Liver Transplantation For Hepatitis Research Articles

Liver transplantation for hepatitis B virus-related cirrhosis with acute-on-chronic liver failure and grade 3-4 hepatic encephalopathy: Survival and quality of life.

Liver transplantation for hepatitis B virus-related cirrhosis with acute-on-chronic liver failure and grade 3-4 hepatic encephalopathy: Survival and quality of life.

LIVER TRANSPLANTATION IN LIVER CIRRHOSIS DUE TO HEPATITIS C: A CRITICAL ANALYSIS OF ITS ADVANTAGES, CHALLENGES AND IMPACT ON PATIENTS' QUALITY OF LIFE.

Liver cirrhosis caused by hepatitis C is a serious condition that often leads to the need for liver transplantation for patients in advanced stages of the disease. This procedure has been a crucial measure to improve survival and quality of life for these patients. However, its effectiveness and impact are the subject of critical analysis due to the associated challenges, such as the scarcity of donor organs, the risks of postoperative complications and the possibility of recurrence of hepatitis C virus infection in the new liver. Understanding the advantages and challenges of liver transplantation in hepatitis C liver cirrhosis is essential to optimize patient outcomes and quality of life. Objective: To critically analyze the advantages, challenges and impact on the quality of life of patients undergoing liver transplantation due to liver cirrhosis caused by hepatitis C. Methodology: A systematic literature review was carried out following the PRISMA guidelines. The PubMed, Scielo and Web of Science databases were searched for articles published in the last 10 years. The descriptors used were "liver transplant", "liver cirrhosis", "hepatitis C", "advantages", "challenges" and "quality of life". The inclusion criteria were original studies that addressed the topic in humans, written in English, Portuguese or Spanish. Exclusion criteria were animal studies, literature reviews and studies focusing on liver conditions other than hepatitis C. Results: The results highlighted the effectiveness of liver transplantation in improving the survival and quality of life of patients with liver cirrhosis due to hepatitis C. However, challenges persist, including the limited availability of donor organs and the risk of relapse of hepatitis C virus infection. Strategies to mitigate these challenges have been discussed, such as the use of next-generation antiviral therapies. Conclusion: Liver transplantation is a vital intervention for patients with liver cirrhosis caused by hepatitis C, providing significant benefits in terms of survival and quality of life. However, the associated challenges need to be addressed to further improve outcomes and ensure the long-term success of this procedure.

Machine Learning Model Validated to Predict Outcomes of Liver Transplantation Recipients with Hepatitis C: The Romanian National Transplant Agency Cohort Experience.

In the early period after liver transplantation, patients are exposed to a high rate of complications and several scores are currently available to predict adverse postoperative outcomes. However, an ideal, universally accepted and validated score to predict adverse events in liver transplant recipients with hepatitis C is lacking. Therefore, we aimed to establish and validate a machine learning (ML) model to predict short-term outcomes of hepatitis C patients who underwent liver transplantation. We conducted a retrospective observational two-center cohort study involving hepatitis C patients who underwent liver transplantation. Based on clinical and laboratory parameters, the dataset was used to train a deep-learning model for predicting short-term postoperative complications (within one month following liver transplantation). Adverse events prediction in the postoperative setting was the primary study outcome. A total of 90 liver transplant recipients with hepatitis C were enrolled in the present study, 80 patients in the training cohort and ten in the validation cohort, respectively. The age range of the participants was 12-68 years, 51 (56,7%) were male, and 39 (43.3%) were female. Throughout the 85 training epochs, the model achieved a very good performance, with the accuracy ranging between 99.76% and 100%. After testing the model on the validation set, the deep-learning classifier confirmed the performance in predicting postoperative complications, achieving an accuracy of 100% on unseen data. We successfully developed a ML model to predict postoperative complications following liver transplantation in hepatitis C patients. The model demonstrated an excellent performance for accurate adverse event prediction. Consequently, the present study constitutes the foundation for careful and non-invasive identification of high-risk patients who might benefit from a more intensive postoperative monitoring strategy.

Unusual Ileocecal Ulcers after Liver Transplantation for Hepatitis B Cirrhosis and Hepatocellular Carcinoma.

