Cadaveric Orthotopic Liver Transplantation Research Articles

Continuous Renal Replacement Therapy after Liver Transplantation: Peri-Operative Associated Factors and Impact on Survival.

Continuous renal replacement therapy (CRRT) following orthotopic liver transplantation (OLT) is usually started for multifactorial reasons, with variable incidence among series. This paper presents a single-center retrospective observational study on the early use (within one week) of CRRT after consecutive cadaveric OLT from January 2008 to December 2016. Preoperative patient characteristics and intraoperative data were collected, and patients were divided into two groups (CRRT and no CRRT) to explore the factors associated with the use of CRRT. Repeated measurements of postoperative creatinine were analyzed with generalized estimating equation (GEE) models. Among 528 OLT patients, 75 (14.2%) were treated with CRRT at least once in the first week. Patients treated with CRRT showed lower survival in a Kaplan–Meier curve (log-rank p value < 0.01). Patients treated with CRRT had a more severe preoperative profile, with a significantly higher age, MELD, BUN, creatinine, and total bilirubin, as well as a longer surgery time and a higher number of transfusions of red blood cells, plasma, and platelets (all p values < 0.05). In a stepwise multiple analysis, the following characteristics remained independently associated with the use of CRRT: the MELD score OR 1.12 (95% CL: 1.07–1.16), p value < 0.001, and the preoperative value for blood urea nitrogen OR 1.016 (95% CL: 1.010–1.023), p value < 0.001. The early use of CRRT after OLT occurred at a low rate in this large cohort; however, it was associated with worse outcomes. Apart from the preoperative severity, repeated intraoperative hypotension episodes, which were likely modifiable or preventable, were associated with the increased use of CRRT and higher postoperative creatinine.

Liver transplantation for chronic hepatitis C virus infection in the United States 2002-2014: An analysis of the UNOS/OPTN registry.

Chronic hepatitis C virus (HCV) infection is a leading cause for orthotopic liver transplantation (OLT) in the U.S. We investigated characteristics of HCV-infected patients registered for OLT, and explored factors associated with mortality. Data were obtained from the United Network for Organ Sharing and Organ Procurement and Transplantation network (UNOS/OPTN) registry. Analyses included 41,157 HCV-mono-infected patients ≥18 years of age listed for cadaveric OLT between February 2002 and June 2014. Characteristics associated with pre- and post-transplant survival and time trends over the study period were determined by logistic and Cox proportional hazard regression analyses and Poisson regressions. Most patients were white (69.1%) and male (70.8%). At waitlist registration, mean age was 54.6 years and mean MELD was 16. HCC was recorded in 26.9% of the records. A total of 51.2% of the patients received an OLT, 21.0% died or were too sick; 15.6% were delisted and 10.4% were still waiting. Factors associated with increased waitlist mortality were older age, female gender, blood type 0, diabetes, no HCC and transplant region (p<0.001). OLT recipient characteristics associated with increased risk for post OLT mortality were female gender, age, diabetes, race (p<0,0001), and allocation MELD (p = 0.005). Donor characteristics associated with waitlist mortality included age, ethnicity (p<0.0001) and diabetes (p<0.03). Waitlist registrations and OLTs for HCC significantly increased from 14.4% to 37.3% and 27.8% to 38.5%, respectively (p<0.0001). Pre- and post-transplant survival depended on a variety of patient-, donor-, and allocation- characteristics of which most remain relevant in the DAA-era. Still, intensified HCV screening strategies and timely and effective treatment of HCV are highly relevant to reduce the burden of HCV-related OLTs in the U.S.

Successful liver allograft inflow reconstruction with the right gastroepiploic vein

Portal vein thrombosis is a common complication in cirrhotic patients. When portal vein thrombectomy is not a suitable option, a large collateral vessel can be used for allograft venous inflow reconstruction. We describe an unusual case of successful portal revascularization using the right gastroepiploic vein. The patient underwent a cadaveric orthotopic liver transplantation with end-to-end anastomosis of the portal vein to the right gastroepiploic vein. Six months after liver transplantation the patient is well with good liver function. The use of the right gastroepiploic vein for allograft venous reconstruction is feasible and safe, with a great advantage of avoiding the need of venous jump graft.

