A.D. Pinna

Multicenter study on double kidney transplantation.

BACKGROUNDnMarginal organs not suitable for single kidney transplantation are considered for double kidney transplantation (DKT). Herein we have reviewed short and long-term outcomes of DKT over a 7-year experience.nnnPATIENTS AND METHODSnBetween 2001 and 2007, 80 DKT were performed in the transplant centers of Bologna, Parma, and Modena, Italy. Recipient mean age was 61+/-5 years. The main indications were glomerular nephropathy (n=33) and hypertensive nephroangiosclerosis (n=14). Mean HLA A, B, and DR mismatches were 3.1+/-1.2. Donor mean age was 69+/-8 years and mean creatinine clearance was 75+/-27 mL/min. Almost all kidneys were perfused with Celsior solution. Mean cold ischemia time was 17+/-4 hours and mean warm ischemia time was 41+/-17 minutes. Mean biopsy score was 4.4. Immunosuppression was based on tacrolimus (n=52) or cyclosporine (n=26).nnnRESULTSnFifty (62.5%) patients displayed good postoperative renal function. Thirty (37.5%) experienced acute tubular necrosis and required postoperative dialysis treatment; 8 acute rejections occurred. Urinary complications were 13.7% with 8/11 requiring surgical revision. There were 6 surgical reexplorations: intestinal perforation (n=2), bleeding (n=3), and lymphocele (n=1). Two patients lost both grafts due to vascular and infectious complications at 7 or 58 days after transplantation. Two patients underwent intraoperative transplantectomy due to massive vascular thrombosis. Four (5%) patients underwent transplantectomy of a single graft due to vascular complications (n=2), bleeding (n=1), or infectious complications (n=1). Graft and patient survivals were 95% and 100% versus 93% and 97% at 3 versus 36 months, respectively.nnnCONCLUSIONSnDKT is a safe approach for organ shortage. The score used in this study is useful to determine whether a kidney should be refused or accepted.

Disease-related intestinal transplant in adults: results from a single center.

Intestinal transplantation is gaining worldwide acceptance as the main option for patients with irreversible intestinal failure and complicated total parenteral nutrition course. In adults, the main cause is still represented by short bowel syndrome, but tumors (Gardner syndrome) and dismotility disorders (chronic intestinal pseudo-obstruction [CIPO]) have been treated increasingly by this kind of transplantation procedure. We reviewed our series from the disease point of view: although SBS confirmed results achieved in previous years, CIPO is nowadays demonstrating an excellent outcome similar to other transplantation series. Our results showed indeed that recipients affected by Gardner syndrome must be carefully selected before the disease is to advanced to take advantage of the transplantation procedure.

Mortality After Steroid-Resistant Acute Cellular Rejection and Chronic Rejection Episodes in Adult Intestinal Transplants: Report From a Single Center in Induction/Preconditioning Era

Steroid-resistant acute cellular rejection (ACR) and chronic rejection (CR) are still major concerns after intestinal transplantation. We report our experience from a single center on 48 adults recipients using 49 grafts from 2001 to 2011, immunosuppressing them initially with daclizumab initially and later Alemtuzumab. Overall patient survival was 41.9% at 10 years while graft survival was 38.5%. The steroid-resistant ACR population of 14 recipients (28.5%) experienced 50% mortality mainly due to sepsis, while the five (8%) CR recipients, included two survivors. All but 1 graft was placed without a liver. CR was often preceded by ACR episodes. Mortality related to steroid-resistant ACR and CR still affects the intestinal transplant population despite induction/preconditioning, especially in the absence of a protective liver effect of the liver. New immunosuppressive strategies are needed.

