Post-liver Transplant Patient Research Articles

Performance of risk prediction models for post-liver transplant patient and graft survival over time.

Given liver transplantation organ scarcity, selection of recipients and donors to maximize post-transplant benefit is paramount. Several scores predict post-transplant outcomes by isolating elements of donor and recipient risk, including the donor risk index, Balance of Risk, pre-allocation score to predict survival outcomes following liver transplantation/survival outcomes following liver transplantation (SOFT), improved donor-to-recipient allocation score for deceased donors only/improved donor-to-recipient allocation score for both deceased and living donors (ID2EAL-D/-DR), and survival benefit (SB) models. No studies have examined the performance of these models over time, which is critical in an ever-evolving transplant landscape. This was a retrospective cohort study of liver transplantation events in the UNOS database from 2002 to 2021. We used Cox regression to evaluate model discrimination (Harrell's C) and calibration (testing of calibration curves) for post-transplant patient and graft survival at specified post-transplant timepoints. Sub-analyses were performed in the modern transplant era (post-2014) and for key donor-recipient characteristics. A total of 112,357 transplants were included. The SB and SOFT scores had the highest discrimination for short-term patient and graft survival, including in the modern transplant era, where only the SB model had good discrimination (C ≥ 0.60) for all patient and graft outcome timepoints. However, these models had evidence of poor calibration at 3- and 5-year patient survival timepoints. The ID2EAL-DR score had lower discrimination but adequate calibration at all patient survival timepoints. In stratified analyses, SB and SOFT scores performed better in younger (< 40 y) and higher Model for End-Stage Liver Disease (≥ 25) patients. All prediction scores had declining discrimination over time, and scores relying on donor factors alone had poor performance. Although the SB and SOFT scores had the best overall performance, all models demonstrated declining performance over time. This underscores the importance of periodically updating and/or developing new prediction models to reflect the evolving transplant field. Scores relying on donor factors alone do not meaningfully inform post-transplant risk.

Implementing an early oral feeding protocol in the post liver transplant patient cohort

Implementing an early oral feeding protocol in the post liver transplant patient cohort

2725. Bacterial blood stream infections in Pediatric Liver Transplant Patients: Prevalence, Organisms and Risk factors. A Systematic review

Abstract Background Bacterial blood stream infection (BSI) is a leading cause for mortality and morbidity in the pediatric solid organ transplant recipient population. This systematic review aims at pooling global data from the leading transplant institutions to identify the overall prevalence and risk factors associated with bacterial BSI and the most common causative organisms. Methods A systematic review of PubMed and OVID databases was conducted for the past 20 years. Initial search from both databases had a yield of 252 unique articles which were reviewed independently by two authors. Data related to demographics, prevalence, organisms and risk factors were extracted from the articles and subsequently analysed. The systematic review was registered on PROSPERO (ID: CRD42023403206). The PRISMA flow diagram visually summarises the screening process Results A total of 14 articles were included from the United States of America, France, Italy, Thailand, Japan, Spain and Korea. A total of 4215 liver transplants were included in the final analysis. The overall prevalence of BSI in pediatric liver transplant patients was 23.5% with the highest prevalence reported in Japan (39.5%) and lowest in the USA (18.7%). Mean age of the patients was 25 months and 54% were females. The most common organisms reported were Staphylococcus epidermidis at 22.8% followed by Enterococcus species (16.6%), Klebsiella species (11.9%) and Escherichia coli (11.4%). Among the risk factors studied, postoperative biliary complications, past medical history of biliary atresia and younger age were the risk factors most associated with BSI. Prevalence of bloodstream infections (BSI) post pediatric liver transplant in included countries. Bacterial organisms isolated in blood cultures in pediatric post liver transplant patient with a bloodstream infection. Conclusion Bacterial BSI post pediatric liver transplantation occurs with high prevalence. Further studies need to be conducted to better define risk factors for BSI and determine the best empirical antibiotic management for BSI in this population as the distribution of organisms varies greatly from otherwise healthy pediatric patients. Disclosures All Authors: No reported disclosures

