Role Of Liver Transplantation Research Articles

The Last Contribution of Hemophiliacs to Blood Coagulation: Atherosclerosis Is Not Prevented by Hypocoagulability

“In principio omnes errant hemophiliacs”. In the past, all bleeding patients were considered as hemophiliacs. Quick demonstrated in the mid thirties that hemophiliacs had a normal prothrombin time (P.T.). This allowed the first distinction of “bleeding patients” in two groups, some with a normal P.T. and some with a prolonged P.T. [1]. Only in 1947, “hemophilia” could be suspected to comprise two different diseases, when Pawlowski in Argentina showed the correction of the defect after mixing the plasmas of two patients known to have hemophilia, thereby suggesting the existence of two types of defect [2]. This was independently confirmed later on by Aggeler et al in the U.S.A. and in England by the Oxford Group in 1952 [3, 4]. Since that time the contribution of hemophilic patients to the understanding of blood coagulation was astonishing and could be summarized along the following lines, without the presumption to be complete: 1). Cryoprecipitates corrected Hemophilia A but not, or very little the hemophilia B defect [5]. 2). Immunological studies on hemophilia A and B have opened new horizons on VWD and demonstrated the existence of hemophilia variants with cross reacting material (CRM) [6, 7]. These studies were then instrumental in the classification of other clotting defects, especially, FX and F VII defects [8]. 3). A hemophilia B variant, hemophilia BM, showed a prolonged prothrombin time when a reagent containing ox-brain thomboplastin was used in the assay system [9]. This opened new horizons in prothrombin complex diseases with regard to their reactivity towards tissue thromploplastins of different origin [10]. 4). Another peculiar contribution was the observation that, in a special type of hemophilia B (Hemophilia B Leyden) there was a variable correction of the defect as the patients aged [11]. This cast light on the androgen-dependent maturation of FIX at the hepatocyte level. 5). Hemophilia patients payed heavily for our delays and faults in the developing of safe concentrates. The pain, sacrifice and the size of the cemetery of hemophiliacs has still to be properly acknowledged and described. 6). Synoviectomy carried out in hemophiliacs in an attempt to impede or delay the occurrence of the arthropathy has considerably spurred the use of this procedure in several orthopedic diseases [12]. 7). The development in some patients of antibodies after replacement therapy has opened important lines of investigation in the genetic control of immunological mechanisms. 8). The widespread treatment of HIV and hepatitis B and C in hemophilia patients has supplied valuable information for the management of these infections even in non-bleeding subjects. 9). The role of liver transplantation in the management of hemophilia is still disputed. However some success has been obtained even by the live donor transplant [13-15]. 10). The status of genetic therapy of hemophilia is still open and very controversial but hemophiliacs have given a contribution even to this field [16, 17]. They represent, at least on theoretical grounds, ideal subjects for gene therapy [16]. Now, hemophiliacs supply us with a new important information. They have shown that atherosclerosis’ may occur in them as in normal persons [18, 19]. Old studies had suggested that the clotting defect could exercise a protection against atherosclerosis. They were wrong. Now it is known that this is not the case. A new medical field has been opened. How to treat hemophilia patients with atherosclerosis and its complications, notably acute coronary syndromes. So, after so many contributions, another major contribution has emerged. Thanks to the improved overall care and to the safety of replacement therapy, the hemophilia population has aged and with age , age related problems have appeared [19, 20]. The demonstration that atherosclerosis may occur in patients with hemophilia and with other congenital coagulation disorders is an event of great importance in blood coagulation. It indicates that hypocoagulability does not prevent the aging of the arteries, namely the formation of fatty streaks or plaques in the intima of the arteries. The focus on the pathogenesis of atherosclerosis must rest therefore on lipids (mainly cholesterol) and inflammation. Congenital hypocoagulability may still protect from atherothrombosis which refers to the formation of a thrombus on fissured on ulcerated plaques. However an arterial occlusion may occur without the formation of a thrombus. This may explain at least part of the myocardial infarctions (M.I.) seen in patients with Hemophilia and other clotting disorders. Autopsy and coronographic data indicate that atherosclerotic streaks and plaques are always present, sometimes complicated by the formation of a thrombus [21, 22]. Manuscript accepted for publication May 27, 2013

Anti-HLA and Anti-MICA Antibodies in Liver Transplant Recipients: Effect on Long-Term Graft Survival