Expanded Efficacy and Indication of Extracorporeal Membrane Oxygenation for Preoperative Pulmonary Bleeding on Pediatric Cadaveric Orthotopic Liver Transplantation

Expanded Efficacy and Indication of Extracorporeal Membrane Oxygenation for Preoperative Pulmonary Bleeding on Pediatric Cadaveric Orthotopic Liver Transplantation

Liver Transplantation in Highest Acuity Recipients

To identify medical predictors of futility in recipients with laboratory Model of End-Stage Liver Disease (MELD) scores of 40 or more at the time of orthotopic liver transplantation (OLT). Although the survival benefit for transplant patients with the highest MELD scores is indisputable, the medical and economic effort to bring these highest acuity recipients through OLT presents a major challenge for every transplant center. This study was undertaken to analyze outcomes in patients with MELD scores of 40 or more undergoing OLT during the period February 2002 to December 2010. The analysis was focused on futile outcome (3-month or in-hospital mortality) and long-term posttransplant outcome. Independent predictors of futility and failure-free survival were identified and a futility risk model was created. During the study period, 1522 adult cadaveric OLTs were performed, and 169 patients (13%) had a MELD score of 40 or more. The overall 1, 3, 5, and 8-year patient survivals were 72%, 64%, 60%, and 56%. Futile outcome occurred in 37 patients (22%). MELD score, pretransplant septic shock, cardiac risk, and comorbidities were independent predictors of futile outcome. Using all 4 factors, the futility risk model had a good discriminatory ability (c-statistic 0.75). Recipient age per year, life-threatening postoperative complications, hepatitis C, and metabolic syndrome were independent predictors for long-term survival in nonfutile patients (Harrels c-statistic 0.72). Short- and long-term outcomes of recipients with MELD scores of 40 or more are primarily determined by disease-specific factors. Cardiac risk, pretransplant septic shock, and comorbidities are the most important predictors and can be used for risk stratification in these highest acuity recipients.

Liver Transplantation Using University of Wisconsin or Celsior Preserving Solutions in the Portal Vein and Euro-Collins in the Aorta

Introduction Orthotopic liver transplantation (OLT) is today the gold standard treatment of the end-stage liver disease. Different solutions are used for graft preservation. Our objective was to compare the results of cadaveric donor OLT, preserved with the University of Wisconsin (UW) or Celsior solutions in the portal vein and Euro-Collins in the aorta. Methods We evaluated retrospectively 72 OLT recipients, including 36 with UW solution (group UW) and 36 with Celsior (group CS). Donors were perfused in situ with 1000 mL UW or Celsior in the portal vein of and 3000 mL of Euro-Collins in the aortia and on the back table managed with 500 mL UW or Celsior in the portal vein, 250 mL in the hepatic artery, and 250 mL in the biliary duct. We evaluated the following variables: donor characteristics, recipient features, intraoperative details, reperfusion injury, and steatosis via a biopsy after reperfusion. We noted grafts with primary nonfunction (PNF), initial poor function (IPF), rejection episodes, biliary duct complications, hepatic artery complications, re-OLT, and recipient death in the first year after OLT. Results The average age was 33.6 years in the UW group versus 41 years in the CS group ( P = .048). There was a longer duration of surgery in the UW group ( P = .001). The other recipient characteristics, ischemia-reperfusion injury, steatosis, PNF, IPF, rejection, re-OLT, and recipient survival were not different. Stenosis of the biliary duct occured in 3 (8.3%) cases in the UW group and 8 (22.2%) in the CS ( P = .19) with hepatic artery thrombosis in 4 (11.1%) CS versus none in the UW group ( P = .11). Conclusion Cadaveric donor OLT showed similar results with organs preserved with UW or Celsior in the portal vein and Euro-Collins in the aorta.