Vibrio cholerae Bacteraemia: Report of Two Cases

Aims: Case reports on Vibrio cholerae bacteraemia are extremely rare and thus such cases should be presented for a proper understanding of the mechanism of these rare conditions.&#x0D; Presentation of Cases: One male patient aged 67 years was suffering from vomiting, hiccups, fever with chills and weakness. The post-liver transplant patient was also suffering from diabetes, hypertension, and chronic kidney disease. There was evidence of acute phase inflammatory reactions. Blood culture revealed polymyxin B sensitive Vibrio cholerae. After treatment, patient became normal and was discharged. Another male patient aged 68 years was suffering from jaundice, vomiting, abdominal pain and fever. The post-cholecystectomy patient was also suffering from COPD. LFT and P-time were grossly abnormal with 1.94x105/ml HBV DNA. CT scan of the lungs showed bronchiectasis, fibrosis and emphysema. Blood culture revealed polymyxin B-resistant Vibrio cholerae. Gradually severe metabolic acidosis and congestive cardiac failure developed and the patient expired.&#x0D; Discussion: Male dominance of Vibrio cholerae bacteraemia as observed also by others was probably due to protection in females by oestrogen; polymyxin B sensitivity, invasion of tissue from colonization and comorbidity conditions may be important factors for treatment outcome.&#x0D; Conclusion: Vibrio cholerae bacteraemia, although rare, may be present in difficult-to-treat cases.

Obesity management for the pre–liver transplant and post–liver transplant patient

Obesity management for the pre–liver transplant and post–liver transplant patient

Pregnancy and contraception in the post-liver transplant patient

Pregnancy and contraception in the post-liver transplant patient

S1697 Biliary Schwannoma in a Post-Liver Transplant Patient Presenting as Biliary Obstruction

Introduction: Schwannomas are benign, mesenchymal-derived neoplasms which present as solid, slow growing tumors. They can rarely be observed in the gastrointestinal (GI) tract, with very limited reports of them occurring in the biliary system. In this case, we describe a bile duct schwannoma in a post-liver transplant patient. Case Description/Methods: A 77-year-old man with a history of alcohol-related cirrhosis with hepatocellular carcinoma treated with orthotopic liver transplantation 16 years prior, and end stage renal disease on hemodialysis presented with jaundice. Labs demonstrated new elevations in his liver enzymes: AST 181 U/L, ALT 189 U/L, alkaline phosphatase 625 U/L, total bilirubin (TB) 7.9 mg/dL, and direct bilirubin 5.0 mg/dL. A magnetic resonance cholangiopancreatography was performed and demonstrated a 16 x 15 x 11 mm enhancing mass causing abrupt narrowing of the mid common bile duct (CBD) with upstream duct dilation to 10 mm ( Figure A) without other discrete mass identified. A follow-up endoscopic ultrasound confirmed a hypoechoic mass in the mid CBD and fine needle biopsy was obtained. An endoscopic retrograde cholangiopancreatography was subsequently performed, which demonstrated a severe biliary stricture at the level of the prior biliary anastomosis which was treated with balloon dilation and placement of a covered metal stent. The procedure was complicated by post-sphincterotomy bleed and mild post-ERCP pancreatitis. His liver enzymes failed to improve, and his TB progressively worsened to 23.3 mg/dL. Pathology returned showing a low-grade spindle cell tumor (Figure B), with staining positive for S100 (Figure C) and negative for CD117 and desmin, consistent with a diagnosis of schwannoma. Surgical intervention was not pursued, in line with his goals of care, and he was ultimately transitioned to comfort-oriented care and passed 5 days after admission. Discussion: Schwannomas are rare neoplasms which can arise from the nonepithelial wall of the GI tract containing nerve fibers. They are composed of highly cellular spindle cells which stain positive for vimentin (marker of mesenchymal origin) and S100 protein (marker of nerve sheath origin), and negative for CD117 (marker of GI stromal tumors) and desmin (muscle cell marker). Neoplasms can often be suspected in late presentations of post-transplant biliary obstruction. To our knowledge, this is the first case report of a biliary schwannoma occurring at the site of a biliary anastomosis in a liver transplant patient.Figure 1.: A) MRCP T1-weighted coronal image demonstrating a 16 x 15 x 11 mm enhancing mass with diffusion restriction (yellow arrow) at the mid common bile duct causing an abrupt biliary stricture with upstream dilation, B) 10x magnification H&E showing spindled, wavy nuclei in a fibroblastic stroma consistent with a spindle cell neoplasm in a background of unremarkable columnar biliary epithelium, C) 10x magnification S100 immunohistochemical stain showing diffuse nuclear and granular cytoplasmic positivity consistent with nerve sheath origin.