Objective. Presence of anti-HLA antibodies has a well-known impact on kidney grafts survival; however their role in liver transplantation has not been fully elucidated. We conducted a 7-year prospective study to show correlation between presence of anti-HLA and anti-MICA antibodies and liver graft survival. Methods. Blood samples from 123 liver transplant recipients were collected during patients routine visits. Time from transplantation to blood sample collection was different for each patient. Blood samples were tested for anti-HLA (separately class I and II) and MICA antibodies using Luminex assays. Results. There were 32 (26%) patients with positive anti-HLA and 37 (30%) with positive anti-MICA antibodies. Graft loss occurred in 7 cases (23%) in anti-HLA positive group compared to 20 (22%) in anti-HLA negative group (P = ns) and in 8 cases (22%) in anti-MICA positive group but 19 (23%) in anti-MICA negative group (P = ns). No correlations were detected between presence of antibodies and acute graft rejection (AGR). Presence of any antibodies (anti-HLA or anti-MICA antibodies) correlated with late graft rejection (P = 0.04). Conclusion. Presence of anti-HLA or anti-MICA had no impact on long-term liver graft survival; however, detection of any antibodies was correlated with episodes of late graft rejection.

Pulmonary vascular complications in portal hypertension and liver disease: A concise review

Chronic liver disease and/or portal hypertension may be associated with one of the two pulmonary vascular complications: portopulmonary hypertension and hepatopulmonary syndrome. These pulmonary vascular disorders are notoriously underdiagnosed; however, they have a substantial negative impact on survival and require special attention in order to understand their diagnostic approach and to select the best therapeutic options. Portopulmonary hypertension results from excessive vasoconstriction, vascular remodeling, and proliferative and thrombotic events within the pulmonary circulation that lead to progressive right ventricular failure and ultimately to death. On the other hand, abnormal intrapulmonary vascular dilations, profound hypoxemia, and a wide alveolar-arterial gradient are the hallmarks of the hepatopulmonary syndrome, resulting in difficult-to-treat hypoxemia. The aim of this review is to summarize the latest pathophysiologic concepts, diagnostic approach, therapy, and prognosis of portopulmonary hypertension and hepatopulmonary syndrome, as well as to discuss the role of liver transplantation as a definitive therapy in selected patients with these conditions.

Alcoholic hepatitis: diagnosis and management in 2012

Alcoholic hepatitis is a severe form of alcohol-related liver injury and one of the most frequent liver presentations seen by acute medical services. The condition typically affects young and middle-aged adults who present with jaundice and coagulopathy. Many patients fulfil the criteria for acute-on-chronic liver failure, though often the diagnosis of cirrhosis is only made after hospitalization. Despite over four decades of study, controversy surrounds many aspects of diagnosis and management, and short-term mortality in severe disease remains high. This review summarizes recent and important literature of relevance to clinicians, including aids to diagnosis, clinical prognostic scores and evidence for current medical therapies. Contentious issues such as the need for liver biopsy in diagnosis and the role for liver transplantation in those who fail to respond to medical treatment are also discussed.

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Case Reports: Disulfiram is an alcohol deterrent used for chronic alcoholism. Fulminant liver failure is a rare but potentially fatal adverse drug reaction with disulfiram. Only 4 cases have been reported in literature who received liver transplant after disulfiram induced fulminant hepatic failure. We report a case of a 42 year old female, with no prior history of liver disease, on disulfiram for 8 months for the treatment of her alcohol dependence. Patient initially presented with 2 days of worsening dull non-radiating abdominal pain. At presentation patient was afebrile, normotensive and saturating 98 % but she was acutely agitated and hallucinating. Bloodwork showed elevated transaminases (AST 18000 IU/L, ALT 5037 IU/L), hyperbilirubinimia and lactic acidosis (18.5 mEq/L). She was intubated for severe metabolic acidosis. Patient was transferred to our tertiary care hospital for management of acute deterioration of mental status, coagulopathy and fulminant hepatic encephalopathy. At presentation patient was intubated, tachycardic and agitated. On examination pupils were 8mm reactive to light bilateral, hepatomeagaly was noticed but tenderness could not be elicited as patient was sedated. Laboratory findings consistent with severe anion gap metabolic acidosis pH 7.16, acute renal failure, ammonia 336 mcg/dl, elevated transaminases, lactate dehyrogenase 7324 U/L, alkaline phosphatase 149 U/L, hyperbilirubinimia, severe coagulopathy. Patient was maintained on supportive care, mechanical ventilation and Continuous Veno-Venous Hemodialysis. After finding no other cause of Liver injury, worsening of encephalopathy and with no signs of improvement with aggressive medical therapy, patient underwent liver transplant for disulfiram induced fulminant liver failure. Post-transplant patient recovered completely from her acute decompensated state. Histopathological analysis of post-transplant liver specimen was consistent with drug induced acute liver toxicity. The authors want to stress the potential importance of monitoring liver function in patients on disulfiram therapy and role of liver transplantation in patients with disulfiram induced fulminant liver failure.