Complete Atrioventricular Block and Torsade de Pointes Occurring in an Adult During Liver Transplantation

Perioperative arrhythmias frequently occur during cardiac surgery and may also occur during non-cardiac surgery, particularly in patients with structural heart disease. Perioperative arrhythmias represents a major cause of morbidity in either cardiac or non-cardiac surgical procedures. Complete atrioventricular block (CAVB) and torsade de pointes (torsades) are critical arrhythmias, although their incidence during non-cardiac surgery is rare in patients with no underlying structural heart disease. We present a rare case of life-threatening arrhythmias of CAVB and torsades that occurred during cadaveric orthotopic liver transplantation in a 59-year-old man with no structural heart disease. Rapid recognition of the arrhythmias and prompt treatment using a transcutaneous pacemaker and cardioversion successfully saved the patient's life. The sinus rhythm was resumed during pacemaker removal postoperatively. The possible etiology and management of CAVB and torsades during liver transplantation are discussed herein.

A 20-Year Period of Orthotopic Liver Transplantation Activity in a Single Center: A Time Series Analysis Performed Using the R Statistical Software

In many Western countries a “minimum volume rule” policy has been adopted as a quality measure for complex surgical procedures. In Italy, the National Transplant Centre set the minimum number of orthotopic liver transplantation (OLT) procedures/y at 25/center. OLT procedures performed in a single center for a reasonably large period may be treated as a time series to evaluate trend, seasonal cycles, and nonsystematic fluctuations. Between January 1, 1987 and December 31, 2006, we performed 563 cadaveric donor OLTs to adult recipients. During 2007, there were another 28 procedures. The greatest numbers of OLTs/y were performed in 2001 (n = 51), 2005 (n = 50), and 2004 (n = 49). A time series analysis performed using R Statistical Software (Foundation for Statistical Computing, Vienna, Austria), a free software environment for statistical computing and graphics, showed an incremental trend after exponential smoothing as well as after seasonal decomposition. The predicted OLT/mo for 2007 calculated with the Holt-Winters exponential smoothing applied to the previous period 1987–2006 helped to identify the months where there was a major difference between predicted and performed procedures. The time series approach may be helpful to establish a minimum volume/y at a single-center level.

Abdominal drains in liver transplantation: Useful tool or useless dogma? A matched case-control study

On the basis of the growing evidence from randomized trials that routine prophylactic drainage is unnecessary in liver surgery or even harmful in chronic liver disease, we challenged the concept of prophylactic drainage in orthotopic liver transplantation (OLT). Since September 2006, we omitted drains in every patient who underwent OLT, regardless of the procedure. Thirty-five cadaveric OLTs were performed during a 12-month period. These patients were matched 1:2 with 70 patients who had prophylactic drainage after OLT according to donor/recipient age, recipient gender, recipient body mass index, and Model for End-Stage Liver Disease (MELD) score. Endpoints were postoperative morbidity, in-hospital mortality, intensive care unit (ICU), and hospital stay. Complications were graded according to a therapy-oriented classification (grades I-V). Both groups (no drainage, n = 35; drainage, n = 70) were comparable in terms of median donor age (47.5 versus 51.0 years), recipient age (50.6 versus 52.0 years), MELD score (18 versus 14), and body mass index (25.3 versus 26 kg/m(2)). Because of the increasing shortage of organs, more marginal grafts were used in the recent period (ie, no-drainage group): 49% (17/35) versus 27% (19/70; P = 0.04). Major complications were not different between groups: grade 3a (endoscopic/radiological intervention) in 20% (7/35) versus 16% (11/70; not significant), grade 3b (surgical intervention) in 23% (8/35) versus 17% (12/70; not significant), grade 4a (ICU therapy, intermittent hemodialysis) in 34% (12/35) versus 21% (15/70; not significant), grade 4b (multiorgan failure) in 14% (5/35) versus 10% (7/70; not significant), and grade 5 (death) in 6% (2/35) versus 7% (5/70; not significant). This matched case study challenges the dogma of prophylactic drainage after OLT. A no-drain strategy provided no disadvantages despite increased use of extended criteria donors in the no-drainage group. Prophylactic drainage appears unnecessary on a routine basis.