Septic Thrombophlebitis of the Internal Jugular Vein in an Immunocompromised Patient with Lemierre Syndrome: A Case Report

Lemierre syndrome is a rare complication of oropharyngeal infection, especially acute pharyngotonsillitis, associated with septicemia and thrombophlebitis of the internal jugular vein (IJV). We present the case of a 52-year-old patient who underwent liver transplantation and returned with symptoms of pain, redness and left cervical bulging 1 month after surgery. After investigation, the diagnosis of septic thrombophlebitis of the IJV was made. The patient responded well to treatment with antibiotic therapy and full anticoagulation. To the best of our knowledge, the present report is the first report of Lemierre syndrome in a post-liver transplant patient.

A bile duct stent broken during repeat pregnancy in a post-liver transplant patient

A young female patient who developed anastomotic biliary stricture following an orthotopic liver transplantation was observed. A self-expandable metallic stent was placed to correct the stricture. At the 8th month of her repeat pregnancy, the stent broke asymptomatically into half. Fortunately, the second childbirth, like the first one, had no complications. Eighteen months later, due to obstruction of fragments by sludge and gallstones, re-stenting was performed with a coated biliary stent. Four years and five months later, recurrent jaundice occurred due to occlusion of the second stent. This was addressed by surgical removal of both stents. Two years after surgery, the bile ducts remain completely patent. We found only two cases in literature on a similar extremely rare biliary stenting complication. It has been suggested that stent deformation may be related to pregnancy. The feasibility of using stenting in benign biliary strictures in some clinical situations is discussed.

A220 AN UNEXPECTED CAUSE OF ACUTE JAUNDICE IN A POST-TRANSPLANT PATIENT

Abstract Background Complications post liver transplantation are common. These may include thromboses, primary graft nonfunction, biliary complications, chylothorax, infection, and rejection. Hepaticojejunostomy with Roux-en-Y limb is a common technique for pediatric liver transplantation. Complications of hepaticojejunostomy include small bowel obstruction due to incarceration of the Roux-en-Y limb within an internal hernia. Acquired diaphragmatic hernia has previously been reported in liver transplant patients. Here we present a unique case of acute biliary obstruction secondary to incarceration of a Roux limb within an acquired diaphragmatic hernia. Aims To describe a unique case of incarcerated Roux-en-Y limb in a diaphragmatic hernia leading to acute jaundice in a pediatric liver transplant patient. Methods Retrospective chart review and case review with the surgical and medical teams. Results A 14 month old girl with unresectable hepatoblastoma received a living donor, left lateral segment liver transplant using standard venous reconstruction, microvascular plastics arterial reconstruction, and the recipient common hepatic duct was anastomosed to the donor left hepatic duct. Serial ultrasounds showed persistent intrahepatic duct dilatation with cholestasis. Given the concern of biliary obstruction, 10 days post-transplant, she underwent repeat laparotomy and was found to have a dilated common bile duct with a proximal obstruction. A Roux-en-Y hepaticojejunostomy was performed to establish adequate biliary drainage. Three months post-transplant she developed lung metastases that required wedge resection and chemotherapy. 7 months post-transplant, while admitted for routine chemotherapy she acutely developed jaundice, pruritus, and transaminitis. Liver ultrasound showed an apparent fluid collection at the cut surface of the liver and biliary dilatation. Extrinsic compression of the biliary tree was suspected, and so a percutaneous biliary drain was placed to drain the collection and decompress the biliary system. Despite improvement in the transaminitis and cholestasis, several days later, she developed severe abdominal pain and associated grunting respirations. An MRI with MRCP to reassess the previous findings and rule out a new intraabdominal cause for her symptoms was completed and unexpectedly showed herniation of her Roux-en-Y limb into a diaphragmatic hernia. She had urgent diaphragmatic hernia repair with reduction of the incarcerated bowel loop, with resolution of her pain and jaundice. Conclusions Post liver transplant Roux-en-Y herniation is uncommon, but can occur with internal hernias and in diaphragmatic hernias. This uncommon complication should be considered for the post liver transplant patient with hepaticojejunostomy in the setting of acute jaundice, particularly if accompanied by acute onset abdominal pain and/or increased work of breathing. Funding Agencies None

