Neeraj Saraf

Rapidly progressive recurrent hepatitis C virus infection starting 9 days after liver transplantation

Early histological recurrence of hepatitis C after liver transplantation (LT) has a negative impact on patient and graft survival. We report a case of histological recurrence of HCV occurring in the second week after LT. A 75‐year‐old woman with chronic HCV and hepatocellular carcinoma underwent LT with an organ from a 75‐year‐old HCV‐negative deceased donor. After an uneventful early postoperative period, an increase in the transaminases was observed, and on postoperative day 9 day, the alanine aminotransferase (ALT) was 673 IU/mL and aspartate aminotransferase (AST) 300 IU/mL, with normal alkaline phosphatase and bilirubin. Analysis of liver biopsy samples showed diffuse necroinflammatory changes with acidophilic bodies and concomitant mild acute cellular rejection. Subsequently there was a further increase in the transaminases, and on postoperative day 13, the AST rose to 445 IU/mL and ALT to 992 IU/mL. Repeat biopsy was performed, and analysis of the samples revealed lymphocytic portal inflammation with lymphoid aggregates and mild interface hepatitis, parenchymal necrosis, activation of sinusoidal lining cells, and mild steatosis. The biopsy sample was characteristic for HCV recurrence. The HCV RNA level was 84,000,000 copies/mL, and markers for other viral causes were not present. The patient became jaundiced and her course progressively worsened. She died on day 87 after transplantation. To our knowledge, this is the earliest reported case of histological recurrence of HCV after LT. It illustrates the importance of older donor and recipient age in the same patient as cofactors for early HCV recurrence and poor outcome. Liver Transpl 13:913–917, 2007.

Endoscopic Ultrasound-Guided Fine-Needle Aspiration of the Adrenal Glands: Analysis of 21 Patients

Background/Aims Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology of adrenal masses helps in etiological diagnosis. The aim of this study was to evaluate the diagnostic yield of EUS-FNA of adrenal masses in cases where other imaging methods failed and/or were not feasible. Methods Twenty-one consecutive patients with adrenal masses, in whom adrenal FNA was performed because conventional imaging modalities failed and/or were not feasible, were prospectively evaluated over a period of 3 years. Results Of the 21 patients (mean age, 56±12.2 years; male:female ratio, 2:1), 12 had pyrexia of unknown origin and the other nine underwent evaluation for metastasis. The median lesion size was 2.4×1.6 cm. Ten patients were diagnosed with tuberculosis (shown by the presence of caseating granulomas [n=10] and acid-fast bacilli [n=4]). Two patients had EUS-FNA results suggestive of histoplasmosis. The other patients had metastatic lung carcinoma (n=6), hepatocellular carcinoma (n=1), and adrenal lipoma (n=1) and adrenal myelolipoma (n=1). EUS results were not suggestive of any particular etiology. No procedure-related adverse events occurred. Conclusions EUS-FNA is a safe and effective method for evaluating adrenal masses, and it yields diagnosis in cases where tissue diagnosis is impossible or has failed using conventional imaging modalities.

Current Status of Immunosuppression in Liver Transplantation

With advancements in immunosuppressive strategies and availability of better immunosuppressive agents, survival rate following liver transplantation has improved significantly in the recent times. Besides improvements in surgical techniques, the most important factor that has contributed to this better outcome is the progress made in the field of immunosuppression. Over the last several years, the trend has changed to tailored immunosuppression with the aim of achieving optimal graft function while avoiding its undesirable side effects. Induction agents are no longer used routinely and the aim is to provide minimal immunosuppression in the maintenance phase. The present review discusses the various types of immunosuppressive agents, their mechanism of action, clinical utility, advantages and disadvantages, and their side effects in short and long-term. It also discusses about tailoring immunosuppression in presence of various situations such as renal dysfunction, metabolic syndrome, hepatitis C recurrence, cytomegalovirus infections and so on. The issue of chronic kidney disease and the available renal sparing immunosuppressive strategies has been particularly stressed upon. Finally, it discusses about the practical aspects of various immunosuppression regimens including drug monitoring.

Innovative approach using an intragastric balloon for weight loss in a morbidly obese patient undergoing liver transplantation