Congenital portosystemic vascular malformations

Congenital portosystemic shunts are developmental abnormalities of the portal venous system resulting in the diversion of portal blood away from the liver to the systemic venous system. Such malformations are believed to come from an insult occurring between the fourth and eighth week of gestation during the development of hepatic and systemic venous systems, and could explain their frequent association with cardiac and other vascular anomalies. They are currently categorized into end-to-side shunts (type I) or side-to-side shunts (type II). This article aims to review the common symptoms and complications encountered in congenital portosystemic shunts, the surgical and endovascular treatment, and the role of liver transplantation in this disease. We will also focus on the current controversies and the areas where there is potential for future studies.

Serum Levels of Interleukin-9 During Acute Rejection in Liver Transplantation

IntroductionInterleukin-9 (IL-9) has been cast as a player in autoimmunity, but its role in liver transplantation remains to be clarified. The aim of our study was to investigate the time course of IL-9 serum levels during hepatic allograft rejection. MethodsIL-9 serum levels were determined in 34 healthy subjects and 50 hepatic transplant recipients. The patients were divided into two groups: group I was composed of 15 patients with acute rejection episodes, and group II, 35 patients free of this problem. Samples were collected on days 1 and 7 after liver transplantation and on the day of liver biopsy. ResultsThe concentrations of IL-9 were similar in the rejection and nonrejection groups over the entire postoperative period. The whole transplant group, including those with stable graft function, showed higher IL-9 serum levels than the controls at all times after liver transplantation. ConclusionsThese preliminary results suggest a lack of participation of IL-9 in human liver allograft rejection.

Disease profile and differential diagnosis of hereditary transthyretin-related amyloidosis with exclusively cardiac phenotype: an Italian perspective

Hereditary transthyretin (TTR)-related amyloidosis (ATTR) is mainly considered a neurologic disease. We assessed the phenotypic and genotypic spectra of ATTR in a Caucasian area and evaluated the prevalence, genetic background, and disease profile of cases with an exclusively cardiac phenotype, highlighting possible hints for the differential diagnosis with hypertrophic cardiomyopathy (HCM) and senile systemic amyloidosis (SSA). In this Italian multicentre study, 186 patients with ATTR were characterized at presentation. Thirty patients with SSA and 30 age-gender-matched HCM patients were used for comparison. Phenotype was classified as exclusively cardiac (n = 31, 17%), exclusively neurologic (n = 46, 25%), and mixed cardiac/neurologic (n = 109, 58%). Among the eight different mutations responsible for an exclusively cardiac phenotype, Ile68Leu was the most frequent. Five patients with an exclusively cardiac phenotype developed mild abnormalities at neurological examination, but no symptoms during a 36-month follow-up (range: 14-50). Exclusively cardiac phenotype was characterized by male gender, age >65 years, heart failure symptoms, symmetric left ventricular (LV) 'hypertrophy', and moderately depressed LV ejection fraction. This profile was similar to SSA, but relatively distinct from HCM. Compared with patients with a mixed phenotype, patients with an exclusively cardiac phenotype showed a more pronounced cardiac involvement on both echocardiogram and electrocardiogram (ECG). A clinically relevant subset of Caucasian ATTR patients present with an exclusively cardiac phenotype, mimicking HCM or SSA. Echocardiographic and ECG findings are useful to differentiate ATTR from HCM but not from SSA. The role of liver transplantation in these patients should be reconsidered.

