Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society
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Randomized Controlled Trial Clinical Trial
A prospective randomized trial of mycophenolate mofetil in liver transplant recipients with hepatitis C.
Hepatitis C is the most common indication for liver transplantation (LT) in the United States. Recurrence of hepatitis C virus (HCV) infection post-LT remains a problem for which there is no completely satisfactory treatment. The aim of the present study is to evaluate mycophenolate mofetil (MMF), which has both immunosuppressive and antiviral properties, to determine whether it is associated with a difference in the rate of HCV recurrence and also examine its impact on patient and graft survival. ⋯ In liver transplant recipients with HCV, MMF has no impact on patient survival, graft survival, rejection, or rate of HCV recurrence based on biochemical changes and histological findings. In addition, there was no difference in HAI or fibrosis score between the two groups. Either MMF has no anti-HCV effect or its immunosuppressive properties overwhelm its antiviral effect in the clinical setting.
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The aim of this study is to (1) characterize the impact of orthotopic liver transplantation (OLT) on splanchnic and systemic oxygen uptake (VO(2)) in patients with liver cirrhosis, and (2) investigate possible influencing factors, as well as metabolic consequences, of reduced splanchnic VO(2) in patients with cirrhosis. Therefore, we measured systemic VO(2) (indirect calorimetry), portal pressure (hepatic venous pressure gradient), hepatic blood flow (HBF; primed continuous infusion of indocyanine green), and hepatic turnover (arteriohepatic venous concentration differences multiplied by HBF) of oxygen, glucose, free fatty acids (FFAs), and aromatic amino acids (AAAs) in 52 patients with advanced cirrhosis and 16 patients with a clinically stable long-term course after OLT. Systemic VO(2) was significantly increased in patients with cirrhosis (261 +/- 7 mL/min) and normalized after OLT (216 +/- 8 mL/min; P < .001). ⋯ In patients with cirrhosis, a decrease in HBF was associated with decreased splanchnic VO(2) (r = 0.74; P < .001). Conversely, decreased splanchnic VO(2) reflected a decrease in hepatic glucose production (r = 0.34; P = .01) and hepatic extraction of FFAs (r = 0.40; P < .01) and AAAs (r = 0.30; P < .05). These results show that (1) splanchnic and systemic VO(2) normalize after OLT, indicating correction of hepatic and extrahepatic metabolic derangements; (2) in cirrhosis, HBF becomes limiting for hepatic oxygen supply; and (3) impaired splanchnic VO(2) reflects a decrease in metabolic liver function.
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Patients with fulminant hepatic failure (FHF) frequently develop cerebral edema and intracranial hypertension. The aim of this study was to evaluate circulating S-100b and neuron-specific enolase (NSE) levels as markers of neurological outcome in patients with FHF. In a subgroup of patients, the cerebral flux of S-100b and NSE was measured. ⋯ In conclusion, blood levels of S-100b were elevated in almost all patients with FHF and AOCLD, but were unrelated to survival. Conversely, NSE showed a clear tendency toward greater circulating levels in patients with FHF who subsequently developed cerebral herniation than in survivors. This finding encourages further evaluation of NSE as a marker of neurological outcome in FHF.
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Combined liver-kidney and kidney-only transplantation outcomes in primary hyperoxaluria (PH) are described. Strategies for the selection of type and timing of transplantation and pretransplantation and posttransplantation management are reviewed. Records were reviewed for 16 patients with PH who received 9 liver-kidney and 10 kidney-only transplants. ⋯ Kidney-alone transplantation is recommended for those with pyridoxine-responsive type I disease because pharmacological therapy allows favorable management of oxalate production in this situation. Kidney-alone transplantation also is recommended for PH type II (PH-II). This disease is less severe than PH-I, and it is currently unknown whether liver transplantation will correct the metabolic defect responsible for PH-II.
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As promoters of orthotopic liver transplantation (OLT) with preservation of caval flow, we reviewed our 8-year experience to assess the feasibility and limits of this technique. Preservation of caval flow during OLT, which improves intraoperative hemodynamic stability, was not considered feasible in a significant proportion of transplant recipients. When transient clamping of caval flow is required, causes and consequences of this clamping during all phases of the procedure were not reported. ⋯ We conclude that IVC preservation is feasible in almost all candidates, allowing the use of split livers from cadaveric or living donors independently from their underlying disease. Although preservation of caval flow was possible in the large majority of cases, transient IVC cross-clamping during hepatectomy was well tolerated in contrast to caval clamping after graft reperfusion. Therefore, if necessary, we recommend transient IVC cross-clamping to perform a large cavocaval anastomosis.