Long-Term Endoscopic Follow-up in Small Bowel Transplant Recipients: Single-Center Series

BACKGROUNDnThe reliability of endoscopic findings after adult intestinal transplantation on short-term follow-up has been shown. The aim of this study was to evaluate in a long-term follow-up the diagnostic value of endoscopies compared with the biopsy value.nnnMETHODSnWe evaluated 52 endoscopies over a period of 2 years (2 in each patient in 2010 and 1 in each patient in 2011, plus 1 endoscopy for suspected post-transplant lymphoproliferative disease [PTLD]) on 17 recipients transplanted between the years 2000 and 2006 (more than 5 years of follow-up).nnnRESULTSnAll the 52 endoscopic findings were comparable to biopsy definitive results: only 1 case of mild enteritis and 1 case of Epstein-Barr virus (EBV) chronic infection at biopsy were not diagnosed by endoscopy. One case of rectal PTLD and 1 of EBV-related enteritis were diagnosed by use of both procedures. Specificity was 98%: we did not calculate sensitivity because no episodes of rejection were diagnosed because recipients were stable in long-term follow-up.nnnCONCLUSIONSnEndoscopy is a reliable procedure even on a long-term follow-up after intestinal transplantation, allowing a support to biopsy for diagnosis on adult recipients, especially for EBV infections and PTLD surveillance.

Long-term maintenance of sustained virological response in liver transplant recipients treated for recurrent hepatitis C.

BACKGROUNDnThe recurrence of hepatitis C viral infection is common after liver transplant, and achieving a sustained virological response to antiviral treatment is desirable for reducing the risk of graft loss and improving patients survival.nnnAIMnTo investigate the long-term maintenance of sustained virological response in liver transplant recipients with hepatitis C recurrence.nnnMETHODSn436 Liver transplant recipients (74.1% genotype 1) who underwent combined antiviral therapy for hepatitis C recurrence were retrospectively evaluated.nnnRESULTSnThe overall sustained virological response rate was 40% (173/436 patients), and the mean follow-up after liver transplantation was 11±3.5 years (range, 5-24). Patients with a sustained virological response demonstrated a 5-year survival rate of 97% and a 10-year survival rate of 93%; all but 6 (3%) patients remained hepatitis C virus RNA-negative during follow-up. Genotype non-1 (p=0.007), treatment duration >80% of the scheduled period (p=0.027), and early virological response (p=0.002), were associated with the maintenance of sustained virological response as indicated by univariate analysis. Early virological response was the only independent predictor of sustained virological response maintenance (p=0.008).nnnCONCLUSIONSnSustained virological response achieved after combined antiviral treatment is maintained in liver transplant patients with recurrent hepatitis C and is associated with an excellent 5-year survival.

Alemtuzumab Plus Cyclosporine Treatment of the Autoimmune Hemolytic Anemia in an Adult Bowel Transplant

An adult male underwent a bowel transplant for tufting enteropathy, receiving alemtuzumab, tacrolimus, and steroids as immunosuppressants. Five years later, he developed an autoimmune hemolytic anemia (AIHA), anti-IgG positive, with reduced reticulocyte count, leukopenia, and thrombocytopenia with antiplatelet antibodies. After an unsuccessful initial treatment with high dose steroids, reduction in tacrolimus dose, and intravenous immunoglobulin (IVIG), a bone marrow biopsy revealed absence of erythroid maturation with precursor hyperplasia. The patient was switched to sirolimus and received four doses of rituximab plus two courses of plasmapheresis, which decreased his transfusion requirements. After a febrile episode one month later, the AIHA relapsed with corresponding decreases in platelet and leukocyte count: cyclosporine A (CsA) was started with a second course of rituximab and IVIG without response, even though repeat bone marrow biopsy did not reveal morphology correlated to an acquired pure red cell aplasia (APRCA). Considering the similarity in his clinical and laboratory findings to APRCA, alemtuzumab was added (three doses over a week) with CsA followed by steroids. The patient was eventually discharged transfusion-independent, with increasing hemoglobin (Hb) levels and normal platelet and leukocyte count. One year later he is still disease-free with functioning graft.