Morbid obesity is associated with poor outcomes after liver transplantation. Bariatric surgery or weight loss by lifestyle modification is often not possible because of the presence of decompensated cirrhosis. A 61-year-old male presented with decompensated alcoholic cirrhosis (jaundice, low albumin level, high international normalized ratio, and mild ascites). His comorbidities included diabetes mellitus and morbid obesity (body mass index 1⁄4 48.3 kg/m). He had residual esophageal varices (after endoscopic variceal ligation) but no fundal varices. He was listed for deceased donor liver transplantation, and a BioEnterics intragastric balloon was placed endoscopically to promote weight loss. He lost 24 kg over 6 months (body mass index at transplantation 1⁄4 39.2 kg/m), and his diabetic control improved significantly (with his hemoglobin A1c level decreasing from 9.2 to 5.4 g/dl). He underwent deceased donor liver transplantation 3 months later; the balloon was removed endoscopically just before surgery in order to facilitate a better operative field. His postoperative recovery was uneventful, and he was doing well 3 months after deceased donor liver transplantation without any rebound weight gain. Patients with decompensated cirrhosis have a significant risk of perioperative mortality after bariatric surgery in comparison with patients with compensated cirrhosis (16.3% versus 0.9%). Intragastric balloon placement is a nonsurgical approach, and it has been shown to improve parameters of insulin resistance, obesity-related complications, and quality of life for obese patients. A metaanalysis including 3608 patients has shown that an intragastric balloon is more effective than a placebo for weight loss, with nausea and vomiting being the most common side effects (8.6%). We could not find any reports regarding the use of intragastric balloons to promote liver transplantation in morbidly obese patients. Although long-term weight loss has not been described with the use of balloons, improved diabetic control and a lower body mass index decrease the perioperative complications of liver transplantation. In conclusion, in a decompensated patient with cirrhosis who is morbidly obese and does not have significant gastroesophageal varices, the placement of an intragastric balloon is a useful and innovative modality for promoting short-term weight loss and thereby making the patient fit for surgery and reducing perioperative morbidity andmortality.

Nonalcoholic fatty liver is not associated with incident chronic kidney disease: a large histology-based comparison with healthy individuals.

Background Nonalcoholic steatohepatitis or fibrosis is associated with the increased prevalence of impaired kidney function. It is not known whether nonalcoholic fatty liver (NAFL), which is steatosis without inflammation or fibrosis, is associated with renal impairment as these individuals are not candidates for liver biopsy. Materials and methods The study group included all liver donors who underwent a preoperative liver biopsy for various reasons. NAFL was defined as more than 5% hepatocytes having steatosis and no changes of steatohepatitis and/or fibrosis. Individuals with NAFL were compared with individuals with normal liver histology. Estimated glomerular filtration rate was calculated with the Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration methods. Results The mean age of the study group was 35±10.3 years and the mean BMI was 26±3.2 kg/m2. A total of 187 adults having NAFL (80 men) were compared with 186 (88 men) individuals with normal liver histology (controls). Individuals with steatosis had significantly higher BMI (26.8±3.5 vs. 25.5±3.8 kg/m2, P<0.001) and serum alanine transaminase levels (33.8±13.3 vs. 27.2±9.8 IU/l, P<0.000). There was no significant difference in the estimated glomerular filtration rate between the normal histology group and the NAFL group with Modification of Diet in Renal Disease (115±21.8 vs. 114.4±23.2 ml/min, P=0.803) and Chronic Kidney Disease Epidemiology Collaboration methods (113.6±14.8 vs. 113±14.7 ml/min, P=0.668). There was no significant difference as regards serum creatinine (0.73±0.16 vs. 0.74±0.16 mg%, P=0.536), proteinuria (P=0.121), diabetes (1 vs. 4, P=0.372), and hypertension (2 vs. 6, P=0.174) in individuals of both groups. Conclusion Presence of NAFL does not adversely affect renal function.

(D+10) MELD as a novel predictor of patient and graft survival after adult to adult living donor liver transplantation

We modified the previously described D‐MELD score in deceased donor liver transplant, to (D+10)MELD to account for living donors being about 10 years younger than deceased donors, and tested it on living donor liver transplantation (LDLT) recipients. Five hundred consecutive LDLT, between July 2010 and December 2012, were retrospectively analyzed to see the effect of (D+10)MELD on patient and graft survival. Donor age alone did not influence survival. Recipients were divided into six classes based on the (D+10)MELD score: Class 1 (0‐399), Class 2 (400‐799), Class 3 (800‐1199), Class 4 (1200‐1599), Class 5 (1600‐1999), and Class 6 (>2000). The 1 year patient survival (97.1, 88.8, 87.6, 76.9, and 75% across Class 1‐5, P=.03) and graft survival (97.1, 87.9, 82.3, 76.9, and 75%; P=.04) was significantly different among the classes. The study population was divided into two groups at (D+10)MELD cut off at 860. Group 1 had a significantly better 1 year patient (90.4% vs 83.4%; P=.02) and graft survival (88.6% vs 80.2%; P=.01). While donor age alone does not predict recipient outcome, (D+10)MELD score is a strong predictor of recipient and graft survival, and may help in better recipient/donor selection and matching in LDLT.

Good outcome of living donor liver transplantation in drug induced acute liver failure: a single centre experience.

Drug‐induced acute liver failure (ALF) is associated with high mortality. There is limited literature on results of living donor liver transplantation (LDLT).