Patrícia Rodrigues Bonazzi

Liver transplant from Anti-HBc-positive, HBsAg-negative donor into HBsAg-negative recipient: is it safe? A systematic review of the literature.

Avelino‐Silva VI, D′Albuquerque LAC, Bonazzi PR, Song ATW, Miraglia JL, de Brito Neves A, Abdala E. Liver transplant from Anti‐HBc‐positive, HBsAg‐negative donor into HBsAg‐negative recipient: is it safe? A systematic review of the literature. 
Clin Transplant 2010: 24: 735–746.

Surgical site infections in liver transplant recipients in the model for end-stage liver disease era: an analysis of the epidemiology, risk factors, and outcomes.

In recipients of liver transplantation (LT), surgical site infection (SSIs) are among the most common types of infection occurring in the first 60 days after LT. In 2007, the Model for End‐Stage Liver Disease (MELD) scoring system was adopted as the basis for prioritizing organ allocation. Patients with higher MELD scores are at higher risk for developing SSIs as well as other health care–associated infections. However, there have been no studies comparing the incidence of SSIs in the pre‐MELD era with the incidence in the period since its adoption. Therefore, the objectives of this study were to evaluate the incidence, etiology, epidemiology, and outcomes of post‐LT SSIs in those 2 periods and to identify risk factors for SSIs. We evaluated all patients who underwent LT over a 10‐year period (2002‐2011). SSI cases were identified through active surveillance. The primary outcome measure was an SSI during the first 60 days after LT. Risk factors were analyzed via logistic regression, and 60‐day survival rates were evaluated via Cox regression. We evaluated 543 patients who underwent LT 597 times. The SSI rates in the 2002‐2006 and 2007‐2011 periods were 30% and 24%, respectively (P = 0.21). We identified the following risk factors for SSIs: retransplantation, the transfusion of more than 2 U of blood during LT, dialysis, cold ischemia for >400 minutes, and a cytomegalovirus infection. The overall 60‐day survival rate was 79%. Risk factors for 60‐day mortality were retransplantation, dialysis, and a longer surgical time. The use of the MELD score modified the incidence and epidemiology of SSIs only during the first year after its adoption. Risks for SSIs were related more to intraoperative conditions and intercurrences after LT than to a patients status before LT. Liver Transpl 19:1011–1019, 2013.

Double-dose hepatitis B vaccination in cirrhotic patients on a liver transplant waiting list

Development of immunity to hepatitis B virus in cirrhotic patients waiting for liver transplantation is highly desirable. Though a double-dose regimen is available, little is know about its effectiveness. We examined the efficacy of double-dose hepatitis B virus vaccination in cirrhotic patients waiting for liver transplantation. We studied 43 patients who were waiting for liver transplantation. They were vaccinated with three doses of 40 mg hepatitis B vaccine at 0, 1 and 6 months; the normal dose is 20 microg. Efficacy was measured based on seroconversion of anti-HBs. Global response to the primary vaccination scheme was 67.5% (29 patients). Forty-one per cent of responders had anti-HBs titers above 1,000 IU/mL. No factors were associated with response, based on multivariate analysis. The vaccination scheme of 40 microg at 0, 1 and 6 months was superior to conventional vaccination doses (20 microg) for cirrhotic patients on a waiting list for liver transplantation.

Polymyxin use as a risk factor for colonization or infection with polymyxin-resistant Acinetobacter baumannii after liver transplantation.

Acinetobacter baumannii is a leading agent of healthcare‐associated infection. The objective of this study was to evaluate cases of colonization or infection with polymyxin‐resistant A. baumannii (PRAB) in liver transplant recipients and to identify the risk factors for the acquisition of PRAB.

Carbapenem‐resistant Acinetobacter baumannii acquired before liver transplantation: Impact on recipient outcomes

Infection with carbapenem‐resistant Acinetobacter baumannii (CRAB) after liver transplantation (LT) is associated with high mortality. This study aimed to identify risk factors for post‐LT CRAB infection, as well as to evaluate the impact of pre‐LT CRAB acquisition on the incidence of post‐LT CRAB infection. This was a prospective cohort study of all patients undergoing LT at our facility between October 2009 and October 2011. Surveillance cultures (SCs) were collected immediately before LT and weekly thereafter, until discharge. We analyzed 196 patients who were submitted to 222 LTs. CRAB was identified in 105 (53.6%); 24 (22.9%) of these patients were found to have acquired CRAB before LT, and 85 (81.0%) tested positive on SCs. Post‐LT CRAB infection occurred in 56 (28.6%), the most common site being the surgical wound. Multivariate analysis showed that the risk factors for developing CRAB infection were prolonged cold ischemia, post‐LT dialysis, LT due to fulminant hepatitis, and pre‐LT CRAB acquisition with pre‐LT CRAB acquisition showing a considerable trend toward significance (P = 0.06). Among the recipients with CRAB infection, 60‐day mortality was 46.4%, significantly higher than among those without (P < 0.001). Mortality risk factors were post‐LT infection with multidrug‐resistant bacteria, LT performed because of fulminant hepatitis, retransplantation, prolonged cold ischemia, longer LT surgical time, and pre‐LT CRAB acquisition, the last showing a trend toward significance (P = 0.08). In conclusion, pre‐LT CRAB acquisition appears to increase the risk of post‐LT CRAB infection, which has a negative impact on recipient survival. Liver Transplantation 22 615‐626 2016 AASLD.

