Antonio Pinna

Infectivity of hepatic allografts with antibodies to hepatitis B virus

BACKGROUNDnSince suitable recipients for hepatic allografts from donors with antibodies to hepatitis B virus (HBV) have not been determined, a review of our 7-year experience with donors positive for hepatitis B surface antibody (anti-HBs), hepatitis B core antibody (anti-HBc), or both was undertaken.nnnMETHODSnRecipients of hepatic allografts from donors with antibodies to HBV were identified by a retrospective review of procurement records and screened for HBV infection.nnnRESULTSnFrom January 1, 1990, to January 1, 1997, 2578 liver transplants were performed and 140 (5.4%) recipients received an allograft from a donor with antibodies to HBV. Twenty-five of 48 recipients of a hepatic allograft from a donor positive only for anti-HBs were screened and none developed HBV infection. Twenty-five of 41 naive recipients of a hepatic allograft from an anti-HBc positive donor were screened and 18/25 (72%) developed HBV infection. Four of these 18 naive recipients with HBV infection received an allograft from a donor positive for both anti-HBc and anti-HBs. Seven of 13 anti-HBs-positive recipients of an allograft from an anti-HBc-positive donor were screened and none developed HBV infection. Fifteen of 16 recipients positive only for anti-HBc who received a hepatic allograft from an anti-HBc-positive donor were screened and 2/15 (13%) developed HBV infection.nnnCONCLUSIONSnHepatic allografts from donors positive only for anti-HBs do not transmit HBV infection. Hepatic allografts from anti-HBc-positive donors frequently transmit HBV infection to naive recipients regardless of the donor anti-HBs status, and antiviral prophylaxis may be indicated. Anti-HBs-positive recipients appear resistant to HBV infection after orthotopic liver transplantation with an allograft from an anti-HBc-positive donor. Recipients positive only for anti-HBc infrequently develop HBV infection when transplanted with an allograft from an anti-HBc-positive donor; however, HBV prophylaxis may be justified.

Single-center experience with primary orthotopic liver transplantation with FK 506 immunosuppression.

OBJECTIVEnThe efficacy for primary orthotopic liver transplantation of a new immunosuppressive agent, FK 506 (tacrolimus, Prograf, Fujisawa USA, Deerfield, IL), was determined.nnnSUMMARY BACKGROUND DATAnAfter 3 years of preclinical research, a clinical trial of FK 506 for orthotopic liver transplantation was begun in February 1989, first as a rescue therapy for patients with intractable rejection with conventional immunosuppression, then as a primary drug.nnnMETHODSnBetween August 1989 and December 1993, 1391 recipients (1188 adult and 203 pediatric) of primary liver allografts were treated with FK 506 from the outset. Results from these patients were analyzed and compared with those of 1212 historical control patients (971 adult and 241 pediatric) given cyclosporine-based immunosuppression.nnnRESULTSnActuarial survival at 4 years was 86.2% with FK 506 versus 65.5% with cyclosporine in the pediatric patients (p < 0.0000) and 71.4% versus 65.5% in the adults (p < 0.0005). The need for retransplantation was reduced significantly for FK 506 patients. Four-year graft survival was 77.0% with FK 506 versus 48.4% with cyclosporine in the pediatric patients (p < 0.0000), and 61.9% with FK 506 versus 51.4% with cyclosporine in the adult recipients (p < 0.0000). Regression analysis revealed that reduction in mortality or graft loss from uncontrollable rejection, sepsis, technical failure, and recurrent original liver disease were responsible for the improved results with FK 506 therapy.nnnCONCLUSIONSnFK 506 is a potent and superior immunosuppressive agent for orthotopic liver transplantation.

Percutaneous transhepatic embolization of an intrahepatic pseudoaneurysm following liver biopsy in a liver transplant patient

A 41-year-old liver transplant patient had severe hemobilia from an intrahepatic pseudoaneurysm secondary to a liver biopsy. Selective intra-arterial embolization was not technically possible due to marked redundancy and tortuosity of the allograft hepatic artery. The pseudoaneurysm was localized by ultrasound and embolized using a direct percutaneous transhepatic approach. This is a novel way of approaching hemobilia in liver transplant patients after liver biopsy and may avoid the risks of arterial embolization.

