F Pisani

A pilot study on the safety and effectiveness of immunosuppression without prednisone after liver transplantation

BACKGROUND Corticosteroids are commonly used in the immunosuppression therapy after liver transplantation, yet are associated with considerable side effects. Retrospective studies have shown that corticosteroids can be safely withdrawn from months to years after transplant. We prospectively investigated the effects of early immunosuppression without the use of corticosteroids on graft outcome and transplant complications. METHODS Forty-five patients undergoing liver transplantation were randomized to receive immunosuppression composed of cyclosporine microemulsion and azathioprine with (n=22) or without prednisone (n=23), in conventional doses. In those patients who received prednisone, this was withdrawn within 3 months after transplant. The median follow-up of survivors was 14 months (range: 6-24). The study end points were to determine graft survival and function, infectious complications, including hepatitis C virus (HCV)-RNA levels in HCV-infected recipients, acute rejection, kidney function, and metabolic complications. RESULTS Eleven deaths occurred, 6 of which were in the prednisone group. Two-year survival did not differ between patients treated with or without prednisone (70.2% vs. 78.3%, P=0.83), nor did the causes of death. No differences were observed with regard to graft function, renal function, and infectious complications. In the subset of patients who received transplants for HCV-related cirrhosis, the dynamics of virus replication HCV-RNA was faster among those treated with prednisone. The incidence and severity of acute rejection was similar in the two groups. More than 80% of acute rejections in both groups were classified as mild or moderate and underwent spontaneous resolution. Only two patients in each group had severe acute rejection requiring additional treatment with high-dose steroids. Patients receiving prednisone tended to have greater biochemical signs of cholestasis, higher serum cholesterol and glucose levels, and more frequent insulin requirement than those treated without corticosteroids. CONCLUSIONS Liver transplantation can be performed safely without using corticosteroids in the early postoperative course, and there is no need for routine aggressive steroid treatment of established acute rejections.

Gravity perfusion versus high-pressure perfusion in kidney transplantation: results from a prospective randomized study

HE VIABILITY of a kidney graft depends on several factors that can be classified as donor-dependent (DDF), recipient-dependent (RDF), or iatrogenic (IF). Among the latter, we distinguish six variables: therapy; surgical technique; preservation method; perfusion solution; type of perfusion; and perfusion technique. Several studies have focused on DDF, RDF, and some iatrogenic factors, but little is known about the effects of perfusion techniques and flow rate on organ viability in the clinical field. During donor operation, the in situ kidney is commonly perfused by a gravity-hydrostatic pressure of 75 to 100 cm H2O (gravity perfusion [GP]). In recent years, some investigators have advocated an apparently more physiologic technique in which perfusion solution is flushed under an additional pressure of 100 mm Hg (high-pressure perfusion [HPP]). The rationale is to create a mean pressure similar to that present in the arterial system in normal conditions, with the aim to perfuse better the small parenchymal vessels. This prospective randomized study was carried out to compare GP vs HPP in terms of outcome on early graft function after kidney transplantation.

Gigantomastia and breast lumps in a kidney transplant recipient

KIDNEY transplantation (Tx) is the treatment of choice for chronic renal failure. A successful graft permits recovery of renal function and a good quality of life, both being seriously compromised by the disease and the haemodialytic therapy. From the first hours after the operation, patients must receive several drugs to prevent rejection and infections, many immunosuppressive regimens are adopted worldwide. The most commonly used is the triple therapy with cyclosporine A (CyA), prednisolone (P), and azathioprine (A). The former two drugs are demonstrated to interfere with the neuroendocrine system, being able to alter the function of different organs and to modify hormone blood levels. Kidney graft recipients are prone to develop high arterial blood pressure (ABP); and despite advances in patient management, the prevalence of posttransplant hypertension (HT) is about 50%. As HT is known to deteriorate renal function, ABP should be kept in the normal range values. Calcium antagonists (CA) are preferred to regulate ABP. Unfortunately, they also somehow interfere with the neuroendocrine system. In this paper, we describe the case of a woman who, a few years after undergoing a cadaver kidney transplant, developed gigantomastia in association with two lumps.

Effect of steroids amount on hepatitis C recurrence following orthtopic liver transplantation.

ONE of the leading causes for orthotopic liver transplantation (OLTx) is hepatitis C. The presence of viremia post-transplant is reported in 95% of patients; one year after OLTx and 30% to 70% of recipients develop histopathologic recurrence of HCV. The intensity of immunosuppression correlates with viral replication. The number of acute rejection episodes correlated with recurrence of HCV (HCV-R). Feray et al reported a positive correlation of the amount of serum HCV-RNA and the occurrence of hepatitis in the transplanted liver, suggesting that intense HCV replication causes severe histological damage. In agreement there is a recent publication which shows how high serum HCV-RNA levels are associated with severe graft damage. The aim of this study is to correlate histologic recurrence of hepatitis C with the administration of steroids in a group of patients who underwent OLTx for the HCV induced cirrhosis.

Kidney transplantation and pregnancy.

HE MAIN goal of transplantation is the restoration of all functional capacity, which includes the return of fertility for women. Pregnancy can be for some the main reason to seek transplantation, but pregnancy after kidney transplantation (Ktx) is not without risks for both mother and fetus. These pregnancies are usually complicated with an increased risk of acute rejection episodes, impairment of graft function, infections, first trimester abortion, intrauterine growth retardation, and premature delivery.’ It is unclear whether or not cyclosporine A (CsA) and FK-506 have a harmful effect on pregnancy outcome and little is known about pregnancy outcome in multiorgan transplant recipients. This paper reviews our experience with pregnancy in our female renal transplant recipients and documents long-term maternal and fetal outcomes.

Replacement Therapy in Acute Liver Failure

Acute liver failure is generally a fatal disease, although mortality is highly dependent on etiology. Renal failure is a common complication in patients with severe liver disease, and may be due to pre-renal causes, acute tubular necrosis, hepatorenal syndrome and chronic renal disease associated with the underlying chronic liver disease. Orthotopic Liver Transplantation (OLTx) has become the accepted treatment of choice for patients with advanced liver disease; dialytic treatment may be useful in treating renal complication, and to gain time either for liver regeneration or for the acquisition of a donor liver. Among the natural toxic causes of ALF, Amanita Phalloides poisoning (APP) is one of the most frequent. Managing patients suffering from APP may be very challenging; furthermore, treatment must be started in time to be effective. In this study we report our experience on replacement therapy in ALF due to APP.

Echographic valuation of risk factors for cardiovascular disease in patients with renal transplantation

CARDIOVASCULAR disease is the major cause of morbidity and mortality among patients with endstage renal disease. After renal transplantation, patients exhibit accumulation of cardiovascular risk factors such as influence of immunosuppressive therapy. Smoking, hypertension, diabetes, fibrinogen, and low-density lipoprotein (LDL) cholesterol are widely accepted coronary heart disease risk factors. These risk factors are also associated with preclinical atherosclerosis, generally measured as the intima media thickness of carotid arteries by B-mode ultrasound. A recent study has shown that increases in intima-media thickness of carotid artery (TCA) are directly associated with an increased risk of myocardial infarction and stroke in older adults without a history of cardiovascular disease. The aim of our study has been to evaluate TCA in renal transplant recipients under 50 without cardiovascular diseases and traditional cardiovascular risk factors.

Renal function in patients with orthotopic liver transplantation

Since 1980 the introduction of Cyclosporine (CyA) into clinical practice has broadened the indications for orthotopic liver transplantation (OLT), because of improved patient and graft survival.