Carbapenem-resistant Enterobacteriaceae Acquired before Liver Transplantation: Impact on Recipient Outcomes.

Background Carbapenem-resistant Enterobacteriaceae (CRE) is an emergent microorganism of infections after liver transplant (LT). The aim of this study was to analyze the risk factors for CRE acquisition and infection after LT. Methods This was a prospective cohort study involving patients who underwent LT in the 2010 to 2014 period. Surveillance cultures for CRE were collected immediately before LT and weekly thereafter until hospital discharge. Results We analyzed 386 patients undergoing a total of 407 LTs. Before LT, 68 (17.6%) patients tested positive for CRE, 11 (16.2%) of those patients having CRE infection, whereas 119 (30.8%) patients acquired CRE after LT. Post-LT CRE infection was identified in 59 (15.7%) patients: Klebsiella pneumoniae was isolated in 83.2%; surgical site infection was the most common type of infection (46.7%). Multivariate analysis showed that post-LT dialysis was the only risk factor for post-LT CRE acquisition. Eighty-two percent of patients who underwent 3 or more post-LT dialysis sessions and acquired CRE before LT evolved with post-LT CRE infection. Other risk factors for CRE infection were acquisition of CRE post-LT, Model for End-Stage Liver Disease score greater than 32, combined transplantation, and reoperation. Patients who acquired CRE before LT had a high risk of developing CRE infection (P < 0.001). Conclusions Measures for minimizing that risk, including altering the antibiotic prophylaxis, should be investigated and implemented.

Surveillance culture for multidrug-resistant gram-negative bacteria: Performance in liver transplant recipients

HighlightsWe examine the sensitivity of surveillance cultures from liver transplant patients.We examine the performance of surveillance cultures for gram‐negative bacteria.Samples collected from the inguino‐rectal area have the best positivity rate.Surveillance cultures for A. baumannii should be performed for more than one site.The proportion of infection is high among transplant patients colonized by GNB. Background: The prevalence of infection with multidrug‐resistant gram‐negative bacteria (MDR‐GNB) after solid‐organ transplantation is increasing. Surveillance culture (SC) seems to be an important tool for MDR‐GNB control. The goal of this study was to analyze the performance of SC for MDR‐GNB among liver transplant (LT) recipients. Methods: This was a prospective cohort study involving patients who underwent LT between November 2009 and November 2011. We screened patients for extended spectrum &bgr;‐lactamase‐producing Escherichia coli, extended spectrum &bgr;‐lactamase‐producing Klebsiella pneumoniae, and carbapenem‐resistant Enterobacteriaceae, carbapenem‐resistant Pseudomonas aeruginosa (CRPA), and carbapenem‐resistant Acinetobacter baumannii (CRAB). We collected SC samples immediately before LT and weekly thereafter, until hospital discharge. Samples were collected from the inguinal‐rectal area, axilla, and throat. The performance of SC was evaluated through analysis of its sensitivity, negative predictive value, and accuracy. Results: During the study period, 181 patients were evaluated and 4,110 SC samples were collected. The GNB most often identified was CRAB, in 45.9% of patients, followed by CRKP in 40.3%. For all microorganisms, the positivity rate was highest among the inguinal‐rectal samples. If only samples collected from this area were considered, the SC would fail to identify 34.9% of the cases of CRAB colonization. The sensitivity of SC for CRKP was 92.5%. The performance of SC was poorest for CRAB (sensitivity, 80.6%). Conclusions: Our data indicate that SC is a sensitive tool to identify LT recipients colonized by MDR‐GNB.

Quantification of C4d deposition and hepatitis C virus RNA in tissue in cases of graft rejection and hepatitis C recurrence after liver transplantation

Histology is the gold standard for diagnosing acute rejection and hepatitis C recurrence after liver transplantation. However, differential diagnosis between the two can be difficult. We evaluated the role of C4d staining and quantification of hepatitis C virus (HCV) RNA levels in liver tissue. This was a retrospective study of 98 liver biopsy samples divided into four groups by histological diagnosis: acute rejection in patients undergoing liver transplant for hepatitis C (RejHCV+), HCV recurrence in patients undergoing liver transplant for hepatitis C (HCVTx+), acute rejection in patients undergoing liver transplant for reasons other than hepatitis C and chronic hepatitis C not transplanted (HCVTx-). All samples were submitted for immunohistochemical staining for C4d and HCV RNA quantification. Immunoexpression of C4d was observed in the portal vessels and was highest in the HCVTx- group. There was no difference in C4d expression between the RejHCV+ and HCVTx+ groups. However, tissue HCV RNA levels were higher in the HCVTx+ group samples than in the RejHCV+ group samples. Additionally, there was a significant correlation between tissue and serum levels of HCV RNA. The quantification of HCV RNA in liver tissue might prove to be an efficient diagnostic test for the recurrence of HCV infection.

Hepatitis C treatment before and after liver transplant

The Brazilian Journal of Infectious Diseases 2007;11 (5) Suppl. 1:61-65.