We presented a case demonstrating ileocecal ulcers after liver transplantation for hepatitis B cirrhosis and hepatocellular carcinoma. The patient presented 4 years post-transplant with paroxysmal right lower abdominal pain. Due to a mild increase in the leukocyte and neutrophil count, infectious diseases were initially suspected. However, probiotic treatment did not help improve the symptom. An enhanced CT scan revealed a thickening in the ileocecal region, and endoscopy later showed multiple giant and deep ulcers in the ileocecal region with polypoid hyperplasia. Histopathology of an ulcer biopsy displayed benign ulcers, and chronic inflammation with non-caseous granulomas, without signs of a fungus or parasite infection. Epithelial exfoliation with atypical hyperplasia was observed, and a tacrolimus-induced ileocecal ulcer was considered by a pathologist. Clinical manifestation, lab findings, radiology, and pathology characteristics of ulcers were not consistent with the pathogenesis of ischemia, tuberculosis, CMV, EBV, tumor, or inflammatory bowel diseases. Abdominal pain was gradually relieved and subsided with the discontinuation of tacrolimus and corticosteroid administration.

Liver Transplantation for Hepatitis D Virus in the United States: A UNOS Study on Outcomes in the MELD Era.

Without available curative therapies for delta hepatitis (hepatitis delta virus [HDV]), hepatic decompensation and hepatocellular carcinoma (HCC) among HDV patients often necessitates liver transplantation (LT). The objective of this study was to evaluate outcomes of LT among hepatitis B virus (HBV)/HDV patients in the United States. We performed the first US-based retrospective study of patients who underwent LT for HDV compared with HBV (monoinfection) in the years 2002-2019. We evaluated posttransplant survival and predictors of survival. We identified a total of 152 HBV/HDV and 5435 HBV patients who underwent LT. HDV patients were younger at transplant (52 versus 55, P < 0.001), less commonly Asian (16% versus 36%, P < 0.001), more likely to be HCV Ab positive (42% versus 28%, P < 0.001), and less likely to be listed for LT with HCC (38% versus 51%, P = 0.001), more likely to have ascites (73% versus 64%, P = 0.019), had worse coagulopathy (mean INR 2.0 versus 1.82, P = 0.04), and were more likely to receive a HCV-positive donor organ (7% versus 3%, P = 0.001). Post-LT overall survival and graft survival were similar between HDV and HBV patients, including among patients with HCC. Older age, HCV coinfection, HCC, and higher model for end-stage liver disease at transplant were associated with higher posttransplant mortality. HDV patients were sicker and more likely to be listed for LT for decompensated disease compared with HBV patients. Post-LT survival was similar between HDV and HBV patients, in contrast to prior international studies that suggested worse post-LT survival in HBV patients due to higher rates of HBV reactivation.

Effect of Hepatitis C Viremia on Posttransplant Diabetes Mellitus in Liver Transplant Recipients.

Posttransplant diabetes mellitus (PTDM) can increase morbidity and mortality in liver transplant recipients. Although hepatitis C seropositivity is a known risk factor for PTDM, the impact of viremia versus no viremia at time of transplant is unknown. This program evaluation sought to compare PTDM in hepatitis C seropositive patients with and without viremia at the time of liver transplant. This single-center retrospective review included adult hepatitis C seropositive liver transplant recipients transplanted between January 1, 2010 to September 5, 2017 without pretransplant diabetes. Primary outcome was PTDM within 1 year. Secondary outcomes included evaluating 1-year posttransplant death-censored graft loss, mortality, and metabolic outcomes. Fifty-seven liver transplant recipients with hepatitis C were included, of which 53% (n = 30) were viremic at transplant. Baseline characteristics were similar between groups. Significantly more patients with pretransplant viremia developed PTDM by 1-year posttransplant compared to the patients without viremia (43% vs 11%, P = 0.01). There were no differences between groups outside of more patients with viremia requiring antihypertensives by 1-year posttransplant compared to patients without viremia (57% vs 22%, P = 0.01). Liver transplant patients with hepatitis C viremia at transplant were more likely to develop PTDM at 1 year compared to those without pretransplant viremia. This is an added consideration when deciding the timing of direct-acting antiviral (DAA) utilization in the context of liver transplant for hepatitis C seropositive patients.