Operative Endoscopy for Treatment of Native Rectal Post-Transplantation Lymphoproliferative Disease After Adult Small Bowel Transplantation: A Case Report

Post-transplantation lymphoproliferative disease (PTLD) of the gastrointestinal (GI) tract is often recognized in transplant recipients. Small bowel recipients are prone to develop GI disease due to the higher incidence of Epstein-Barr Virus (EBV) infection and enteritis as a consequence of heavy immunosuppressive regimens. So far treatment has been based on anti-CD20 therapy (Rituximab), modulation of immunosuppression, antiviral therapy (Gancyclovir), and surgery (up to allograft enterectomy if necessary), whereas endoscopy is usually used to perform the diagnosis via biopsy. We report a case of an adult small bowel recipient, who underwent transplantation due to Gardners Syndrome 6 years earlier and was EBV positive. A native rectal PTLD was treated using opertive endoscopy combined with antiviral therapy using 4 courses of Rituximab for positive pelvic lymph nodes in addition to reduced immunosuppression. Two years after treatment the recipient is alive and disease-free with a functional graft.

Intrahepatic Blood Flow Redistribution After Temporary Occlusion of the Middle Hepatic Vein During Right Lobe Liver Donation: Report of a Case

INTRODUCTIONnOne of the critical factors that influence graft function after live donor liver transplantation is the presence or absence of global or sectorial liver congestion. Many authors advocate for routine middle hepatic vein (MHV) reconstruction because it is often difficult to determine when the MHV or one of its major branches have functional significance. Predictive tests to assess hemodynamic and functional significance of the MHV and its tributaries are still under study.nnnCASE REPORTnWe have described a novel intraoperative manipulation and Doppler ultrasonographic evaluation that led to the decision to include the MHV with the right lobe graft.

265 COST-EFFECTIVENESS OF HEPATIC RESECTION VERSUS PERCUTANEOUS ABLATION FOR HEPATOCELLULAR CARCINOMA WITHIN THE MILAN CRITERIA

session. The remaining 40/179 of patients (22.3%) had a stable disease (SD) or a progressive disease (PD) after at most two sessions of RFTA. Overall recurrence rate in patients who achieved a complete response by one or two sessions of RFTA was 69%. By Cox regression analysis, survival was independently predicted by tumor size <3cm, complete radiological response at 1 month after treatment, high albumin levels and no former treatment for HCC. Conclusions: Patients with the longest survival are those with a baseline HCC ≤3 cm, normal albumin and no former treatment, who have a complete response at imaging 1 month after treatment. Complete necrosis of the primary lesion after one or two sessions of RFTA is related to a long survival and may be considered as a strong surrogate endpoint for efficacy of treatment.

498 EFFECT OF PROPHYLAXIS FOR VENOUS THROMBOEMBOLISM AFTER LIVER RESECTION IN CIRRHOTIC PATIENTS

Introduction: The imbalance in the coagulative function can increase the risk of bleeding in cirrhotic patients after hepatic surgery; as no data or specific guidelines are available, prophylaxis of venous thromboembolism could be hazardous. Objective: To assess the effect of venous thrombosis prophylaxis after hepatic resection for hepatocellular carcinoma (HCC) in cirrhotic patients. Patients and Methods: 229 consecutive cirrhotic patients with HCC who underwent hepatic resection over a 10-year period were retrospectively evaluated to assess whether there was any difference in the incidence of thrombotic or hemorrhagic complications between those who received prophylaxis with lowmolecular weight heparin and those who did not. Differences and possible effect of the following parameters were investigated: age, sex, Child–Pugh and MELD score, platelet count, presence of esophageal varices, type of hepatic resection, duration of surgery, intraoperative transfusion of blood and fresh-frozen plasma (FFP), body mass index (BMI), diabetes and previous cardiovascular disease. Results: 157 out of 229 (68.5%) patients received antithromboembolic prophylaxis (group A) while the other 72 (31.5%) did not (group B). Patients in group B had higher Child–Pugh and MELD scores, lower platelet counts, a higher prevalence of esophageal varices and higher requirements of intraoperative transfusion of FFP. Incidence of venous thromboembolism and postoperative hemorrhage was respectively 0.63% and 3.18 in group A and 1.38% and 1.38% in group B; these differences were not significant. None of the variables analyzed including prophylaxis proved to be risk factors for venous thromboembolism while only the presence of esophageal varices was associated with an increased risk of bleeding. Conclusions: Prophylaxis is safe in cirrhotic patients without esophageal varices; its real need has to be better assessed.