Current opinion on the role of resection and liver transplantation for hepatocellular cancer

Hepatocellular carcinoma (HCC) represents one of the most common cancers worldwide with rising incidence in developed countries. The best treatment options with curative intent for patients with HCC are liver resection or transplantation, although the role of hepatic ablative therapies has also been recognized. Surgical resection has emerged as the primary treatment in carefully selected patients of HCC. With the advances in surgical and radiological techniques, the perioperative mortality has been reduced to less than 5 % depending on the extent of resection and hepatic reserve. The role of liver transplantation (LT) as the mainstay of treatment for the majority of patients with HCC has evolved in the last few decades. Historically, the Milan criteria have been considered the gold standard for selecting patients; more expanded selection criteria to include those with more advanced tumors have been implemented in recent years. Living donor liver transplantation (LDLT) has emerged as a way to expand the donor pool and has influenced the role of transplantation for HCC, especially in communities with little access to cadaveric transplantation. Salvage transplantation is an alternative option as it allows a window for the biologically less favorable lesions to declare tumor behavior. Salvage transplantation also decreases the burden on transplant resources. Sirolimus, a novel immunosuppressant drug with anti-tumor effect, may have a role in limiting the severity of recurrent disease after transplantation for HCC, and play an important role in the future management of transplant recipients. This article examines the literature on current status of management of HCC.

Liver transplantation in an adult patient with situs inversus

Objective To study the feasibility and technique in liver transplantation (LT) in an adult with situs inversus (SI) and reviewed the medical literature on this subject.Methods A 45-year-old male with complete SI,suffered from progressive hepatic failure secondary to hepatolithiasis,obstructive jaundice,portal hypertension and liver cirrhosis.He underwent liver transplantation in July 2004.His anatomy was studied by preoperative CT scan and three-dimensional liver reconstruction imaging and angiography.LT was performed using the modified piggyback technique.The donor right liver was rotated 45 degree to the left,making the donor left liver pointing to the left paracolic sulcus and the donor right liver was in the recipient hepatic fossa.The donor suprahepatic vena cava was anastomosed end-to-side to the recipient vena cava,and the infrahepatic vena cava was closed by oversewing.Result The patient recovered uneventfully.His liver function was stable during a follow-up of 75 months.Conclusion LT in patients with SI is safe and feasible.Exact determination of the anatomy,comprehensive preoperative planning,and good technique in liver transplantation play important roles in LT for patients with SI. Key words: Situs inversus; Transplantation

Liver transplantation for unresectable hepatocellular carcinoma in normal livers

The role of liver transplantation in the treatment of hepatocellular carcinoma in livers without fibrosis/cirrhosis (NC-HCC) is unclear. We aimed to determine selection criteria for liver transplantation in patients with NC-HCC. Using the European Liver Transplant Registry, we identified 105 patients who underwent liver transplantation for unresectable NC-HCC. Detailed information about patient, tumor characteristics, and survival was obtained from the transplant centers. Variables associated with survival were identified using univariate and multivariate statistical analyses. Liver transplantation was primary treatment in 62 patients and rescue therapy for intrahepatic recurrences after liver resection in 43. Median number of tumors was 3 (range 1-7) and median tumor size 8 cm (range 0.5-30). One- and 5-year overall and tumor-free survival rates were 84% and 49% and 76% and 43%, respectively. Macrovascular invasion (HR 2.55, 95% CI 1.34 to 4.86), lymph node involvement (HR 2.60, 95% CI 1.28 to 5.28), and time interval between liver resection and transplantation < 12 months (HR 2.12, 95% CI 0.96 to 4.67) were independently associated with survival. Five-year survival in patients without macrovascular invasion or lymph node involvement was 59% (95% CI 47-70%). Tumor size was not associated with survival. This is the largest reported series of patients transplanted for NC-HCC. Selection of patients without macrovascular invasion or lymph node involvement, or patients ≥ 12months after previous liver resection, can result in 5-year survival rates of 59%. In contrast to HCC in cirrhosis, tumor size is not a predictor of post-transplant survival in NC-HCC.

