Carlos G. Fasola

The elderly liver transplant recipient : A call for caution

ObjectiveTo determine whether liver transplantation is judicious in recipients older than 60 years of age. Summary Background DataThe prevailing opinion among the transplant community remains that elderly recipients of liver allografts fare as well as their younger counterparts, but our results have in some cases been disappointing. This study was undertaken to review the results of liver transplants in the elderly in a large single-center setting. A secondary goal was to define, if possible, factors that could help the clinician in the prudent allocation of the donor liver. MethodsA retrospective review of a prospectively maintained single-institution database of 1,446 consecutive liver transplant recipients was conducted. The 241 elderly patients (older than 60 years) were compared with their younger counterparts by preoperative laboratory values, illness severity, nutritional status, and donor age. Survival data were stratified and logistic regression analyses were conducted. ResultsElderly patients with better-preserved hepatic synthetic function or with lower pretransplant serum bilirubin levels fared as well as younger patients. Elderly patients who had poor hepatic synthetic function or high bilirubin levels or who were admitted to the hospital had much lower survival rates than the sicker younger patients or the less-ill older patients. Recipient age 60 years or older, pretransplant hospital admission, and high bilirubin level were independent risk factors for poorer outcome. ConclusionsLow-risk elderly patients fare as well as younger patients after liver transplantation. However, unless results can be improved, high-risk patients older than 60 years should probably not undergo liver transplantation.

Laparoscopic drainage of lymphoceles after kidney transplantation: Indications and limitations

BACKGROUND Symptomatic lymphoceles are not uncommon after kidney transplantations. Surgical marsupialization with internal drainage is the treatment of choice. However, laparoscopic drainage is reportedly as effective, with only minimal trauma. METHODS We attempted 14 laparoscopic lymphocele drainages during a 3-year period and studied the indications and limitations, using intraoperative ultrasonography in all cases. RESULTS Laparoscopic drainage was successful in only 9 (64%) of 14 patients. A conversion to open laparotomy was necessary in five patients; their lymphoceles were lateral and either posterior or inferior to the kidney. Two patients with initially successful laparoscopic drainage required conversion to open laparotomy 21 and 83 days later; their lymphoceles were inferior to the kidney. Laparoscopic drainage shortened the median hospital stay by 4 days versus open surgical drainage and by 7 days versus conversion. Hospital costs for laparoscopic drainage averaged

Renal transplantation for patients 60 years of age or older: A single- institution experience

7400 less versus open drainage and

A prospective study of FK506 versus CsA and pig ATG in a porcine model of small bowel transplantation

10,300 less versus conversion. CONCLUSIONS In patients with symptomatic lymphoceles medial and either superior or anterior to the kidney, laparoscopic drainage under intraoperative ultrasonographic guidance is easy, safe, and effective. It decreases hospitalization, convalescence, and costs. In patients with symptomatic lymphoceles lateral and either posterior or inferior to the kidney, laparoscopic drainage may fail because of anatomic inaccessibility and technical impracticability.

Does interferon use prior to liver transplant influence hepatitis C outcomes following transplantation

ObjectiveThe authors reviewed renal transplant outcomes in recipients 60 years of age or older. BackgroundBefore cyclosporine, patients older than 45 years of age were considered to be at high risk for transplantation. With cyclosporine, the age limits for transplantation have expanded. MethodsThe authors compared patient and graft survival, hospital stay, the incidence of rejection and rehospitalization, and the cause of graft loss for primary kidney recipients 60 years of age or older versus those 18 to 59 years of age. For those patients ≥ 60 years transplanted since 1985, the authors analyzed pretransplant extrarenal disease and its impact on post-transplant outcome. In addition, all surviving recipients ≥ 60 years completed a medical outcome survey (SF-36). ResultsPatient and graft survival for those ≥ 60 years of age versus those 18 to 59 years of age were similar 3 years after transplant. Subsequently, mortality increased for the older recipients. Death-censored graft survival was identical in the two groups. There were no differences in the cause of graft loss. Those 60 years of age or older had a longer initial hospitalization, but had fewer rejection episodes and fewer rehospitalizations. Quality of life for recipients 60 years of age or older was similar to the age-matched U.S. population. ConclusionRenal transplantation is successful for recipients 60 years of age or older. Most of them had extrarenal disease at the time of transplantation; however, extrarenal disease was not an important predictor of outcome and should not be used as an exclusion criterion. Post-transplant quality of life is excellent.

Impact of immunosuppression in hepatitis C recurrence after liver transplantation: a controllable factor?

