Shiraz Organ Transplantation Center Research Articles

Factors Associated with Chronic Rejection in Liver Transplant Recipients: A Retrospective Cohort Study From Shiraz Organ Transplant Center.

Identification of chronic rejection risk factors in liver transplant recipients is critical for early detection and prevention of further graft loss. We investigated characteristics of liver transplant recipients who had experienced chronic rejection and the associated risk factors versus patients without chronic rejection. Data from 3022 adult liver transplant recipients between 2011 and 2018 were analyzed; of these, 80 patients had experienced chronic rejection. The control group included 98 randomly selected liver transplant recipients who did not have chronic rejection. The age of the recipients and the donors was significantly lower in the group with chronic rejection versus the group without chronic rejection.The results indicated that chronic rejection was significantly associated with the sex of the recipients (hazard ratio 3.2, 95% CI 1.77-6.08; P < .001) and with the sex concordance between the recipients and donors (hazard ratio 2.93, 95% CI 1.67-5.13; P < .001, respectively). Also, in the group without chronic rejection, there were no male donors; however, the group with chronic rejection had mostly male donors (P <.001). Cold ischemia time was longer in patients with chronic rejection versus that shown in the control group (P = .031), and there was a significant difference between the 2 groups in acute rejection frequency (P < .001). Recipient sex and sex concordance were independent risk factors for chronic rejection. Most transplantrecipients with chronic rejection responded to medicaltreatment, and the rate of graftloss was low among our recipients.

Antibiotic stewardship implementation at the largest solid organ transplantation center in Asia: a retrospective cohort study

BackgroundUsing Antimicrobial stewardship programs (ASP) to monitor the use of antibiotics can lead to improved antibiotic use and reduced costs.MethodsThis retrospective cohort study was done at Shiraz Organ Transplant Center, the largest transplant center in Asia. Antimicrobial use, cost, clinical outcomes, and antibiotic resistance pattern were evaluated before and after ASP.ResultsThis study included 2791 patients, 1154 of whom were related to the time before ASP and 1637 to the time after ASP. During the period of the research, a total of 4051 interventions were done. The use of all classes of antibiotics was significantly reduced by ASP, with 329 DDD/100PD before the intervention compared to 201 DDD/100PD after it (p = 0.04). In addition, the overall cost of antibiotics purchased was much lower after the ASP measures were implemented ($43.10 per PD) than before implementation of the ASP measures ($60.60 per PD) (p = 0.03). After the implementation of ASP, the number of MDR isolates was significantly reduced.ConclusionThe results of our study showed that the implementation of ASP significantly reduced the number and costs of antibiotics and also the number of resistant pathogens, but did not affect the patients’ length of stay.

Prope tolerance after pediatric liver transplantation: Experience at Shiraz Organ Transplant Center

BackgroundChildren receive transplants at a younger age, and the period of immunosuppression therapy may extend over decades. However, immunosuppression seems to be responsible for long-term mortality and morbidity. Pediatric liver transplant recipients can benefit from achieving immune tolerance and the opportunity of freedom from lifelong immunosuppression. This study aimed to investigate the frequency of prope tolerance among pediatric liver transplant recipients and the characteristics of these patients. MethodsIn this retrospective cohort study of pediatric liver transplant recipients, the medical records of transplant recipients treated at Shiraz Organ Transplant Center between 1994 and 2017 were reviewed. Prope tolerance was defined as normal laboratory values and stable clinical status on low-dose monotherapy. Children treated with low-dose monotherapy were categorized as the prope tolerant group. We compared the characteristics of prope tolerant recipients on low-dose monotherapy with patients on standard immunosuppression, i.e. full-dose tacrolimus plus steroids and mycophenolate mofetil. The data were analyzed with the t-test, chi-squared test, and a Cox proportional hazard model at a 5% significance level in SPSS software version 16. ResultsA total of 585 children with a mean age of 8.32 ± 5.23 years were enrolled. 341 patients were categorized as prope tolerant and 244 comprised the full immunosuppression regimen group. Mean age at transplantation and rejection frequency were lower in the prope tolerant group (p < 0.001, p < 0.001). Based on the underlying diseases, metabolic/genetic, biliary tract, and cryptogenic liver diseases were significantly more prevalent in the prope tolerant group (p < 0.001). However, autoimmune liver disease was found to be more prevalent in the full immunosuppression regimen group. Also, those who received living organs (p = 0.001) and recipients of organs from female donors had a greater likelihood of achieving prope tolerant. According to the multiple Cox regression results, age at transplantation (p = 0.022), rejection frequency (p < 0.001), and autoimmune liver diseases (p = 0.028) had a prognostic effect on prope tolerance. ConclusionFactors as underlying disease, age at transplantation, and rejection frequency were factors that were predictive of prope tolerance in this sample of children. However, the risk of rejection should be considered during the tapering period.

