Edie Y. Chan

Ischemic cholangiopathy following liver transplantation from donation after cardiac death donors

The use of donation after cardiac death (DCD) donor hepatic allografts is becoming more widespread; however, there have been published reports of increased graft failure from specific complications associated with this type of allograft. The complication of ischemic cholangiopathy (IC) has been reported to occur more frequently after the use of DCD hepatic allografts. We report the results of 52 liver transplants from DCD donors and the factors that influenced the development of IC. We conducted a retrospective review of all DCD and donation after brain death (DBD) donor liver recipients from September 2003 through December 2006 at a single institution. Survival and complication rates were compared between the 2 groups. The Cox proportional hazards model was then used to identify recipient and donor factors that predict the development of IC in the DCD group. There was no difference in 1‐year patient or graft survival rates between the 2 groups. There was no incidence of primary nonfunction from the DCD allografts. Hepatic artery complications and anastomotic bile duct complications were comparable in the 2 groups. There was, however, an increased risk for the development of IC in the DCD group (13.7% versus 1%, P = 0.001). Donor weight >100 kg and total ischemia times ≥9 hours, in donors older than 50 years of age, predicted the development of IC in the DCD group. In conclusion, there is a higher incidence of IC in recipients receiving DCD donor livers; however, patient and graft outcomes with DCD donors remain comparable to those with DBD donors. Careful donor selection may improve utilization of these grafts. Liver Transpl 14:604–610, 2008.

Identifying risk for recurrent hepatocellular carcinoma after liver transplantation: Implications for surveillance studies and new adjuvant therapies

The recurrence of hepatocellular carcinoma (HCC) is a major cause of mortality for patients transplanted with HCC. There currently exists no standard method for identifying those patients with a high risk for recurrence. Identification of factors leading to recurrence is necessary to develop an efficient surveillance protocol and address new potential adjuvant therapies. We conducted a retrospective review of 834 consecutive liver transplants from 1/1/1996 to 12/31/2005 (mean follow‐up 1303 ± 1069 days) at one institution and 352 consecutive transplants from 1/2/2002 to 12/31/2005 (mean follow‐up 836 ± 402 days) at a second institution. The test cohort comprised patients identified with HCC in their explanted livers from 1/1/2001 to 12/31/2005 at the first institution. Explant pathology and donor and recipient characteristics were reviewed to determine factors associated with HCC recurrence. These predictors were validated in the remaining liver transplant recipients. The test cohort had 116 patients with findings of HCC in their explanted livers. Twelve patients developed recurrent HCC. Stepwise logistic regression identified 4 independent significant explant factors predictive of recurrence. Size of one tumor (>4.5 cm), macroinvasion, and bilobar tumor were positive predictors of recurrence, whereas the presence of only well‐differentiated HCC was a negative predictor. Designating each significant factor with points in relation to its odds ratio, a Predicting Cancer Recurrence Score (PCRS) with results ranging from −3 to 6 was developed that accurately determined risk of recurrence. These findings were then applied to the two validation cohorts, which confirmed the high predictive value of this model. In conclusion, patients transplanted for HCC with a PCRS of ≤0 have a low risk of recurrence. Patients with a PCRS of 1 or 2 have a moderate risk of recurrence, and those with a PCRS of ≥3 have a high risk for recurrence. Liver Transpl 14:956–965, 2008.

Recipient and donor factors influence the incidence of graft‐vs.‐host disease in liver transplant patients

Acute cellular graft‐vs.‐host disease (GVHD) following liver transplantation has an incidence of 1 to 2% and a mortality rate of 85%. Our aim was to identify a patient population at high risk for developing GVHD using a large clinical database to study both recipient and donor factors. We compared our liver transplant patients who developed GVHD to those that did not for recipient and donor factors and combinations of factors. For 2003–2004 we had 205 first‐time liver transplant patients surviving >30 days. From this group, 4 (1.9%) developed GVHD. Compared to the control group, there were no significant differences in recipient age, recipient gender, donor age, donor gender, total ischemia time, donor‐recipient human leukocyte antigen (HLA) mismatch, or donor‐recipient age difference. Percentages of liver disease etiologies among the patients who developed GVHD were as follows: 16% (1/6) autoimmune hepatitis (AIH) (P = 0.003), 5.6% (3/54) alcoholic liver disease (ALD) (P = 0.057), and 7.1% (3/42) hepatocellular carcinoma (HCC) (P = 0.026). The incidence of GVHD in patients with glucose intolerance (either Type I or Type II diabetes mellitus [DM]) was significant (P = 0.022). Focusing on patients only with high‐risk factors for GVHD during the years 2003–2005, we had 19 such patients. Four of these high‐risk patients developed GVHD. Three of these 4 patients had received a donor liver with steatosis of degree ≥mild compared to only 2 of the 15 high‐risk patients who did not develop GVHD (P = 0.037). In conclusion, we have identified liver transplant patients with AIH or the combination of ALD, HCC, and glucose intolerance who receive a steatotic donor liver as being at high risk for developing GVHD. Liver Transpl 13:516–522, 2007.

