V. Sánchez-Turrión

Effect of antibiotic prophylaxis on the risk of surgical site infection in orthotopic liver transplant

Surgical site infections are common bacterial infections in orthotopic liver transplantation. The purpose of this study was to determine the incidence, timing, location, and risk factors, specifically antibiotic prophylaxis, for surgical site infections. A prospective study was performed that included a population of 1222 consecutive patients (73.0% males) who underwent liver transplantation in Spanish hospitals belonging to the Red de Estudio de la Infección en el Trasplante research network. One hundred seven patients developed surgical site infections. The predominant infection sites were incisional wound (53 episodes) and peritonitis (40 episodes). The timing of the organ/space surgical site infections was slightly delayed in comparison with incisional surgical site infections. Enterococcus spp., Escherichia coli, Staphylococcus aureus, and Acinetobacter baumannii were the predominant pathogens. Choledochojejunal or hepaticojejunal reconstruction (odds ratio, 4.2; 95% confidence interval, 1.6–10.7), previous liver or kidney transplant (odds ratio, 2.6; 95% confidence interval, 1.1–6.3), and more than 4 red blood cell units transfused (odds ratio, 2.0; 95% confidence interval, 1.1–3.4) were independently associated with the development of surgical site infections. Biliary reconstruction by choledochojejunostomy or hepaticojejunostomy increases the risk of surgical site infections. Liver Transpl 14:799–805, 2008.

Mycophenolate Mofetil Can Be Used as Monotherapy Late After Liver Transplantation

We report our experience with calcineurin inhibitor (CNI) withdrawal and MMF monotherapy in 50 adult liver transplant (OLT) recipients with CNI‐related toxicity. Thirty‐four patients had chronic renal dysfunction (CRD) associated with arterial hypertension, 11 had only CRD and other five patients had hypertension. The mean time between OLT and introduction of MMF was 81 months. After the introduction of MMF, CNI was progressively reduced and withdrawn if possible. At the end of the follow up (mean time: 18 months) CNI was withdrawn in 39 patients (78%), and there was a significant decrease from baseline in serum creatinine (1.81–1.49 mg/dL; p < 0.0001), BUN (76.6–52.8 mg/dL; p < 0.0001) and uric acid (9–7.5 mg/dL; p < 0.0001) levels, and an increase in creatinine clearance (44.7–55.1 mL/min; p < 0.0001). Excluding patients who developed graft rejection and two patients who died, CRD improved in 32 of 40 patients (80%), and arterial hypertension improved in 22 of 29 patients (76%). Five patients (10%) developed acute rejection, and one patient (2%) chronic rejection. Twenty‐six patients (52%) experienced side‐effects, with asthenia, herpes virus infection, and diarrhea being the most common. Only eight patients (16%) required MMF dose reduction. In conclusion, MMF monotherapy late after OLT improves CRD and hypertension in most patients, is safe and well tolerated.

Breakthrough rhinocerebral mucormycosis in a liver transplant patient receiving caspofungin.

Zygomycetes are among the most frequent causes of non-Aspergillus mycelial fungal infections in transplant recipients. We have described a single case of breakthrough zygomycosis. A young Japanese woman presented because of idiopathic fulminant hepatitis and renal failure. On the third day of admission, she underwent orthotopic liver transplantation. A considerable amount of red blood cells and fresh frozen plasma were transfused during surgery. On posttransplant day 2, Candida albicans was isolated from respiratory secretions; prophylactic caspofungin was prescribed. During the next 6 days, C albicans was isolated from tracheal secretions, surgical wound, and exudates and stools. Ventilator-associated pneumonia was diagnosed day 4. Her renal function did not improve during the postoperative period; the patient continued on hemodialysis. On day 28, a dark blue eschar due to zygomycosis was detected on the skin of the nose. Tracheal and nasal exudates yielded Rhizopus sp. The patient died 12 hours later due to multiorgan failure with hypothermia. The fatal evolution in this case may be related to a presumed brain infarction after progressive vessel fungal invasion. The presented case had 2 risk factors related to zygomycosis. A high index of suspicion is required in transplant recipients with risk factors for zygomycosis. Early diagnosis and surgery with appropriate systemic fungal drugs (amphotericin B) are mandatory to improve the prognosis.

Usefulness of mycophenolate mofetil in patients with chronic renal insufficiency after liver transplantation

NEPHROTOXICITY is a common side effect after liver transplantation (LT). Chronic renal insufficiency (CRI) appears in 50% to 79% of patients during long-term follow-up. The incidence of end-stage renal disease (ESRD) ranges between 2% and 9.5%. The use of calcineurin inhibitors (CNI) is the main cause of CRI after LT. Although acute renal failure related to CNI responds to dosage adjustment, the management of patients with CRI is difficult because cyclosporine or tacrolimus dose reduction generally does not improve renal function and withdrawal can be associated with graft rejection. In contrast to CNI, the newer immunosuppressive agents, mycophenolate mofetil (MMF) and sirolimus, are not nephrotoxic. Therefore, trials have been designed to withdraw CNI with the use of these new immunosuppressive agents in patients with chronic renal insufficiency. MMF is an inhibitor of inosine monophosphate dehydrogenase, which inhibits proliferation of T and B lymphocytes. The aim of our study was to evaluate the evolution of the renal function in patients with chronic renal dysfunction after liver transplantation with the use of mycophenolate mofetil, associated with a slow tapering and withdrawal of CNI.

Late mortality in patients with liver transplantation: causes and risk factors

LIVER TRANSPLANTATION (OLT) has become the treatment of choice for end-stage liver failure. Survival after OLT has improved over recent years owing to improved surgical and medical management of these patients. The majority of deaths occur during the first 3 months after liver transplantation, mainly due to infections, allograft failure following primary allograft dysfunction and nonfunction, and technical causes. Although causes of early mortality are well defined, there is a paucity of data on causes of death in long-term survivors of liver transplantation. The aim of this study was to review the causes of late mortality (more than 1 year after OLT) in liver transplant patients in a single adult Liver Transplantation Center.

Influence of immunosuppressive therapy in the incidence of chronic renal failure after liver transplantation

Patients and Methods: Group I: 8 patients undergoing liver transplantation; group II: 9 control patients. Both groups had similar features with respect age, sex, histology and evolution of the disease. Serum samples were collected with a difference of 5 years. HCV quasispecies diversity was analysed in the hypervariable region 1 (HVRl) of the viral genome and assessed by: 1) single-stranded conformational polymorphism (SSCP) and 2) RT-PCR, cloning and sequencing in pretransplantation and posttransplantation serum samples. Results: By SSCP analysis, there were not statistically significant differences in quasispecies complexity in preand post-transplant samples intra or inter groups. By sequencing evaluation, HCV sequence diversity was lower in the postransplanted samples of liver transplant pantients with respect to the non-transplant ones (piO.04 vs piO.07, respectively). Conclusion: The post-transplant immunosuppression therapy seems to decrease HCV quasispecies diversity.