Endoscopic findings in cirrhotic children candidates for liver transplantation

Background: Liver cirrhosis is an end-stage liver failure that can develop as a result of acute or chronic liver disease. Patients are at risk of fatal complications such as portal hypertension and bleeding from esophageal varices. Methods: This cross-sectional study examined the endoscopic findings in child patients &lt;18 years with cirrhosis qualifying as candidates for liver transplantation. Our subjects were children admitted from 2012 to 2017 to the Shiraz Organ Transplantation Center of Nemazee Hospital, Shiraz University of Medical Sciences. The data was collected using a researcher-made questionnaire. Results: We studied 199 patients (49.2% boys) with liver cirrhosis admitted for upper gastrointestinal endoscopy. Their average age was 6.2 ±4.7 years old. The most common clinical sign present at admission was icterus (58.8%). The mean values of the children’s Child-Pugh and PELD/MELD scores were 8.53 ±2.34 and 14.85 ±14.93, respectively. Of 199 children examined, 145 total (72.8%) suffered from esophageal varices, further divided by severity into grades 1, 2, 3, and 4 – 39 (19.7%), 53 (26.8%), 42 (21.2%), 11 (5.6%), respectively. Further symptoms, such as portal hypertensive gastropathy (PHG), gastric erythema, fundal varices, gastric erosion, and gastric ulcer were found in 31.1%, 15.1%, 6.5%, 5.5%, and 2% of the patients, respectively. No associations were observed between esophageal or gastric varices and Child-Pugh (P = 0.076), PELD/MELD score (P = 0.607), clinical symptoms, laboratory parameters, or underlying diseases. Conclusion: Our patients’ main cause of liver cirrhosis was biliary atresia, and the most common presenting sign in endoscopy was esophageal varices. Keywords biliary atresia, esophageal varices, jaundice, endoscopic treatment

Predictors of Death in the Liver Transplantation Adult Candidates: An Artificial Neural Networks and Support Vector Machine Hybrid-Based Cohort Study.

Model for end-stage liver disease (MELD) is currently used for liver transplantation (LT) allocation, however, it is not a sufficient criterion. This current study aims to perform a hybrid neural network analysis of different data, make a decision tree and finally design a decision support system for improving LT prioritization. In this cohort follow-up-based study, baseline characteristics of 1947 adult patients, who were candidates for LT in Shiraz Organ Transplant Center, Iran, were assessed and followed for two years and those who died before LT due to the end-stage liver disease were considered as dead cases, while others considered as alive cases. A well-organized checklist was filled for each patient. Analysis of the data was performed using artificial neural networks (ANN) and support vector machines (SVM). Finally, a decision tree was illustrated and a user friendly decision support system was designed to assist physicians in LT prioritization. Between all MELD types, MELD-Na was a stronger determinant of LT candidates' survival. Both ANN and SVM showed that besides MELD-Na, age and ALP (alkaline phosphatase) are the most important factors, resulting in death in LT candidates. It was cleared that MELD-Na <23, age <53 and ALP <257 IU/L were the best predictors of survival in LT candidates. An applicable decision support system was designed in this study using the above three factors. Therefore, Meld-Na, age and ALP should be used for LT allocation. The presented decision support system in this study will be helpful in LT prioritization by LT allocators.

Drug-related Problems in Solid-Organ Transplant Recipients Hospitalized for COVID-19: An Experience of a Referral Tertiary Center in Iran.

Transplanted patients receiving immunosuppressive agents are at a higher risk of Coronavirus-disease-2019 (COVID-19), and their polypharmacy state makes the choice of treatment challenging. This study aimed to assess the drug-related problems (DRP) and clinical pharmacists' interventions to manage transplanted patients and candidates for transplantation with COVID-19. This cross-sectional study was conducted in the COVID-19 intensive care unit of Shiraz Organ Transplantation Center (Iran), from March 2020 to April 2021. Patients were admitted to the COVID-19 intensive care unit based on clinical symptoms or positive polymerase chain reaction (PCR) tests. The clinical pharmacist reviewed all medications and physicians' orders on a daily basis and evaluated DRPs in accordance with the pharmaceutical care network of Europe (PCNE) classification (V 8.01). The treatment team was informed of the DRPs, and the acceptance or rejection of the intervention was also documented. Data were analyzed using SPSS (Version 25.0). In order to determine the proportion and determinants of drug-related problems, descriptive statistics and logistic regression were applied, respectively. A clinical pharmacist reviewed 631 individuals with 11770 medication orders, and 639 DRPs were found in 69% of them with an average of 1.01±1 per patient. The most commonly reported DRPs were treatment efficacy issues followed by adverse drug reactions (ADRs). A total of 982 interventions were provided at prescriber, patient, and drug levels, of which 801 were accepted, and 659 (82.27%) were fully implemented. There have been considerable drug-related issues in managing transplanted patients with COVID-19. DRPs are more common in people with polypharmacy, more than three comorbidities, and hydroxychloroquine regimens.

The experience and outcomes of multidisciplinary clinical pharmacist-led parenteral nutrition service for individuals with intestinal failure in a center without home parenteral nutrition.