THE TALE OF A HALO SIGN

SESSION TITLE: Fellows Imaging Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Halo sign on chest imaging is characterized by a circular area of ground-glass attenuation around a central pulmonary nodule or mass. It is most commonly associated with invasive fungal infections; however, can also be seen in a wide range of neoplastic and inflammatory conditions. Here we present a case of angio-invasive neoplasm presenting with characteristic halo sign in an immunocompromised patient. CASE PRESENTATION: A 62-year-old male with alcoholic cirrhosis post orthotopic liver transplant on chronic immunosuppression with recurrent cirrhosis of his graft liver was initially admitted for management of acute hepatic encephalopathy. A CT scan of his chest showed numerous part solid centrilobular nodules bilaterally with central solid component and surrounding ground glass halo. Invasive fungal infection was suspected, and micafungin was initiated. Serum aspergillus antigen and beta D-glucan were negative. He underwent bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB). BAL was negative for bacterial, fungal and acid-fast bacilli cultures. Pathology from the TBB showed atypical epithelioid cells that could be reactive or due to a metastatic disease. A repeat CT scan performed after 10 days of antifungal therapy showed a significant increase in size of the previously noted centrilobular nodules with surrounding ground glass halo. Surgical open lung biopsy was considered but he was deemed to be a poor surgical candidate due to his frailty and comorbidities. Transbronchial cryobiopsy was then performed which showed poorly differentiated epithelioid neoplasm predominantly within the vascular spaces. Based on immunohistochemical staining positive for both cytokeratin and vascular markers, a differential diagnosis of epithelioid angiosarcoma vs. epithelioid sarcoma was made. After detailed discussion with him and his family in regards to his overall prognosis, he wished for no further testing or interventions and chose to go home with hospice. DISCUSSION: Halo sign indicates presence of hemorrhagic nodules. It was first described in immunocompromised patients with invasive pulmonary aspergillosis where the nodule itself is a focus of pulmonary infarction with surrounding alveolar hemorrhage. However, it has now been associated with a variety of pulmonary diseases including both infectious and non-infectious hemorrhagic nodules, tumor cell infiltration and few non-hemorrhagic etiologies. Metastatic lung disease from hyper vascular tumors such as angiosarcoma, chondrosarcoma and melanoma can form a halo of ground glass attenuation as a result of peritumoral hemorrhage or infiltration. Malignancy is a leading cause of death in post liver transplant patients and should always be considered in the evaluation of these patients. CONCLUSIONS: While evaluating halo sign a wide differential should be considered including malignancy in a post liver transplant patient. Reference #1: Georgiadou SP, Sipsas NV, Marom EM, Kontoyiannis DP. The diagnostic value of halo and reversed halo signs for invasive mold infections in compromised hosts. Clin Infect Dis. 2011;52(9):1144-1155. doi:10.1093/cid/cir122 Reference #2: Parrón M, Torres I, Pardo M, Morales C, Navarro M, Martínez-Schmizcraft M. Signo del halo en la tomografía computarizada de tórax: diagnóstico diferencial con correlación anatomopatológica [The halo sign in computed tomography images: differential diagnosis and correlation with pathology findings]. Arch Bronconeumol. 2008;44(7):386-392. DISCLOSURES: No relevant relationships by Sadia Benzaquen, source=Web Response No relevant relationships by Ena Gupta, source=Web Response No relevant relationships by ATUL MATTA, source=Web Response No relevant relationships by Corrado Minimo, source=Web Response No relevant relationships by Carlos Oberto, source=Web Response

Approach to prevention of non-alcoholic fatty liver disease after liver transplantation

Non-alcoholic fatty liver disease (NAFLD) is one of the most common causes of liver disease and non-alcoholic steatohepatitis (NASH) related cirrhosis is third common indication for liver transplantation (LT). Patients who have NASH related cirrhosis and are candidates for LT often have multiple comorbidities. These comorbidities need to be addressed before and after transplantation as it affects overall survival. Like hepatitis B, hepatitis C, primary biliary cirrhosis, autoimmune hepatitis which recurs after transplantation, NASH also recurs after transplant however the impact of the recurrence on allograft and patient outcomes is unclear. Limited data suggests that it does not affect graft and patient survival. De novo NAFLD which is defined as occurrence of fatty liver in a patient who did not have fatty liver prior to LT can also occur in the allograft of patients transplanted for non-NAFLD liver disease. Obesity, hyperlipidemia, diabetes as well as steroid dose and duration after LT are common predictors of recurrence of NAFLD after transplantation. Studies on prevention and treatment of NASH in post-transplant patients are lacking. Prevention of weight gain, regular exercises, weight reducing surgery, limited steroid use or steroid free regimen have been tried with varying success. Future studies for the prevention of NAFLD/NASH are required especially in post liver transplant patient.

