situation.

Materials and Methods

We retrospectively reviewed the medical files of 2524 patients who underwent either renal, liver or heart transplantations at Ankara Hospital of Başkent University during the years 1985 and 2016.

The keywords "kidney transplantation", "liver transplantation", “heart transplantation”, "intracerebral haemorrhage", "subdural haemorrhage" and "epidural haemorrhage" were also used to find the kidney, liver and heart recipient patients who experienced haemorrhage in different compartments of the intracranial cavity.

Results

Our research revealed that 25 patients have experienced intracerebral haemorrhage (ICH) at different times following kidney, liver or heart transplantation. In this group, 20 patients were kidney-transplanted, 3 patients were liver-transplanted, and 2 patients were heart-transplanted. The group included 11 female and 14 male patients. The age range was between 20 and 63 years (Table 1). One patient had an intracranial aneurysm and epidural haematoma while other 4 patients had subdural haematoma in addition to ICH. Sites of intracerebral haematoma included right frontal lobe (3 patients), right parietal lobe (5 patients), right temporal lobe (3 patients), right thalamus (4 patients), right basal ganglia (4 patients), left temporal lobe (2 patients) and left frontal lobe (4 patients). Twelve patients were treated medically. Eleven patients with subdural haemorrhage, epidural haemorrhage or intraparenchymal haemorrhage underwent craniotomy and evacuation of the haematoma. In two patients with midline shift and intraventricular extension, external ventricular drainage (EVD) was inserted. Nine patients after surgery died within 2 days to 4 months.

Conclusion

Neurological complications such as intraparenchymal haemorrhage, subdural haematoma or epidural haematoma were not uncommon in kidney, liver or heart recipients. The occurrence of these complications was associated with prolonged PT and APTT time, trauma or thrombocytopenia. These complications contributed to prolongation of hospital stay, increased in-hospital mortality, and decreased graft and patient survival.

Introduction

For patients diagnosed with hepatic cirrhosis and portal hypertension, qualified for liver transplantation, the presence of portosystemic collateral circulation constitutes a typical phenomenon. One of its types is the spontaneous splenorenal shunt. Large or multiple ones may cause the steal syndrome and graft hypoperfusion. An attempt to remove such shunts directly is technically difficult and fraught with complications. An easier and safer method would involve ligating the left renal vein. The aim of this paper is to present a case where proper perfusion of a transplanted liver is ensured by the left renal vein ligation, performed in a recipient with a splenorenal shunt, and to review the scientific reports devoted to portosystemic shunts in liver transplant recipients.

Case report

A 63-year-old female with alcoholic liver disease was qualified for liver transplantation. The CT-angiography showed numerous splenorenal shunts with diameter up to 13 mm. During the anhepatic phase of the liver transplantation a very weak effusion from the portal vein was observed, which improved significantly following clamping of the left renal vein. Thus renal vein orifice was ligated in order to achieve the correct graft reperfusion. Postoperative Doppler ultrasound showed a correct portal blood flow. The early liver and renal function was good. Finally, in the 7th month, the patient underwent a re-transplantation due to biliary necrosis caused by late hepatic artery thrombosis.

Conclusion

Ligation of the left renal vein efficiently prevents the steal syndrome in the liver transplant recipients with splenorenal shunt and ensures good graft perfusion.

Background

Kidney transplantation is the definitive treatment for patients with end-stage kidney diseases. Quality of life and longevity following transplantation are nearly equal to those of healthy individuals. Immunosuppression has improved graft survival but leaves the patient susceptible to viral infections. Alpha-herpesviruses belong to a subfamily of herpesviruses and are widely distributed in nature. The human alpha-herpesviruses include herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) and varicella zoster virus (VZV). HSV-1, HSV-2 and VZV often reactivate in the setting of immune suppression after kidney transplantation. The management of infectious disease in transplantation are major contributors to improved outcomes in organ transplantation.

Objectives

The aim of this study was to report cases of alpha-herpesvirus infection following kidney transplantation.

Methods

From July 2014 to December 2018, we performed 55 kidney transplantations at Osaka Medical College Hospital. All alpha-herpesvirus infection cases following kidney transplantation were retrospectively evaluated.

Results

We treated 7 patients with alpha-herpesvirus infection. Median age was 60; 2 patients were female. All patients were able to be treated with acyclovir and valacyclovir. A patient was complicated by postherpetic neuraglia (chronic pain). A patient was complicated by secondary bacterial infection and treated with antibiotic.

Conclusion

The human alpha-herpesviruses include HSV-1, HSV-2 and VZV often reactivate after kidney transplantation. This case report demonstrates the successful medical treatment of alpha-herpesvirus infection cases following kidney transplantation.