Niacin, the Internet, and Urine Drug Testing: A Cause of Acute Liver Failure

Niacin (Vitamin B3) is a naturally occurring human nutrient found in abundance in meat, yeast, vegetables, and seeds. Deficiencies of this vitamin lead to pellagra and it has also been found to be useful in the treatment of hypercholesterolemia. As the use of niacin has increased, several cases of hepatotoxicity have been reported resulting in the recommendation to initiate treatment with a lower dose and to monitor liver function test. We report two cases of hepatotoxicty in young adults who attempted to pass a drug screening test based on faulty internet advice to use niacin.

Limited Hepatitis B Immunoglobulin With Potent Nucleos(t)ide Analogue Is a Cost-Effective Prophylaxis Against Hepatitis B Virus After Liver Transplantation

BACKGROUND Prophylaxis against hepatitis B virus (HBV) recurrence after orthotopic liver transplantation (OLT) includes lifelong hepatitis B immunoglobulin (HBIG) and oral antiviral agent(s). In the presence of high-genetic-barrier nucleos(t)ide analogues, the need for lifelong HBIG is questioned. We evaluated the safety and cost-effectiveness of a limited HBIG course. METHODS OLT from 2006 to 2013 were reviewed. Patients with pre-OLT hepatitis B virus surface antigen who received HBV prophylaxis with 2 HBIG doses (anhepatic and first post-operative day; 10,000 units/dose) and potent nucleos(t)ide analogues were included. The primary end point was HBV recurrence (HBV-DNA detection). RESULTS Thirteen patients (primary transplants) were included, median Model for End-Stage Liver Disease score was 18, and there was no fulminant failure; HBV-DNA was detected in 4 patients at OLT. After OLT, 10 patients received entecavir and/or tenofovir. Median follow-up was 23 months. One recurrence occurred (7.7%) at month 13 (HBV-DNA: 14 IU/mL); the graft maintained excellent function. This minimal viremic expression is related to hepatocellular carcinoma recurrence with neoplastic replication carrying integrated HBV-DNA; thus, there is no defined HBV viral recurrence. No graft loss or patient death was related to HBV recurrence. The 1-year patient and graft survival rate was 84.6%. Cost-savings in the first year was

Coronary Computed Tomographic Angiography in the Evaluation of Liver Transplant Candidates

178,100 per patient when compared with Food and Drug Administration-approved HBIG dosing. CONCLUSIONS In the era of potent oral nucleos(t)ide analogues, a limited HBIG course appears to be cost-effective in preventing HBV recurrence.

Intestinal Tuberculosis in a Liver Transplant Patient

The feasibility, safety, and value of coronary computed tomographic angiography (CCTA) in evaluating orthotopic liver transplant (OLT) candidates are unknown. We studied a cohort of consecutive OLT candidates with intermediate-to-high risk of coronary artery disease (CAD). Intermediate risk candidates received CCTA, and those at high risk or with abnormal noninvasive testing underwent invasive coronary angiography (ICA). One hundred consecutive patients were evaluated. Fifty patients underwent a CCTA, 71.4% were β-blocked, the image quality was “good” or “excellent” in 71.4% of cases, and there was no event of significant contrast-induced nephropathy. Twenty (20%) patients were found to have severe CAD (≥70% stenosis) by CCTA and/or ICA. Independent predictors of severe CAD were age (odds ratio [OR] = 5.4 per 10-year increment, 95% confidence interval [CI] = 1.7-17.0; P = .004), dyslipidemia (OR = 12.3, 95% CI = 2.6-57.6; P = .001), and chest pain (OR = 6.0, 95% CI = 1.2-29.1; P = .03). Implementing CCTA in the evaluation of intermediate/high CAD risk OLT candidates is challenging but feasible and seems safe.

Outcomes after combined liver-kidney transplant vs. kidney transplant followed by liver transplant

Intestinal tuberculosis (TB) is an uncommon manifestation of tuberculosis, especially in Western countries, and is most often seen in immigrant and immunosuppressed patients The incidence of intestinal TB has not been well documented for liver transplant patients in Western countries. This case report discusses the complications of intestinal TB in a liver transplant patient and addresses the importance of identifying the necessity for and timing of surgery. Given the immunosuppressed state of these patients, the expedient diagnosis and treatment of this potentially fatal condition is critical.

Needle Tract Seeding Following Irreversible Electroporation (IRE) of Metastatic Colorectal Carcinoma to the Liver

The decision for isolated kidney transplant (KT) vs. combined liver–kidney transplant (CLKT) in patients with end‐stage renal disease (ESRD) with compensated cirrhosis remains controversial. We sought to determine outcomes of patients requiring listing for a liver transplant (LT) following either a cadaveric or living donor KT and compare these outcomes to similar patients receiving a CLKT.

Intra-abdominal desmoid tumor after liver transplantation: A case report.

Irreversible electroporation (IRE) is an increasingly popular tissue ablative technology that creates pores in the cell membrane by means of electricity. For hepatocellular carcinoma or metastatic colorectal cancer to the liver, it can target lesions near ducts and vessels without risk of thrombosis or stricture. Its non-thermal mechanism, however, may allow for increased rates of needle tract seeding. We present the first known case report of peritoneal needle tract seeding following IRE. Case