Outcomes in Hepatitis C Positive Liver Transplantation: Timing of Direct-Acting Antiviral Treatment and Impact on Graft Fibrosis

Liver transplantation for hepatitis C virus (HCV)-related disease has the lowest five-year graft survival among all liver transplant recipients. Graft failure due to accelerated fibrosis from unrestrained HCV replication is common. Optimal timing of HCV treatment with direct-acting antiviral agents remains unknown. We compared HCV liver transplant recipients successfully treated for HCV before transplant to those treated within 1 year of transplant to determine if graft fibrosis, measured by Fib-4 scores, differs with timing of treatment. Fib-4 scores less than or equal to 1.45 defined minimal fibrosis and greater than 1.45 defined greater than minimal fibrosis. We identified 117 liver transplant recipients: 52 treated before transplantation and 65 treated within 1 year of transplantation. Overall, 34% of recipients had minimal fibrosis, and the likelihood of having minimal fibrosis following treatment and liver transplantation did not differ by timing of treatment. The odds ratio of having greater than minimal fibrosis was 0.65 (95% CI 0.30, 1.42) among those treated within 1 year after transplantation compared to those treated before transplantation (p-value 0.28). Importantly, nearly 2/3 of these patients had evidence of fibrosis progression one year after sustained virologic response, supporting recommendations for early antiviral-based treatment to prevent accumulation of HCV-related disease.

Long-term Outcomes of Preventing HBV Recurrence after Liver Transplantation for Hepatitis B Associated Liver Disease with Nucleotide and HBIG

Long-term Outcomes of Preventing HBV Recurrence after Liver Transplantation for Hepatitis B Associated Liver Disease with Nucleotide and HBIG

S3511 Management of Complications After Liver Transplantation for Hepatitis C Negative Patients Receiving Hepatitis C Positive Organs

INTRODUCTION: More than 16,000 patients are awaiting a liver transplant with less than 6,700 successful liver transplants in the U.S. that occur each year. Using a hepatitis C virus (HCV) positive donor liver for transplantation increases the donor pool. When HCV negative patients receive an HCV positive liver, they are at risk of acquiring HCV infection. We report two cases of patients who were HCV negative and received HCV positive donor liver subsequently acquiring HCV infection and developing associated complications. CASE DESCRIPTION/METHODS: The first patient is a 71 year old male with a history of non-alcoholic steatohepatitis (NASH) cirrhosis, hepatocellular carcinoma, and hepatic encephalopathy. He developed HCV infection status-post orthotopic liver transplantation from HCV donor. Imaging before transplant and explant pathology showed hepatocellular carcinoma. He was found to have HCV genotype 2B infection 2 weeks post-transplant as part of protocol testing. He was treated with sofosbuvir/velpatasvir for 12 weeks and achieved sustained viral response (SVR). Imaging at 5 months post-op revealed 2 hypovascular masses diagnosed as epstein barr virus associated B-cell post-transplant lymphoproliferative disorder (PTLD). Treatment was initiated with rituximab and his hospital course was complicated by bacteremia and atrial fibrillation. The second patient is a 52 year old male with NASH cirrhosis status-post orthotopic HCV positive liver transplant. His post-transplant course was complicated by elevated liver enzymes and renal insufficiency. He was found to have HCV genotype 1a, 3 months after transplant, and was treated with sofosbuvir/velpatasvir for 12 weeks with achieving SVR. Liver tests subsequently returned to normal with treatment. DISCUSSION: Although using HCV positive donor liver increases the donor pool it is associated with increased risk of HCV transmission to the recipient. These recipients need to be closely monitored so they could be treated in a timely manner to prevent any associated complications.Figure 1.: CT scan showing two hypovascular hepatic masses in the right and left lobes, measuring up to 3 cm.

Artificial liver treatment improves survival in patients with hepatitis B virus-related acute-on-chronic liver failure: A case-control matched analysis.