S2441 Acute Liver Failure Due to Toxoplasmosis After Orthotopic Liver Transplantation

INTRODUCTION: Solid organ transplant recipients are at risk for a wide range of opportunistic infections, the most common being Cytomegalovirus (CMV). These infections may occur as re-activation of latent disease, donor-derived or de novo. Though less common, infection with Toxoplasma gondii may also present in patients following solid organ transplantation. We present a case of acute liver failure secondary to toxoplasmosis following orthotopic liver transplantation. CASE DESCRIPTION/METHODS: A 61-year-old female presented five weeks after orthotopic liver transplantation with altered mental status and fatigue. Her immunosuppression regimen included tacrolimus, mycophenolic acid, and prednisone. In addition, she was on prophylactic acyclovir for CMV. However, trimethoprim-sulfamethoxazole prophylaxis was held 4 weeks prior due to renal dysfunction. Upon presentation, laboratory data revealed acute kidney injury and elevated liver tests (total bilirubin 1.2 mg/dL, alanine aminotransferase 69 U/L, aspartate aminotransferase 101 U/L, alkaline phosphatase 286 U/L). She was found to have elevated CMV PCR in the blood (679,198 IU/mL) and cerebrospinal fluid (>2,000,000 IU/mL), as well as biopsy proven CMV hepatitis. CMV infection resolved with intravenous ganciclovir. However, she subsequently developed acute liver failure due to toxoplasmosis, which is hypothesized to be donor derived, and expired. Postmortem histological studies performed during the acute illness showed hepatic necrosis and intrahepatic protozoa, consistent with Toxoplasma bradyzoites. Immunohistochemical stain for Toxoplasma performed by the Centers for Disease Control and Prevention confirmed Toxoplasma infection. DISCUSSION: Infection with Toxoplasma may be asymptomatic in the immunocompetent host. However, in immunocompromised hosts, such as solid organ transplant recipients, this infection can be life threatening. Though prophylaxis with trimethoprim-sulfamethoxazole may prevent infection with Toxoplasma, it is often held for renal dysfunction, hyperkalemia, or other side effect, placing patients at risk. With 13 cases now reported, routine screening of donor and recipient for Toxoplasma exposure may be warranted. Although disseminated toxoplasmosis is rare in the post orthotopic liver transplant patient, 61% of reported cases have resulted in death of the patient.Figure 1.: CMV viral inclusion (Hematoxylin and Eosin stain at 600x original magnification).Figure 2.: Intrahepatic protozoa (∼1–2 um in diameter), consistent with Toxoplasma cyst with bradyzoites (Hematoxylin and Eosin stain at 600x original magnification).Figure 3.: Immunohistochemical stain for Toxoplasma gondii confirms the diagnosis. It shows multiple intrahepatocytic protozoa that are arranged individually, consistent with Toxoplasma tachyzoites infection. (IHC at 200X). Inset box at 630x original magnification).

Oesophageal Variceal-Pulmonary Venous Fistula A Rare Cause of a Right-to-Left Shunt.

Oesophageal varices are a dilated submucosal venous plexus in the lower third of the oesophagus which result from increased pressure in the portal venous system. The portal system is connected to the systemic circulation in specific locations referred to as sites of portosystemic anastomosis. An increase in portal venous pressure is therefore reflected at these anastomotic sites, causing manifestations such as oesophageal varices, rectal varices, caput medusae and splenorenal shunts. Varices do not cause symptoms until they leak or rupture and this is the main complication which requires prompt treatment. Here, we present a post-liver transplant patient with metastatic hepatocellular carcinoma who had oesophageal varices that fistularized with a left pulmonary vein, thus creating a right-to-left shunt. Right-to-left shunts are usually intracardiac or intrapulmonary in location. The complications of a right-to-left shunt include predominantly hypoxia, cyanosis and, sometimes, paradoxical emboli in the case of intracardiac shunts. This patient had a very uncommon cause of such a shunt caused by a direct fistulous connection.LEARNING POINTSRight-to-left shunts create a ventilation-perfusion mismatch.Recognizing situations where there is a connection between the systemic circulation and pulmonary circulation without intermediate oxygenation is important because of possible clinical implications such as hypoxia.