Efficacy and safety of liver transplantation in patients with cholangiocarcinoma: A systematic review and meta‐analysis

The aim of our study was to evaluate the efficacy and safety of liver transplantation in patients with cholangiocarcinoma. According to the requirements of Cochrane systematic review, a thorough literature search was performed in PubMed/Medline, Embase and Cochrane electronic databases between 1995 and 2009 in terms of the key words "liver transplantation" and "cholangiocarcinoma," "cholangiocellular carcinoma" or "bile duct cancer," with restricted articles for the English language. Data were processed for a meta-analysis by Stata 10 software. Altogether 14 clinical trials containing 605 transplanted patients of bile duct cancers were finally enrolled in our study. The overall 1-, 3- and 5-year pooled survival rates were 0.73 [95% confidence interval (CI) = 0.65-0.80], 0.42 (95% CI = 0.33-0.51) and 0.39 (95% CI = 0.28-0.51), respectively. Of note, preoperative adjuvant therapies [orthotopic liver transplantation (OLT)-PAT group] rendered the transplanted individuals with comparably favorable outcomes with 1-, 3- and 5-year pooled survival rates of 0.83 (95% CI = 0.57-0.98), 0.57 (95% CI = 0.18-0.92) and 0.65 (95% CI = 0.40-0.87). In addition, the overall pooled incidence of complications was 0.62 (95% CI = 0.44-0.78), among which that of OLT-PAT group (0.58; 95% CI = 0.20-0.92) was relatively acceptable compared to those of liver transplantation alone (0.61; 95% CI = 0.33-0.85) and liver transplantation with extended bile duct resection (0.78; 95% CI = 0.55-0.94). In comparison to curative resection of cholangiocarcinoma with the 5-year survival rate reported from 20 to 40%, the role of liver transplantation alone is so limited. In the future, attention will be focused on liver transplantation following neoadjuvant radiochemotherapy, which requires a well-designed, prospective randomized controlled study.

Efficacy of liver transplantation for acute hepatic failure: a single-center experience

Acute hepatic failure (AHF) is a devastating clinical syndrome with a high mortality rate. The outcome of AHF varies with etiology, but liver transplantation (LT) can significantly improve the prognosis and survival rate of such patients. This study aimed to detect the role of LT and artificial liver support systems (ALSS) for AHF patients and to analyze the etiology and outcome of patients with this disease. A retrospective analysis was made of 48 consecutive patients with AHF who fulfilled the Kings College Criteria for LT at our center. We analyzed and compared the etiology, outcome, prognosis, and survival rates of patients between the transplantation (LT) group and the non-transplantation (N-LT) group. AHF was due to viral hepatitis in 25 patients (52.1%; hepatitis B virus in 22), drug or toxic reactions in 14 (29.2%; acetaminophen in 6), Wilson disease in 4 (8.3%), unknown reasons in 3 (6.3%), and miscellaneous conditions in 2 (4.2%). In the LT group, 36 patients (7 underwent living donor LT, and 29 cadaveric LT) had an average model for end-stage liver disease score (MELD) of 35.7. Twenty-eight patients survived with good graft function after a follow-up of 27.3+/-4.5 months. During the waiting time, 6 patients were treated with ALSS and 2 of them died during hospitalization. The 30-day, 12-month, and 18-month survival rates were 77.8%, 72.2%, and 66.7%, respectively. In the N-LT group, 12 patients had an average MELD score of 34.5. Four patients were treated with ALSS and all died during hospitalization. The 90-day and 1-year survival rates were only 16.7% and 8.3%, respectively. Hepatitis is the most prominent cause of AHF at our center. Most patients with AHF, who fulfill the Kings College Criteria for LT, did not survive longer without LT. ALSS did not improve the prognosis of AHF patients, but may extend the waiting time for a donor. Currently, LT is still the most effective way to improve the prognosis of AHF patients.

M-TOR inhibitors: What role in liver transplantation?

The development of calcineurin inhibitors (CNIs) led to marked improvements in patient and graft survival after liver transplantation (LTx). We have been left, however, with a dependence on immunosuppressive agents with nephrotoxicity, neurotoxicity, adverse impacts on cardiac risk profile, and risk for malignancy. These challenges need to be met against a dominance of hepatitis C virus (HCV) and hepatocellular carcinoma (HCC) as indications for liver transplant. Unmet needs for immunosuppression (IS) in LTx include: (1) Effective drugs that avoid CNIs toxicities. (2) Agents without adverse impact on HCV recurrence. (3) Compounds that minimize risk of HCC recurrence. New immunosuppressives will need to address the above needs while supporting patient and graft survival equivalent to those achievable with CNIs, ideally without important new toxicities. Two new classes of agents are currently in advanced clinical development: belatacept, and the mammalian target of rapamycin inhibitors (m-TORi). This manuscript will review evidence for a role for m-TORi in LTx in a range of clinical scenarios including patients with CNI nephrotoxicity or neurotoxicity, patients at risk of (or with) HCV recurrence, and patients at risk of HCC recurrence.