The artificial liver support system (ALSS) is recognized as a bridge to liver transplantation in hepatitisB virus-related acute-on-chronic liver failure (HBV-ACLF) patients. However, patient survival remains unknown. We aim to assess the effects of ALSS on survival in HBV-ACLF patients. The clinical data of HBV-ACLF patients receiving standard medical treatment (SMT) plus ALSS (ALSS group, n = 507) or only SMT (SMT group, n = 417) were collected for survival assessment. The main end-points were cumulative survival rates at days21, 28, and 90. Four different rigorous analyses were carried out to reduce bias and confounding. In the entire cohort, the cumulative survival rates at days21, 28, and 90 were significantly higher in patients who underwent ALSS treatment (73.3% vs. 59.6%, 69.2% vs. 56.6%, 56.5% vs. 49.1%, respectively, P < 0.01) than in those who underwent SMT only. In the 276-pair case-control matched cohort, a significantly higher survival rate was also observed in the ALSS group than in the SMT group on days21, 28, and 90 (72.5% vs. 60.3%, 68.3% vs. 57.4%, 55.9% vs. 48.5%, respectively, P < 0.05), especially in patients with ACLF-1 and -2. By a multivariable-adjusted analysis, ALSS treatment was associated with a significantly lower risk of mortality, especially for ACLF-2 at days21, 28, and 90. These findings were also confirmed through propensity score matching and inverse probability treatment weighting analysis. ALSS treatment can improve short-term survival and is associated with a significantly lower risk of short-term mortality in patients with HBV-ACLF, especially ACLF-2.

Liver transplantation for hepatitis C patients in the era of direct-acting antiviral treatment: A retrospective cohort study

Direct-acting antivirals (DAA's) have revolutionized hepatitis-C virus (HCV) treatment, however controversy remains regarding timing of treatment in relation to liver-transplant (LT). Single-center retrospective study assessing outcomes of listed HCV positive patients in the DAA-era (2014-2017). Patients treated with DAA's before LT (DAA pre-LT) were compared to those who were not treated before LT (No DAA pre-LT) RESULTS: 156 HCV positive patients were listed during study-period; 104 (67%) underwent LT while 52 (33%) were de-listed. Of transplanted patients, 48 (46%) received DAA pre-LT while 56 (54%) were treated post-LT. Both groups were comparable in age, gender, MELD, patient and graft survival and cure-rates (98% in DAA pre-LTvs.95% in No DAA pre-LT; p>0.05). DAA pre-LT group required higher number of treatments-per-patient to clear virus (1.46vs.1.06; p=0.0006), spent more time on waitlist (331d.vs150d; p=0.0040) and were less likely to receive livers from HCV positive donors (6%vs.25%; p=0.0148). Twenty-nine (56%) of the 52 delisted received DAA. They had lower listing-MELD (12vs.18; p=0.0033), and were more likely to be delisted for "condition improved" (34%vs.4%; p=0.0143) compared to the 23 (44%) delisted patients who did not receive DAA's. DAA's were equally effective in clearing HCV in listed patients irrespective of timing. DAA pre-LT can disadvantage some patients through increase number of treatments needed and longer waitlist times, but treatment in some listed patients with low-MELD can improve condition and alleviate need for LT.

Expanding the donor pool: Hepatitis C, hepatitis B and human immunodeficiency virus-positive donors in liver transplantation.

Liver transplantation (LT) remains the best option for patients with end-stage liver disease but the demand for organs from deceased donors continues to outweigh the available supply. The advent of highly effective anti-viral treatments has reduced the number of patients undergoing LT for hepatitis C (HCV) and hepatitis B (HBV) related liver disease and yet the number of patients waiting for LT continues to increase, driven by an increase in the patients listed with a diagnosis of cirrhosis due to non-alcoholic steatohepatitis and alcohol-related liver disease. In addition, human immunodeficiency virus (HIV) infection, which was previously a contra-indication for LT, is no longer a fatal disease due to the effectiveness of HIV therapy and patients with HIV and liver disease are now developing indications for LT. The rising demand for LT is projected to increase further in the future, thus driving the need to investigate potential means of expanding the pool of potential donors. One mechanism for doing so is utilizing organs from donors that previously would have been discarded or used only in exceptional circumstances such as HCV-positive, HBV-positive, and HIV-positive donors. The advent of highly effective anti-viral therapy has meant that these organs can now be used with excellent outcomes in HCV, HBV or HIV infected recipients and in some cases uninfected recipients.