Extended Donor Criteria Have No Negative Impact on Early Outcome After Liver Transplantation: A Single-Center Multivariate Analysis

The organ shortage has driven many transplant centers to accept extended donor criteria and to modify graft allocation policies. This study was designed to analyze the impact of applying extended donor criteria (EDC) in orthotopic liver transplantation (OLT). Between December 2001 and December 2004, we performed 165 primary cadaveric whole OLTs. Up to three EDC, that is, ventilation >7 days; aminotransferases (ALT or AST) >3× normal; bilirubin >3 mg/dL; anti-HBc or HBs Ag positivity; donor age >65 years; liver steatosis >40%; donor body mass index >30; cold ischemia time >14 hours; peak serum Na + >165 mmol/L; history of extrahepatic malignancy; or previous drug abuse were present in 55% of all grafts. Both univariate and multivariate analysis revealed that EDC status had no effect on graft or patient survival, the necessity for retransplantation, the length of intensive care/intermediate care unit stay, mechanical ventilation, complications, or posttransplant laboratory findings. Recipient age of ≥55 years was the only independent prognostic factor for survival, regardless of EDC. These findings suggested that the use of grafts from EDC donors are safe and expand the donor pool.

Characteristics of Waitlisted Patients for Liver Transplantation at a Liver Transplantation Unit in the City of Ribeirão Preto, São Paulo, Brazil, Especially Considering Child and Model for End Stage Liver Disease (MELD) Scores

Liver transplantation represents the most effective therapy for patients suffering from chronic end-stage liver disease. Until recently, in Brazil liver allocation was based on the Child-Turcotte-Pugh score and the waiting list followed a chronological criterion. The aim of this study was to show the clinical and laboratory patterns of our patients awaiting a liver transplantation. Seventy-nine medical records were reviewed in January 2005 to classify patients according to their age, sex, cause of cirrhosis, and Child and Model for End Stage Liver Disease (MELD) scores. The mean age of patients was 47 years; 70% were men. The main diagnosis was liver cirrhosis (97%): 27% alcoholic, 26% viral hepatitis, 20% alcoholic plus viral hepatitis, 13% cryptogenic, and 11% other causes. Sixty-three patients (80%) were Child B or C. The average MELD, scores for Child A, B, and C were 10 ± 5, 13 ± 3.4, and 21 ± 4.3, respectively. Nine deaths (11%) on the waiting list occurred in 2005. Among these, 1 patient was Child B with MELD 10, while the others were Child C, with mean MELD scores of 21 ± 3.8. Twelve patients (15%) received cadaveric orthotopic liver transplantation. Thus, in this small series, the higher MELD scores corresponded to Child C class and mortality on the waiting list.

FACTORS ASSOCIATED WITH BLOOD PRODUCT USE IN LIVER TRANSPLANTATION USING PIGGYBACK HEPATECTOMY.

Background Orthotopic liver transplantation (OLT) may be associated with massive blood loss related to the coexistence of varices, thrombocytopenia or other coagulopathies, or portal hypertension. Piggyback hepatectomy (PGB) is a surgical technique increasingly used in OLT to avoid venovenous bypass and vena cava clamping. This study evaluates the factors associated with blood product requirement with the use of this surgical approach. Methods We retrospectively reviewed the anesthesia preoperative and operative notes and laboratory values for all adult cadaveric OLTs over a 42-month period (N = 527). Ninety-eight percent of the transplants were performed using a PGB approach with no use of venovenous bypass. A direct entry multivariate regression analyses was performed. Results Overall median blood loss was 1,000 cc, with the median transfusion rate being PRBCs 3 units, FFP 7 units, and platelets 6 units. Multivariate regression found significant predictors of PRBC transfusion to be male gender, starting Hgb, MELD, age, starting platelets, and a history of major surgery. These results correspond with a mean 1.0 additional unit for males, an additional 0.7 unit for each g/dL Hgb below 11.8, an additional 1.0 unit for each 5 MELD points above 18.1, an additional 0.5 unit for each 10 years age above 52, an additional 0.5 units for each 50,000 platelets below 100,000, and an additional 2.2 units for major surgery versus no surgery. Conclusions These results demonstrate that, similar to previous reports using venovenous bypass or clamping of the vena cava, certain factors predictably increase the likelihood that blood products will be administered during OLT. Our data also indicate that overall, the PGB technique, typically requiring less warm ischemia time, may represent a safe and cheaper alternative to the conventional approach.