The use of Sirolimus should be restricted in liver transplantation

Sirolimus and mTOR inhibitors are important additions to the therapeutic armamentarium to prevent allograft rejection, but their role in liver transplantation is evolving. De novo use of Sirolimus in the early post-transplant period has undoubtedly been influenced by the high incidence of hepatic artery thrombosis and decreased patient and graft survival leading to a black box warning. The jury remains undecided on the role of conversion from CNIs to mTOR inhibitors in those developing renal insufficiency and it must be noted that a second warning was issued by the FDA because of decreased survival in those conversion studies. Finally, the anti-atherogenic, antiviral, and anti-neoplastic effects associated with Sirolimus, which might favor their use in certain liver transplant patients, need further evaluation before firm recommendations can be made.

Hepatocellular carcinoma and liver transplantation

Hepatocelluar carcinoma (HCC) continues to grow in scope and magnitude as a clinical entity. Liver transplantation has been shown to be a potentially curative treatment for a select group of patients with HCC. The role of liver transplantation as part of the multidisciplinary treatment of HCC continues to evolve. The use of liver transplantation as treatment for HCC continues to grow as selection criteria are refined to optimize outcomes. The Milan criteria (T2) are considered the standard selection criteria but have been challenged in recent years as being too limiting. Treatment for HCC patients awaiting liver transplantation includes a number of ablative techniques that may arrest tumor growth. Similar treatments may potentially downsize large (>T2) HCC so that they fall into the exception criteria for liver transplantation (downstaging), which is an area of ongoing study. Prioritizing HCC patients on the liver transplantation waiting list remains a difficult balance with non-HCC patients. After several downward adjustments of priority for HCC patients, the current system of awarding set, defined priority scores with time-dependent increases for HCC patients who remain within Milan criteria (compared to a continuous priority scale for non-HCC patients), continues to give HCC patients excess priority in access to liver transplantation. Despite this, outcomes for HCC patients remain inferior to non-HCC patients after liver transplantation. Liver transplantation remains an acceptable treatment for select HCC patients. Optimizing patient selection and pretransplant treatment, and refining prioritization in relation to non-HCC patients for these scarce resource cadaveric livers continues to challenge the transplant community.

The Role of Liver Transplantation in Hereditary Non-Neuropathic Systemic Amyloidosis

The Role of Liver Transplantation in Hereditary Non-Neuropathic Systemic Amyloidosis

Acute liver failure associated with antiretroviral treatment for HIV – is there a role for liver transplantation?

IntroductionCombination antiretroviral medication has dramatically improved the prognosis of HIV infected individuals. Hepatotoxicity is an adverse event that can lead to interruption of therapy, clinical hepatitis and death. HIV was...

Liver Transplantation for Massive Hepatic Lymphangiomatosis in a Child

Liver Transplantation for Massive Hepatic Lymphangiomatosis in a Child

Divergences in KIR2D + natural killer and KIR2D +CD8 + T-cell reconstitution following liver transplantation

Natural killer (NK) and CD8 + T cells may be active elements in the allograft response, but little is known about their role in liver transplantation. Some of these cells express killer immunoglobulin-like receptors (KIRs), which after binding specific ligands may transmit inhibitory/activating signals. In this study, circulating NK and CD8 + T cells expressing CD158a/h (KIR2DL1/S1) or CD158b/j (KIR2DL2/3/S 2) receptors were analyzed in 142 liver recipients by flow cytometry. They were underrepresented in patients before transplantation, but following transplantation, whereas the KIR2D + NK subsets experienced a late recuperation (day 365) mainly in C2-homozygous patients developing early acute rejection, recovery of the 2 CD8 +KIR2D + T cells started earlier, showing significant differences on day 365 between patients without acute rejection and those suffering from it ( p = 0.004 and p < 0.0001, respectively). These differences were also evident when the human leukocute antigen-C genotypes of the recipient were considered. In conclusion, whereas the late recovery of KIR2D + NK cells in C2/C2 patients appears to be linked to acute rejection, the increase in early CD8 +KIR2D + T cells in overall liver recipients correlates with a most successful early graft outcome. Therefore, monitoring of KIR2D + cells appears to be a useful tool for liver transplant follow-up.