Improved Graft Survival After Liver Transplantation for Recipients With Hepatitis C Virus in the Direct‐Acting Antiviral Era

Highly effective direct-acting antiviral (DAA) therapy has transformed outcomes of liver transplantation in hepatitis C virus (HCV) patients. We examined longer-term outcomes in HCV-positive recipients in the DAA era and analyzed the Scientific Registry of Transplant Recipients for primary adult, single-organ, nonfulminant liver transplant recipients in the United States from January 1, 2008 to June 30, 2018. Graft loss was compared among HCV-positive liver transplant recipients who received either an HCV-negative or HCV-positive donor (donor [D]-/recipient [R]+; D+/R+) and HCV-negative liver transplant recipients who received a HCV-negative donor (D-/R-). The groups were further divided between the pre-DAA and DAA eras. There were 52,526 patients included: 31,193 were D-/R- patients; 18,746 were D-/R+ patients; and 2587 were D+/R+ patients. The number of D-/R+ transplants decreased from 2010 in 2008 to 1334 in 2017, with this decline particularly noticeable since 2015. D-/R+ patients in the DAA era (n=7107) were older, had higher rates of hepatocellular carcinoma, and lower Model for End-Stage Liver Disease scores than those in the pre-DAA era. Graft survival improved for all recipients in the DAA era but improved most dramatically in HCV-positive recipients: D-/R+ 1-year survival was 92.4% versus 88.7% and 3-year survival was 83.7% versus 77.7% (DAA versus pre-DAA era, respectively) compared with D-/R- 1-year survival of 92.7% versus 91.0% and 3-year survival of 85.7% versus 84.0% (DAA versus pre-DAA era, respectively). The magnitude of improvement in 3-year graft survival was almost 4-fold greater for D-/R+ patients. The 3-year survival for D+/R+ patients was similar to HCV-negative patients. In conclusion, the number of liver transplants for HCV has decreased by more than one-third over the past decade. Graft survival among HCV-positive recipients has increased disproportionately in the DAA era with HCV-positive recipients now achieving similar outcomes to non-HCV recipients.

De Novo Hepatitis B Virus Infection After Liver Transplantation in Hepatitis B Core-positive Recipients Using Hepatitis B Core-negative Grafts

BackgroundHepatitis B core antibody-positive (HBcAb+) graft is known as a risk for de novo hepatitis B virus (HBV) infection in recipients after liver transplantation (LT). However, little is known about the possibility or incidence of de novo HBV infections after LT in hepatitis B surface antigen-negative (HBsAg−)/HBcAb+ recipients using HBsAg−/HBcAb− grafts. The study aimed to evaluate the prevalence of de novo HBV infection in HBsAg−/HBcAb+ recipients using HBsAg−/HBcAb− grafts. A retrospective review was performed with the records of 1129 adult patients who underwent primary LT at a single institution in an HBV endemic area between January 2000 and December 2013. A total of 78 patients (6.9%) were reviewed for de novo HBV infection after LT. De novo HBV infection was developed in 1 patient (1.28%). The patient was a 65-year-old woman who underwent LT due to alcoholic liver cirrhosis. De novo HBV was not related to graft loss or death and well treated with tenofovir. In conclusion, de novo HBV infections may occur in HBsAg-/HBcAb+ recipients using HBsAg−/HBcAb− grafts, and caution is needed in these patients.

Liver transplantation for hepatitis C virus (HCV) non-viremic recipients with HCV viremic donors.

In the context of organ shortage, the opioid epidemic, and effective direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV), more HCV-infected donor organs may be used for liver transplantation. Current data regarding outcomes after donor-derived HCV in previously non-viremic liver transplant recipients are limited. Clinical data for adult liver transplant recipients with donor-derived HCV infection from March 2017 to January 2018 at our institution were extracted from the medical record. Ten patients received livers from donors known to be infected with HCV based on positive nucleic acid testing. Seven had a prior diagnosis of HCV and were treated before liver transplantation. All recipients were non-viremic at the time of transplantation. All 10 recipients derived hepatitis C infection from their donor and achieved sustained virologic response at 12weeks posttreatment with DAA-based regimens, with a median time from transplant to treatment initiation of 43days (IQR 20-59). There have been no instances of graft loss or death, with median follow-up of 380days (IQR 263-434) posttransplant. Transplantation of HCV-viremic livers into non-viremic recipients results in acceptable short-term outcomes. Such strategies may be used to expand the donor pool and increase access to liver transplantation.

Long-term safety and efficacy of tenofovir disoproxil fumarate substitution for hepatitis B immunoglobulin following liver transplantation.