Medical Management after Liver Transplantation

AbstractMedical management of the liver transplant recipient requires consideration of the complex interactions between the transplanted liver, immunosuppression and all organ systems. An aging transplant population, improvement in long-term liver transplant outcomes, and the increase in nonalcoholic fatty liver disease as an indication for transplant have amplified the number of co-morbidities among post-transplant patients. In addition to balancing immunosuppression with infection risk, medical management of the transplanted patient includes monitoring for, and treating, recurrence of the primary liver disease, metabolic syndrome, cardiovascular disease, and post-transplant neurologic and renal dysfunction. Additionally, general healthcare maintenance such as management of osteoporosis, immunizations, and screening for malignancy are essential in this high-risk population. In this review, we summarize the evidence behind best practices for the current medical management of the post liver transplant patient.

2399 West Nile Encephalitis in a Post-Liver Transplant Patient

INTRODUCTION: West Nile Virus (WNV) is a neurotropic flavivirus that is transmitted from animals to humans by the bite of the Aedes, Anaphales, or Culex mosquito, with disease incidence peaking in the late summer and early fall. It is the leading cause of arboviral illness in the U.S. While many infected with WNV are asymptomatic, 25% of patients develop fever, and less than 1% of patients will develop neurologic symptoms. Age over 75-years old and immunosuppressed state are risk factors for developing neuroinvasive disease. CASE DESCRIPTION/METHODS: A 65-year old woman with a history of HCV cirrhosis complicated by HCC status post successful orthotopic liver transplantation (OLT) in 2016 compliant with tacrolimus and everolimus immunosuppression (ISP) presented with painless jaundice and acute transaminemia. Liver biopsy revealed severe acute cellular rejection (ACR), so steroids and thymoglobulin were started. Tacrolimus was increased and everolimus was changed to mycophenolate mofetil. Clinically, she appeared well and her LFTs responded to treatment. Suddenly, she developed fever to 103º associated with bilateral hand tremors. Infectious workup was obtained, and she was started on broad-spectrum antibiotics. Initially, symptoms were attributed to changes in ISP and treatment of ACR. However, she developed progressively worsening dyskinesia and encephalopathy eventually requiring intubation. Given initial negative infectious workup, lumbar puncture was obtained; see Table 1. HSV, VZV, and Lyme PCR as well as VDRL in the CSF were negative. Given clinical symptoms, positive WNV IgM in the CSF, and MRI Brain concerning for WNV neuroinvasive disease, patient was treated with IVIG for 5 days. WNV IgG became positive as well on repeat lumbar puncture 2 weeks later. Patient’s encephalopathy improved, and she was able to be extubated. DISCUSSION: There may be a delay in diagnosis and treatment of WNV encephalitis in post-liver transplant patients as neurologic symptoms may be attributed to ISP or as in this patient, to the treatment of acute cellular rejection. West Nile encephalitis must remain on the differential diagnosis when neurologic symptoms are present in a post-liver transplant patient, especially in endemic areas during the summer and fall months. A change in this patient’s ISP for the treatment of ACR may have caused the development of a more severe, neuroinvasive response to WNV infection and ISP management in such patients should be studied further.