Venous-right atrial bypass for superior vena cava thrombosis during orthotopic liver transplantation

The introduction of veno-venous bypass during orthotopic liver transplantation (OLT*) in 1984 avoided venous stagnation and hemodynamic instability during the anhepatic phase (1). In patients with superior vena cava (SVC) thrombosis or stenosis, the use of veno-venous bypass with the standard technique should be avoided because it can precipitate the onset of severe SVC syndrome (2). We describe here the use of a veno-right atrial bypass in a patient with SVC thrombosis who underwent simultaneous OLT and kidney transplantation. n nA 51-year-old man with the diagnosis of cryptogenic cirrhosis and chronic renal failure underwent simultaneous OLT and renal transplantation at our institution on February 5, 1995. A LeVeen shunt had been implanted elsewhere in October 1994 for refractory ascites and was subsequently removed 4 weeks later due to infection and occlusion. At the time of transplantation, insertion of an oxymetric pulmonary artery catheter was attempted through both the right and left internal jugular veins, but it could not be advanced on either side. An intraoperative venogram showed thrombosis of the SVC with several small collaterals draining caudally (Fig. 1). An oximetric pulmonary artery catheter was subsequently inserted through the right femoral vein and positioned in the pulmonary artery. In order to infuse volume during the transplant, a Biomedicus venous cannula with a side port was inserted through the left femoral vein. This cannula also served as the outflow catheter for the inferior vena cava (IVC) during the subsequent bypass. After a median sternotomy, a single straight Bard cannula (no. 32), modified in order to have a side port for volume infusion, was placed in the right atrium and secured with two 2-O Ethibond pledgeted purse-string sutures (Fig. 2). After transaction of the bile duct and the hepatic artery, the portal vein was cannulated with a Gott shunt cannula (no. 9) and connected with the other cannulas to a centrifugal force pump. n n n nFIGURE 1 n nIntraoperative SVC venogram shows obstruction of the SVC at the junction with the left subclavian vein, right subclavian vein thrombosis with collaterals. n n n n n nFIGURE 2 n nAs shown in this scheme of the portal-atrial bypass, a femoral vein cannula and a right atrial cannula were used as infusion ports for volume replacement. n n n nDuring the bypass, the flow was maintained at 3 L/min. The central venous pressure during bypass was 12 mmHg, and the pulmonary capillary wedge pressure was 16 mmHg. n nThe hepatectomy was performed using the piggyback technique (3) to maintain blood flow through the Ive and preserve the pulmonary catheter. During the veno-atrial bypass, the patient was hemodynamically stable with a total blood loss of 7 U of packed red blood cells. After reperfusion of the liver allograft, the right atrial cannula was removed and the purse-string suture was ligated to close the right atrial defect. Two no. 28 thoracostomy tubes were left in the mediatinum, and the sternum was closed with interrupted wire. The left kidney from the same donor was transplanted into the left iliac fossa. n nThe patient had an uneventful postoperative course. He received an antiarrhytmic agent for prophylaxis against atrial fibrillation, and the immunosuppression was iniated using tacrolimus and steroids. n nThe LeVeen modification for the peritoneovenous shunt has been used extensively for the treatment of refractory ascites since its introduction in 1974 (4). The incidence of SVC thrombosis or stenosis after LeVeen shunt has been reported with a variable incidence between 18.6% and 43% (5–7). Performing a liver transplantation in the presence of an SVC obstruction carries potential hemodynamic consequences, especially during the anhepatic phase. Volume infusion and hemodynamic monitoring were assured in this patient with an IVC access; interruption of the IVC was avoided by using the piggyback technique, and venous return was optimized with a portal-atrial bypass by right atrial cannulation. Given the concerns that had arisen because of this case, we currently assess SVC patency with Doppler ultrasound and SVC cavogram as needed in all candidates with prior LeVeen shunt in order to detect the presence of SVC thrombosis or stenosis before liver transplantation. It would also be possible to use transesophageal echocardiography instead of a pulmonary artery catheter for hemodynamic monitoring if occlusion of the IVC is necessary (e.g., in the case of cancer patients).