Resolution of medically resistant hypothyroidism after liver transplantation for hepatic hemangioendothelioma

Hepatic hemangioendothelioma (HHE) is a rare vascular tumor in neonates and may cause high-output cardiac failure and coagulopathy, and rarely has been associated with hypothyroidism. Hepatic hemangioendothelioma treatment options consist of corticosteroids, α-interferon, surgical resection, and liver transplantation. Herein, we report the case of a 6-week-old female neonate that presented with an HHE that involved all segments of the liver, resulting in respiratory failure and severe hypothyroidism that was recalcitrant to exogenous l-thyroxine therapy. After failure of medical and supportive therapy for the HHE, the patient underwent a cadaveric orthotopic liver transplantation that resulted in successful treatment of the severe hypothyrodism, respiratory failure, and cardiac symptoms. The patient is currently 1-year posttransplantation and disease free with normal thyroid function.

ENDO-GIA Staplers for Side-to-Side Anastomosis of Veins

To study the application of ENDO-GIA staplers for the side-to-side anastomosis of veins. An animal study was conducted. Five dogs received side-to-side anastomosis of allograft IVC by ENDO-GIA staplers (Group 1). In addition, five received the same operation with right renal vein reimplantation to allograft IVC (Group 2). Five dogs, receiving the same operation as in Group 1 using polypropylene sutures (control group, Group 3). An autopsy was performed if the dogs survived more than 8 weeks. The IVC anastomosis remained patent in four subjects (80%) for Group 1, in five subjects (100%) for Group 2 and in four subjects (80%) for Group 3. From the results of our experiment, ENDO-GIA staplers can be considered for use in the side-to-side anastomosis of large veins such as piggyback cavacaval side-to-side anastomosis in cadaveric orthotopic liver transplantation (OLT) or side-to-side splenorenal shunt in portal hypertension.

Chronic kidney disease post-liver transplantation

Renal disease is a recognized complication of orthotopic liver transplantation (OLT). We aimed to determine the incidence of all stages of chronic kidney disease (CKD), as defined in the Kidney Disease Outcomes Quality Initiative Guidelines. We also wanted to determine the risk factors for development of CKD and its impact on patient survival. All patients who underwent cadaveric OLT, from January 1993 until July 2004, were analysed. The glomerular filtration rate (GFR) was determined using the equation developed by the Modification of Diet in Renal Disease Study. Thirty potential risk factors were examined by univariate and multivariate ordinal logistic regression analysis. Kaplan-Meier survival analysis, the log-rank test and Cox regression analysis were performed to evaluate the survival data. A total of 230 patients were included (107 males and 123 females) with a mean age of 47.7 years (4.5-70.35). Mean follow-up was 5.57 years (0.53-16.5). The following was the 10 year cumulative incidence for each stage of CKD: 0/1, 9.61%; 2, 53.71%; 3, 56.77%; 4, 6.11%; 5, 2.62%. Female gender, age, pre-OLT proteinuria, lower GFR from 1 year and higher creatinine from 6 months were associated with progression of CKD. The use of tacrolimus had a favourable impact. A GFR <30 ml/min, the need for re-transplantation and fulminant hepatic failure were all associated with reduced patient survival. Moderate CKD was very prevalent. We identified the risk factors for progression of CKD and also that severe CKD was associated with reduced patient survival.