Background and AimsLimitations to the use of long‐term Hepatitis B Immunoglobulin (HBIg) following liver transplantation for hepatitis B (HBV) have led to the substitution of HBIg with oral nucleo(s)tide analogue prophylaxis. We prospectively assessed the long‐term safety and efficacy of switching to tenofovir disoproxil fumarate (TDF) from HBIg.MethodsAn open‐label, multicenter switch study was conducted to evaluate the substitution of TDF for HBIg whilst continuing lamivudine (LAM) therapy in preventing the recurrence of HBV in patients who had been maintained as hepatitis B surface antigen (HBsAg)‐negative posttransplantation for at least 12 months.ResultsEighteen patients were enrolled (median age 66 years, range 42–78 years); 84% were male, and 78% on calcineurin inhibitors. Median time after transplantation was 14 years (range 5–19), and median duration of HBIg/LAM prior to the switch was 10 years (range 1–14). Median follow‐up was 5 years (range 5–8). Of 18 patients, 16 (89%) remained HBsAg and HBV DNA negative at the end of follow‐up. Two patients had re‐emergence of HBsAg without a detectable HBV DNA and no clinical sequelae. Creatinine clearance significantly reduced (median 59 mL/min to 51 mL/min, P = 0.03), necessitating dose reduction of TDF in six (33%) participants, with two eventually ceasing TDF. One patient switched back to HBIg by choice. All patients who changed therapy maintained an undetectable HBsAg.ConclusionSubstitution of HBIg with TDF in patients on LAM is well tolerated and effective for the long‐term prevention of HBV recurrence posttransplantation. Renal dysfunction occurs frequently in the posttransplant setting and can require dose adjustment of TDF or change of therapy.

Trends in liver transplantation for hepatitis C in a country with reduced access to direct-acting antiviral agents.

Hepatitis C virus (HCV)-related cirrhosis is a leading indication for liver transplantation (LT) worldwide. Access to effective HCV treatment is inequitable globally. We aimed to analyze whether the introduction of effective HCV treatment caused an impact in LT trends in a middle-income country. Cross-sectional analysis of all adult patients who were listed/received a LT in Argentina for HCV, alcohol-related liver disease (ALD), or autoimmune hepatitis/primary biliary cirrhosis (AIH/PBC) from 2007 to 2017. Joinpoint regression analysis was used to identify changes in the cumulative incidence rates in waiting list (WL) registration, WL mortality, and LT. Liver transplantation WL for HCV increased significantly between 2007 and 2014, with an annual percentage change (APC) +7.8%, P=.01, followed by a downward slope from 2014 to 2017 with an APC -9.8%, P=.1. There were no significant changes in WL mortality. LT trends remained stable. LT for HCV without MELD exception points for HCC decreased (APC -6.6%, P=.01), whereas LT for HCV with HCC exception points increased (APC +11.1, P=.01) during the study period. Waiting list and LT for HCV without HCC decreased, whereas LT for HCV and HCC increased; this may be related to selective antiviral treatment access for patients with advanced fibrosis.

Liver Transplantation in Hepatitis C–Infected Patients: Experience From a South American Transplant Center

BackgroundAround 2.4% of the world's population is infected with hepatitis C virus (HCV), and it is the most common cause of liver transplantation (LT) in the world. Latin America (LA), with nearly 9% of the world population, has had a continuous increase in the number of LTs per year. Yet, due to the lack of mandatory data collection and a well-developed health-care system, access to transplantation is limited in most LA countries. We report the first LA experience of HCV-infected LT patients. MethodsWe performed a retrospective cohort study by reviewing the medical histories of all HCV-infected LT patients between 1996 and 2016 who acquired HCV before their LT, at the Fundación Valle del Lilí, Cali, Colombia. ResultsBetween January 1996 and December 2015, a total of 770 LTs were performed, of which 75 had a cirrhotic liver due to HCV infection. With a median follow-up time of 24.4 months (interquartile range [IQR] 4.7–61.2 months), patient survival was 44.9% and 66.9% for the time periods 1996–2006 and 2007–2015, respectively. Hepatocellular carcinoma (HCC) was present in 30.6% of the patients, and overall postoperative complications had an incidence of 80%. ConclusionsThis is the first report of LT in HCV-infected patients in Colombia and in LA. Our results are comparable to those of other transplant centers worldwide with regard to postoperative complications and patient survival. Patients with LT in the 1996–2006 time frame had higher morbidity and mortality. Studies including larger numbers of patients are needed to determine the reason for this finding.