Rejection remains a major barrier to successful bowel transplantation, and immunosuppressive protocols are far from standardized. In 88 nonrelated outbred pigs, we compared the effects of two immunosuppressive regimens--one with FK506, the other with cyclosporine (CsA) and pig antithymocyte globulin (ATG)--on incidence and severity of rejection in the early, critical posttransplant period. Group A (n = 14) was nonimmunosuppressed (controls). Group B (n = 17) received pig ATG (10 mg/kg/day x 10 days), CsA (3 mg/kg/day), prednisolone (2 mg/kg/day), and azathioprine (2.5 mg/kg/day); prednisolone and azathioprine were each reduced by 50% at 8 and 15 days posttransplant. Trough CsA whole-blood concentrations were > or = 400 ng/ml for the first 7 days, > or = 200 ng/ml thereafter. Group C (n = 13) received FK506 (0.2 mg/kg/day) and prednisolone (2 mg/kg/day); prednisolone was reduced by 50% at 8 and 15 days. FK506 whole-blood concentrations were > or = 20 ng/ml. All immunosuppression in groups B and C was given intravenously. We performed orthotopic small bowel transplants with systemic venous drainage. Recipient bowel was resected distal to the second portion of the duodenum and proximal to the rectum at transplant; bowel continuity was restored by duodenojejunostomy; ileostomy was created distally to allow access for daily biopsies. We graded interstitial and vascular rejection separately, according to a scoring system (no, mild, moderate, and severe rejection). Rejection-free graft survivals at 7, 14, and 21 days posttransplant were 38%, 19%, and 0% in group A; 93%, 93%, and 62% in group B; and 100%, 91%, and 82% in group C (P < 0.001). Comparing rejection in the immunosuppressed groups, group C (FK506) had a stronger tendency toward rejection than group B (CsA-ATG); significant differences between groups B and C were, however, noted only on individual days posttransplant, not over time. The death rate due to irreversible rejection was not significantly different in groups B and C (P = 0.8), but was significantly better in both of these immunosuppressed groups than in group A (P < 0.001). Pig survival was significantly longer in group C than in B (P = 0.001) due to a lower infection rate in group C. Posttransplant serum interleukin 2 and 7 levels did not correlate with rejection grades. Graft-versus-host reaction was noted only in the skin in 29% of group A, 73% of group B, and 77% of group C pigs; liver and native bowel were not involved.(ABSTRACT TRUNCATED AT 400 WORDS)

Diagnosis and Treatment of Cytomegalovirus Disease in Transplant Patients Based on Gastrointestinal Tract Manifestations

Background. The most frequent reason for orthotopic liver transplantation (OLT) in the United States is due to complications of hepatitis C (HCV). Recent reports have shown decreased survival for HCV after OLT. Of note, the use of interferon (IFN) products has become wide spread with the majority of HCV patients being treated before transplant. Aim. To review the outcomes of HCV patients who have received IFN products before liver transplant compared with HCV patients those who have never received IFN. Method. Single-center, retrospective review of patients transplanted for HCV since December 1998 (n=131). Primary endpoint is the effect of IFN exposure before transplant on posttransplant outcomes. Results. Patients receiving before transplant (pre-IFN group; n=45) had a more aggressive recurrence of HCV with earlier recurrence (181.1±236 days vs. 303.4± 327 days; P=0.031), frequency of recurrence [41/45 (91.1%) vs. 62/86 (72.1%); P=0.013], and 1-year recurrence free survival [20% (±0.06) vs. 48.2% (±0.05); P=0.005]. Survival difference was noted in the pre-IFN group at 1 year and 3 years [79.7% (±0.06) vs. 90.5% (±0.03); 65.7 (±0.08) vs. 75.9% (±0.05); P=0.05] when compared with patients not receiving IFN (n=86) before transplant. Conclusions. Based on this study, interferon use before transplant for the HCV patient indicates poor outcomes After OLT. Because of the increasing numbers of HCV patients coming to transplant, validation of these results should be of utmost importance.

Bacterial translocation in a large-animal model of small-bowel transplantation : portal vs systemic venous drainage and the effect of tacrolimus immunosuppression

The current outcome typical of hepatitis C virus-infected liver recipients after a first transplant is worrisome. Prophylaxis with antivirals has yielded a low rate of success. Without effective prophylaxis, the attention should be focused on the one factor that can be controlled: immunosuppression. A summarized review of the impact of immunosuppressive agents used for the past few years is presented in the context of hepatitis C virus recurrence. Steroids have been blamed for years as the main culprit in the higher incidence of hepatitis C virus recurrence reported in some series. New experience with these agents may prove the opposite. Purine synthesis inhibitors such as azathioprine and mycophenolate mofetil may help to reduce the incidence of hepatitis C virus recurrence after liver transplantation, although further studies are needed to confirm these recent reports. Antilymphocytic therapy with monoclonal or polyclonal antibodies does not seem to be harmful when used at induction. Most reports have analyzed these agents in the context of steroid-resistant rejection, a confounding factor in many studies. The calcineurin-inhibitors, cyclosporine and tacrolimus, appear with similar incidences of hepatitis C virus recurrence and their current use is only center-dependent. Newer agents like sirolimus and antibodies against IL-2 receptors still need to pass the test of time before firm recommendations can be given in any sense. Larger, randomized studies will finally answer questions concerning the best immunosuppressive agent combinations for treating the high-risk hepatitis C virus-infected population of liver transplant recipients. Curr Opin Organ Transplant 2003, 8:146–152