Management of a cadaveric orthotopic liver transplantation in a pediatric patient with complex congenital heart disease

Pediatric orthotopic liver transplantations (OLT) are commonly performed nowadays. Two primary reasons for OLT in children are complications from either extrahepatic biliary atresia (EHBA) or inborn errors of metabolism. However, congenital liver disease may be associated with significant other congenital abnormalities. We present a case of a successful OLT in a pediatric patient with a history of EHBA, situs inversus, and complex congenital heart disease. The cardiac anomalies include dextrocardia, absence of the atrial septum (single atrium), single atrioventricular valve (a-v canal), and an incomplete ventricular septum. Prior surgery include a Kasai procedure for EHBA, banding of the proximal main pulmonary artery, and Broviac catheter placement. We present the anesthesia concerns and management for this complicated case.

Biliary Complications Following Liver Transplantation: Single-Center Experience

Biliary complications (BC) following orthotopic liver transplantation (OLT) remain one of the major causes of postoperative complications and treatment failures. The list of common BC consists of biliary stricture, fistula, ischemic type biliary lesions (ITBL), cholangitis, and bile leakage following T-drain removal. Between July 2000 and December 2004, 101 consecutive cadaveric OLTs were performed in our institution. All but three were first full-size grafts. Seventeen patients were transplanted from the urgent list, the remaining 84 (83.16%) from the elective list. All but three patients had a choledochocholedochostomy over a straight drain. Bile cultures were taken routinely. The bile drain was removed following cholangiography 6 weeks after OLT. All patients received antibiotic prophylaxis. Ursodeoxycholic acid was used in selected cases. During the first 6 weeks positive bile cultures in absence of clinical and biochemical symptoms of cholangitis were found in 61 (60.4%) cases. Symptomatic cholangitis requiring antibiotic treatment was observed in 19 (18.8%) patients during the first 6 weeks. Two patients required endoscopic sphincterotomy and temporary stenting due to anastomotic stricture (1) or papilla of Vater fibrosis (1). Bile leakage following drain removal was observed in 8 (7.9%) patients. Five of them were treated conservatively, the remaining 3 (2.9%) required surgery (lavage) and stenting. In one case extrahepatic bile duct necrosis was diagnosed requiring reconstruction of the biliary anastomosis. No case of ITBL, bile leak at the anastomostic site, or stricture requiring surgical repair was noted. Despite the high incidence of positive bile cultures most likely related to use of a drain, the overall number of BC was low.

Pulmonary hypertension—A new manifestation of mitochondrial disease

Mitochondrial respiratory chain (RC) abnormalities in children can present as multiorgan disease, including liver failure, usually within the first year of life. Cardiorespiratory complications have previously been described in association with RC defects; however, to our knowledge no cases of pulmonary hypertension have been described. We discuss two patients with proven mitochondrial RC liver disease who developed severe pulmonary hypertension, one subsequent to cadaveric orthotopic liver transplantation, the second in the neonatal period. It is our contention that pulmonary hypertension should now be included as another potential manifestation of paediatric mitochondrial disease.

Retransplantation for Acute Liver Failure Due to Combined Antiviral Agents in an HIV-HCV Coinfected Liver Transplant Recipient

