Stanley Martin Cohen

Transmission of human immunodeficiency virus and hepatitis C virus through liver transplantation

In November 2007, a liver transplant recipient was confirmed to have human immunodeficiency virus (HIV) and hepatitis C (HCV) infection after the organ procurement agency notified our institution that the donor has been HIV and HCV positive. We reviewed medical records and the collected blood sample results for HIV and HCV testing. A 66 year old female with nonalcoholic steatohepatitis cirrhosis underwent liver transplantation. The donor was a male who had sex with men who received multiple blood transfusions during resuscitation. Preoperative testing for HIV and HCV antibodies were negative for both donor and recipient. Ten months later, HIV and HCV were identified with nucleic acid testing in the recipient and in the stored donor sera. This is the first reported case of HIV transmission from solid organ transplantation in 20 years, and the first ever reported case of simultaneously transmitted HIV and HCV. The current case represents a high risk donor with newly‐acquired HIV and HCV who transmitted the diseases during the window period of the infections. In this era of organ shortages one option would be avoidance of any high‐risk donor organs. Another option would be to continue the use of such organs with appropriate informed consent, acknowledging the limitations of current screening tests for HIV and HCV. This report should serve as a wake‐up call to the transplant community to consider revamping organ donor screening for HIV and HCV using nucleic acid testing as well as reconsidering the ongoing use of high‐risk donors. Liver Transpl 14:1603–1608, 2008.

Biliary cast syndrome following liver transplantation: Predictive factors and clinical outcomes

Biliary cast syndrome (BCS), the presence of biliary casts and debris causing biliary obstruction, occurs in 4%‐18% of orthotopic liver transplant (OLT) recipients. Potential consequences include cholangitis and graft damage or loss. Limited data exist regarding the etiology and outcomes of BCS. The purpose of this study was to evaluate donor and recipient risk factors and determine the impact of BCS. A retrospective review of 355 OLT cases identified 9 BCS patients (2.5%) diagnosed by cholangiography. Twenty‐six matched controls were also identified. The warm ischemic time was significantly longer in BCS patients. Other recipient and donor preoperative and intraoperative characteristics, including the donor risk index, revealed no significant differences. Overall patient survival showed a trend toward worse outcomes at 6, 12, and 18 months and end of follow‐up in the BCS group. Overall graft survival was also worse in the BCS group at all time periods, with statistical significance demonstrated at 18 months and end of follow‐up. The number of therapeutic biliary procedures and hospital readmissions was significantly higher in the BCS group. Twenty‐two percent of the BCS patients required repeat OLT versus none of the control patients. In conclusion, BCS is an uncommon complication of OLT. Except for a longer warm ischemic time, recipient and donor factors did not predict the occurrence of BCS. BCS patients showed a significantly worse graft survival, as well as a trend toward worse patient survival. Given the negative impact of BCS on liver transplant outcomes, further studies appear justified. Liver Transpl 14:1466–1472, 2008.

Duplex Doppler ultrasound of the hepatic artery in patients with acute alcoholic hepatitis

Background Acute alcoholic hepatitis (AAH) is a clinical diagnosis associated with increased hepatic artery diameter and flow. Duplex Doppler ultrasound (DDU) has been shown to accurately measure arterial flow in both liver and kidney transplant patients. The authors conducted a blinded, controlled study to evaluate the accuracy of measuring hepatic artery parameters with DDU in diagnosing AAH. Study Duplex Doppler ultrasound was performed by an investigator, blinded to group makeup, on 22 consecutive hospital inpatients with the clinical diagnosis of AAH. The diagnosis of AAH was based on specific criteria, including the following: recent alcohol abuse, hyperbilirubinemia, prolonged prothrombin time, leukocytosis, hepatomegaly, hepatic bruit, and marked redistribution of isotope on 99mTc-sulfur colloid liver–spleen scan. Controls were 12 cirrhotic patients without AAH and 17 healthy volunteers. Duplex Doppler ultrasound measurements were obtained most consistently from the proximal right hepatic artery. Measured parameters included the following: peak systolic velocity (PSV); resistive index = (PSV − end diastolic velocity [EDV])/PSV; pulsatility index = (PSV − EDV)/mean velocity; and hepatic artery diameter. Results The mean hepatic artery diameter was significantly larger in patients with AAH (3.55 ± 0.72 mm) than in patients with cirrhosis (2.75 ± 0.69 mm;p = 0.003) and healthy controls (2.68 ± 0.69 mm;p = 0.001). The mean PSV was significantly higher in patients with AAH (187 ± 52 cm/s) compared with cirrhotic (67 ± 51 cm/s) and healthy (66 ± 51 cm/s) controls (p = 0.0001). The mean resistive index was lower in AAH patients (0.60 ± 0.11) compared with cirrhotic (0.69 ± 0.10;p value was not significant) and healthy controls (0.72 ± 0.11;p = 0.004). The mean pulsatility index was lower in AAH patients (1.04 ± 0.47) compared with cirrhotic (1.36 ± 0.45;p value was not significant) and healthy controls (1.53 ± 0.45;p = 0.01). Conclusions In the appropriate clinical setting, an elevated hepatic artery diameter or PSV measurement is suggestive of AAH. Duplex Doppler ultrasound offers a noninvasive test to assist in the diagnosis of AAH.

Fatal lactic acidosis associated with the use of combination oral medications to treat reactivation of hepatitis B.

Oral nucleos(t)ide analogs for the treatment of hepatitis B virus (HBV) infection are well tolerated with minimal side effects. These agents do carry a Food and Drug Administration black box warning about the development of fatal lactic acidosis on the basis of data from the human immunodeficiency virus literature. However, no previously published cases of this lethal side effect have been reported in patients undergoing HBV treatment using the current Food and Drug Administration-approved HBV medications. We report a case of HBV reactivation after chemotherapy for leukemia, and the development of fatal lactic acidosis attributed to the use of combination oral HBV medications.

The downstream financial effect of hepatology

As a more consultative but less procedurally oriented specialty, Hepatology has been considered a financial liability in some academic centers. However, no actual data exist on the relative contribution of a Hepatology practice. The purpose of this study was to evaluate the direct and indirect (i.e., downstream effect) charges generated by a Hepatology section in comparison with a Gastroenterology section. Using a computerized database, retrospective cohorts of new outpatient consultations and initial admissions seen by the Hepatology and Gastroenterology sections over a 3‐month period were created. The cohorts were followed for 12 months. Charges generated directly to the section (direct charges) and to the hospital system (indirect charges) were calculated. Each cohort consisted of 179 patients. The Hepatology patients generated

Use of Specialty Care Versus Standard Retail Pharmacies for Treatment of Hepatitis C

5,851,463 in overall charges for the hospital, compared with

A case of complete resolution of gastric varices.

2,273,339 for the Gastroenterology cohort. Only 3.6% of the Hepatology charges were direct, compared with 15.9% of the Gastroenterology charges. For every

Sa1010 Outcomes and Safety of Open vs. Laparoscopic Surgery in Patients With Cirrhosis

1 billed by Hepatology, the hospital system generated an additional

The liver transplant recipient: what you need to know for long-term care.

26.95 in charges (

Fulminant Hepatic Failure in an Adult Patient With Giant-Cell Hepatitis

51.03 for the orthotopic liver transplantation patients, and