Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society
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Hepatitis B virus (HBV) infection after orthotopic liver transplantation (OLT) is associated with a high recurrence rate and poor prognosis. This is the first study of the efficacy of long-term lamivudine therapy for patients with HBV infection after OLT. Eight patients (5 men, 3 women) aged 35 to 63 years (mean, 50 years) with HBV infection after OLT (6 patients, recurrent infection; 2 patients, de novo infection) were treated with lamivudine, 100 mg/d, on a compassionate-use basis. ⋯ Of these, 2 patients (40%) had hepatic failure (1 patient died of massive variceal bleed) and 3 patients remain clinically stable. Lamivudine therapy was continued in the latter patients. Although lamivudine is a potentially effective therapy for HBV infection after OLT, emergence of high mutation rates with long-term therapy, histological progression, and the possibility of hepatic failure point to the need to investigative combinations of antiviral therapy.
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During evaluation for liver transplantation, a 63-year-old man with cirrhosis secondary to hepatitis C was diagnosed with severe aortic stenosis (aortic valve area, 0.87 cm(2)) and coronary artery disease. A combined procedure involving aortic valve replacement (pericardial xenograft), coronary artery bypass surgery, and orthotopic liver transplantation was performed. Convalescence was uneventful, and at 2 years after the procedure, the patient has normal cardiac function, good prosthetic valve function, and biochemically normal liver function.
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Transmission of hepatitis B virus (HBV) infection from donors who are negative for hepatitis B surface antigen (HBsAg-) but positive for antibody to hepatitis B core antigen (anti-HBc+) has been reported. However, previous studies were generally performed in geographic regions with a low prevalence of anti-HBc positivity in the liver donor population. The aims of this study are (1) to assess the risk for de novo hepatitis B in recipients of livers from anti-HBc+ donors in an area of high prevalence of anti-HBc positivity in the donor population, and (2) to analyze the risk factors for acquisition of HBV infection from anti-HBc+ donors. ⋯ In our area, testing liver donors for anti-HBc is mandatory, particularly in older donors. With such information available, anti-HBc+ donors can be safely directed to appropriate recipients, mainly those with anti-HBs and/or anti-HBc at the time of transplantation. In the current era of donor shortage, this policy would allow adequate use of such donors.
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Randomized Controlled Trial Comparative Study Clinical Trial
Experience with the use of sirolimus in liver transplantation--use in patients for whom calcineurin inhibitors are contraindicated.
Sirolimus (SRL) provides effective immunosuppression for kidney transplantation and may be useful in patients with delayed allograft function after kidney transplantation. We review our experience with SRL in liver transplant recipients for whom calcineurin inhibitors are undesirable. Fourteen patients with renal insufficiency or acute mental status impairment were administered SRL after liver transplantation (5- to 10-mg load, 1 to 4 mg/d). ⋯ SRL is safe after liver transplantation in patients with acute neurological or renal impairment. SRL is an attractive alternative when calcineurin inhibitors are undesirable, but serum trough levels of SRL should be monitored. A prospective randomized study of an SRL-based calcineurin inhibitor-avoiding regimen compared with standard therapy in patients with renal insufficiency will further evaluate the role for SRL in liver transplantation.
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Comparative Study
Regional cerebral blood flow autoregulation in patients with fulminant hepatic failure.
The absence of cerebral blood flow autoregulation in patients with fulminant hepatic failure (FHF) implies that changes in arterial pressure directly influence cerebral perfusion. It is assumed that dilatation of cerebral arterioles is responsible for the impaired autoregulation. Recently, frontal blood flow was reported to be lower compared with other brain regions, indicating greater arteriolar tone and perhaps preserved regional cerebral autoregulation. ⋯ In the remaining patients, V(mean) increased approximately 25% in both the anterior and middle cerebral arteries. Thus, this study could only partially confirm the hypothesis that autoregulation is preserved in the brain regions supplied by the anterior cerebral artery in patients with FHF. Although the findings of this small study need to be further evaluated, one should consider that autoregulation may be impaired not only in the brain region supplied by the middle cerebral artery, but also in the area corresponding to the anterior cerebral artery.