We report the case of a human immunodeficiency virus (HIV)-hepatitis C virus (HCV) coinfected patient retransplanted 22 weeks after a first orthotopic liver transplantation (OLT) because of drug-induced acute liver failure. A cytomegalovirus (CMV)-negative patient with severe hemophilia A was diagnosed with HIV-HCV (genotype 1b) coinfection that was thought to be acquired before 1985. Since 1996, he had been receiving didanosine, stavudine, and saquinavir. In February 1998, interferon-α2b (IFN-α2b) was introduced for chronic HCV, associated with a 2-month course of ribavirin stopped because of severe thrombocytopenia, and stavudine was discontinued and switched to efavirenz. At the end of 2000, the patient presented severe HCV-related cirrhosis (Child-Pugh score C11) and refractory ascites. Plasma HIV-RNA was undetectable. On January 2001 (D0), this 34-year-old patient underwent a cadaveric OLT with a CMV negative donor and antiretroviral therapy was stopped. Immunosuppressive treatment was based on tacrolimus (targeted trough blood concentrations 12-17 ng/ml) and prednisone (20 mg/day, tapered to 5 mg/day at 3 months). Acute rejection (D13) was treated by a transient increase of the tacrolimus dose. Stavudine (40 mg bid), didanosine (400 mg daily) and efavirenz (200 mg tid) were reintroduced on D53 for sustained HIV replication (plasma viral load=251 000 copies/ml). On D82 a liver biopsy showed mild hepatitis C recurrence (METAVIR score A2F0) and insignificant steatosis. A second liver biopsy performed on D146 because of elevated transaminases (ALT=8N) and low prothrombin index (40%), was assessed as A2F1 and also showed marked steatosis. On D150, IFN-α2b (3MUI) and ribavirin (600 mg daily) were restarted. The following day, the patient developed 200-fold increase of AST and ALT over normal values, 6% prothrombin index (Fig. 1), blood lactate level to 8.6 mmol/L, encephalopathy and acute renal failure requiring hemodialysis. Nucleoside reverse transcriptase inhibitors (NRTIs) liver toxicity was suspected and any antiviral therapy was discontinued. Treatment with levocarnitine was ineffective and the patient was retransplanted seven days later (D158). The explanted graft showed major microvacuolar steatosis involving more than 40% hepatocytes, associated with massive centro- and mediolobular necrosis. In contrast inflammation was mild-to-moderate. After the second OLT, mild acute rejection was documented on D276 without HCV recurrence. Antiretroviral therapy without NRTIs using efavirenz and lopinavir-ritonavir was reintroduced later (D409) and tacrolimus was reduced to 0.5 mg once a week. At 4-year follow-up, the patient is perfectly well.FIGURE 1.: Evolution of alanine aminotransferase (ALT) and prothrombin index (PI) from the first liver transplantation over 4 years in our patient.Because HCV infection has a more rapid progression in HIV-coinfected patients, antiviral therapy with IFN-α plus ribavirin has been proposed. The toxicity of NRTIs, particularly didanosine and stavudine, is due to inhibition of DNA polymerase-γ, which causes mitochondrial dysfunction (1) and ribavirin increases didanosine toxicity (2). Although IFN-α-induced liver toxicity has been reported (3), marked microvacuolar steatosis associated with hyperlactatemia is consistent with NRTIs toxicity enhanced by ribavirin in our patient (4, 5). HIV-HCV coinfected patients receiving nucleoside analogues, ribavirin and IFN-α, may develop severe liver toxicity, whether or not they are transplanted, especially if didanosine is used. Even though liver transplantation is not common for such patients, it should be considered as the best therapeutic option in selected situations. Elisabeth Polard Christophe Camus Anne-Yvonne Abault Bruno Turlin Cédric Arvieux Michel Messner Hervé Allain Karim Boudjema Centre Régional de Pharmacovigilance, Service des Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Rennes, France

Cadaveric Orthotopic Auxiliary Split Liver Transplantation and Kidney Transplantation: An Alternative for Type 1 Primary Hyperoxaluria

Liver transplantation (LTX) corrects the enzymatic defect responsible for type 1 primary hyperoxaluria (PH1). It has been advocated in combination with kidney transplantation (KTX) in patients with renal failure from PH1 because KTX alone can result in early graft loss. A 58-year-old male patient with PH1 on hemodialysis underwent resection of the left lateral segment of the liver followed by orthotopic auxiliary left lateral segment liver transplantation and kidney transplantation from a deceased donor. The serum oxalate dropped from 34.8 micromol/L before transplant to 3.6-8.3 in the first months posttransplant to <1 micromol/L (normal range 0.4-3.0). One year after posttransplant, the patient has an iothalamate glomerular filtration rate of 58 ml/min. Orthotopic auxiliary LTX is an alternative to whole LTX in PH1. By using a split deceased donor liver, it does not deprive the donor pool and protects the recipient from liver failure in case of graft loss.