2425 A Rare Case of Alloimmune Hepatitis Induced After Direct-Acting Antiviral Treatment in a Liver Transplant Patient

INTRODUCTION: Cases of autoimmune hepatitis induced after Direct-acting antiviral (DAA) in patients undergoing treatment for hepatitis C virus (HCV) infection have been reported in the literature. This is a case report of alloimmune hepatitis in a post-liver transplant patient shortly after starting DAA treatment for recurrent hepatitis C in the graft. CASE DESCRIPTION/METHODS: A 56-year-old Egyptian woman with history of liver cirrhosis secondary to chronic HCV, genotype 4, complicated by hepatocellular carcinoma underwent orthotopic liver transplant. Two months later, an increase of the aminotransferases and the HCV viral load of 734,703 IU/mL were noted. Liver biopsy was suggestive of recurrent HCV infection. Treatment was started with sofosbuvir, velpatasvir, and voxilaprevir. Repeat HCV viral load was 537 IU/mL 2 weeks after starting DAA. At this point she presented with jaundice, nausea, and vomiting. Vital signs were normal. Scleral icterus and moderate abdominal tenderness were noted. AST 1,395 U/L, ALT 1,359 U/L, ALP 601 U/L, total bilirubin 12.2 mg/dL, direct bilirubin 9.6 mg/dL, and INR 1.5 were noted. Liver biopsy showed hepatitis with abundant plasma cells and interface activity, compatible with an alloimmune process. The patient was started on IV methylprednisolone and N-acetyl cysteine. Her symptoms resolved and liver enzymes normalized on subsequent follow up. She achieved sustained viral response. DISCUSSION: Alloimmune hepatitis is a rare cause for graft dysfunction that can occur among patients who have undergone liver transplantation for other reason than autoimmune hepatitis. The exact pathogenesis is not fully understood but believed to share similar mechanisms with classical autoimmune hepatitis. Calcineurin inhibitors may cause impairment of the regulatory T-cells function by reducing the production of IL-2, a cytokine important for the regulatory T-cells proliferation. The treatment of recurrent HCV with interferon can stimulate the activation of T-cells, which enhance the presentation and release of antigens. With DAA therapy's anti-HCV activity and its potential to stimulate host immunity, it has been suggested that rapid elimination of HCV might favor a dysregulation of immune surveillance, which precipitates alloimmune process. In summary, we report a rare case of alloimmune hepatitis in a liver transplant patient with recurrent HCV responding to DAAs and steroid. Thorough follow up of patients undergoing DAA therapy after liver transplantation for alloimmune hepatitis is warranted.

A review of the use of transient elastography in the assessment of fibrosis and steatosis in the post-liver transplant patient.

Liver biopsy is considered the gold standard method for diagnosing and staging liver disease, particularly in the post-liver transplant setting. Given the invasive nature of biopsy, alternate means for accurately assessing liver fibrosis and steatosis are preferred especially as the number of patients with fatty liver disease is increasing. Transient elastography has been validated as a useful tool for evaluation of liver fibrosis, as has controlled attenuation parameter index as a tool for assessing steatosis. It is a non-invasive, rapid, and highly reproducible approach to demonstrate the presence of fibrosis among non-transplant patients with chronic liver disease of various etiologies. However, it has not yet found wide acceptance in liver transplant recipients. There are few published studies evaluating the merits and applicability of transient elastography to assess allografts after liver transplantation. We review the published data on the use of transient elastography with concurrent controlled attenuation parameter in liver transplant recipients and recommend its greater use to follow allograft function over time.

Chronic infection in a post–liver transplant patient

Chronic infection in a post–liver transplant patient

A case of post liver transplant hepatitis: the meaning of the non-specific liver biopsy result

A 57-year-old male post liver transplant patient was admitted to the hospital due to pulmonary tuberculosis. His medical history was significant for chronic hepatitis B cirrhosis, hepatocellular carcinomaand diabetes. His current medication included sirolimus, mycophenolic acid, entecavir, insulin and antituberculosis drugs. Hepatitis was detected from his blood test with total bilirubin 0.55 mg/dL, directbilirubin 0.37 mg/dL, AST 237 U/L, ALT 70 U/L and ALP 160 U/L. Acute cellular rejection, drug/toxin induced hepatitis, tuberculosis of the liver, opportunistic infection and recurrent hepatitis B were possibledifferential diagnosis. A liver biopsy revealed only non-specific change. Without any features of acute cellular rejection, immunosuppressive drugs were reduced accordingly to bring up the immune system.The liver enzyme improved within 2 weeks thereafter. Despite a negative-biopsy result, this was still an important clinical clue which led to a proper management for post liver transplant patient.&#x0D; Figure 1 พยาธิสภาพของชิ้นเนื้อตับ ย้อมด้วย hematoxylin และ eosin (H&amp;E) บริเวณ portal area (A) และ บริเวณ hepatic lobule (B)&#x0D;