Bile leak from the gallbladder fossa after liver transplantation

Bile leaks are common complications following liver transplantation (LT). The majority of leaks involve the anastomosis but other sites should be considered. Bile leaks are associated with biliary peritonitis and intra-abdominal abscess formation. Subvesical bile ducts formerly called ducts of Luschka are aberrant bile ducts in the gallbladder fossa. Leaks from this structure have been reported following laparoscopic cholecystectomy. Only three cases of leaks from this duct after LT have been thus far reported. A 43-year-old man with a MELD (model for end stage liver disease) score of 29 underwent an uncomplicated LT for hepatitis C–cirrhosis and reformed alcohol abuse. Four days after discharge he developed significant abdominal pain and leukocytosis of 16,000/ml; AST was 23 IU/l and total bilirubin 2.0 mg/dl. A computed tomography scan showed massive ascites and a perihepatic hematoma. Paracentesis (5 l) revealed 10,000 nucleated cells, 98% neutrophils, and a bilirubin level of 3.4 mg/dl. Antibiotics were started; endoscopic retrograde cholangiopancreatography showed a patent anastomosis but a small leak from a side branch of the right hepatic duct. A transampullary common bile duct stent was placed. The patient developed increasing abdominal pain, ileus, and underwent laparotomy during which the perihepatic hematoma was evacuated and a bile leak from a subvesical bile duct was identified and oversewn. Cultures grew Escherichia coli and antibiotics were continued. The patient recovered from the complication and the biliary stent was removed after the leak had completely sealed. The patient is alive with a well-functioning graft 4 years after the procedure. Leaks from subvesical bile ducts are rare complications in LT recipients, but should be recognized as a source of intra-abdominal infection.

Active immunization in patients transplanted for hepatitis B virus related liver diseases: A prospective study.

IntroductionProphylactic administration of hepatitis B immunoglobulin (HBIG) and nucleos(t)ide analogues (NAs) is the standard treatment for controlling hepatitis B virus (HBV) recurrence after liver transplantation (LT). Since lifelong use of HBIG is expensive and inconvenient and the antibodies level in anti-hepatitis B surface (HBs) is not sustainable and stable, an alternative strategy is to produce anti-HBs antibodies by active immunization. Our present study aimed to prospectively investigate the efficacy and safety of procedural HBV vaccination in transplanted patients.MethodsRecipients who had undergone LT for hepatitis B related liver diseases more than one year before, with no evidence of HBV recurrence or rejection and normal liver function were enrolled. All subjects received the hepatitis B vaccine (40 μg) by intramuscular injection at months 0, 1, 2, 6 and 12 after enrollment with continuous administration of NAs. The liver function and anti-HBs titers were measured before each vaccination and HBIG (400U) was administrated intramuscularly when anti-HBs titer was lower than 30 IU/L during the course. The results of routine blood tests, liver function, concentration of immunosuppressant, and HBV-DNA copies were monitored during the research. After completion of the vaccination procedure, recipients were regarded as responders if their anti-HBs greater than 30 IU/L were maintained for up to six months without using HBIG and vaccine.ResultsTwenty-seven patients were enrolled in this study and the average anti-HBs titer before vaccination was 19.86±14.80 IU/L. The average anti-HBs titer of the nine responders at the end of the follow-up was 57.14±22.75 IU/L, giving an overall response rate of 33.3% (9/27). There were no reports of reactivation of HBV, rejection, severe anaphylaxis or other adverse events. Responders and non-responders showed their significant difference in anti-HBs titers after the fourth vaccination (P<0.01). Moreover, the majority of non-responders (11/18, 63.64%) had high LY/EO rates (lymphocyte number/eosinophil number>15) while most responders (8/9, 88.89%) had low LY/EO rates at the beginning of vaccination (P = 0.019).ConclusionsActive immunization is an effective, cost-saving, and safe method for the prevention of HBV reactivation in patients transplanted for hepatitis B virus related liver diseases. The LY/EO rate may be a valuable indicator in selecting potential recipients for vaccination.