Intestinal Failure (IF) is a rare but serious form of organ failure, and patients with IF are dependent on Total Parenteral Nutrition (TPN) to maintain growth and development. This study aimed to describe the experiences of a multidisciplinary clinical pharmacist-led TPN service in the Intestinal Rehabilitation Unit of Shiraz Organ Transplant Center. This prospective study was conducted in Shiraz Organ Transplant Center, Iran from February 2018 to October 2020, including seven months with and 24 months without the clinical pharmacist involvement. Clinical and nutritional outcomes as well as the potential complications of TPN were compared in these two periods. This study was conducted on 107 patients. The most important complication occurred among the patients receiving TPN were catheter infection (42.05%), sepsis, and catheter thrombosis (18.69%). Portal vein thrombosis (OR = 26.56) and length of Intensive Care Unit (ICU) stay (OR = 1.12) were significantly associated with the rate of parenteral nutrition-associated liver disease. The results also revealed an association between the rate of sepsis and history of malignancy, catheter thrombosis, length of the small bowel, length of PN, length of hospital stay, and length of ICU stay. Moreover, the results showed a significant difference regarding the patients' outcomes and TPN complications before and after the clinical pharmacist interventions (P < 0.05). Working as a multidisciplinary team in Intestinal Rehabilitation Unit (IRU) has been suggested to improve patients' outcomes and reduce mortality and morbidity. Presence of a clinical pharmacist in this team can help improve the TPN service provided for individuals with IF.

Comparison of the characteristics of adult liver transplant recipients with prope (almost) tolerance and full immunosuppression regimen

BackgroundThe liver transplant recipients are often subjected to excessive therapy by immunosuppressive drugs which produce several complications. Consequently, the minimization or even withdrawal of immunosuppression in selected patients is an attractive alternative. We investigated the frequency and characteristics of these near (or prope from Latin) tolerance in liver transplant recipients in Shiraz Organ Transplant Center. Material and methodsWe reviewed the medical records of over 3800 adult liver transplant recipients to select a group treated with a low-dose tacrolimus monotherapy (n = 90) between 1994 and 2017 in our transplant center. The patients with the best liver function parameters were selected; then, the clinician arbitrarily decided to withdraw steroids first and then mycophenolate mofetil and maintain each patient on a low dose tacrolimus.We compared the characteristics of prope tolerant recipients on a low-dose tacrolimus with those on standard immunosuppression, namely full-dose tacrolimus plus steroids and mycophenolate mofetil (n = 233). Data were analyzed by t-test, chi-square test using SPSS software version 16. ResultsOut of over 3800 liver transplant patients, 90 (2.34%) recipients were treated with a minimum dose of tacrolimus monotherapy. These recipients were compared to a selected group of 233 (6.1%) recipients treated with full-dose tacrolimus plus steroids and mycophenolate mofetil. In a prope tolerant group, there were 55 males (61.1%) and 35 females (38.9%) recipients. Mean age at the time of transplant was 39.92 ± (SD = 13.40) years with an average time from the transplantation time to completed weaning from triple immunosuppression to low-dose monotherapy of 41.35 months (SD = 17.27). The most common etiology of liver disease among both groups was viral hepatitis. ConclusionThe achievement of prope (almost) immune tolerance was possible only in some liver transplant recipients with a relatively low risk of rejection. Our analysis suggests that there is a difference in the underlying diseases and recipients' age and the number of rejections between the two groups.

Clinical Course and Outcome of Liver Transplantation in Patients with Hepatitis C in Iran

Background: Hepatitis C is one of the most common causes of end-stage liver disease and liver transplant worldwide. In recent years, with the rapid advances in the treatment of hepatitis C by direct-acting antiviral drugs (DAAs), the clinical course of the disease as well as liver transplantation have had significant improvement. Also, DAAs have completely replaced interferon-based regimens in the treatment and prevention of HCV recurrence after liver transplant. Objectives: This is the first study that aimed to investigate the clinical course of liver transplantation in patients with hepatitis C in Iran. Methods: This retrospective study was conducted on patients with HCV liver transplantation within five years (2012 - 2017) with the age range of 18 to 65 years at Shiraz Organ Transplant Center. All demographic and clinical data were recorded. Pre-transplant viral load, disease recurrence, graft rejection, and mortality rate were the most important indices in this study. Results: Among 55 transplant patients, 49% had received hepatitis C treatment before liver transplantation and interferon-based regimens were more prevalent. Besides, HCV genotype 3, followed by genotype 1, was the most prevalent one. A liver biopsy was performed in patients with elevated liver enzyme levels. The numbers of patients with HCV recurrence at 2, 6, 12, and 24-month intervals were three, two, zero, and two patients, respectively. At these time intervals, eight, eight, one, and three cases of acute graft rejection were found, respectively. Eight patients died with a one-year survival rate of 85%. Sepsis and infectious complications were the most leading causes of death. Conclusions: This study is the first study of liver transplant patients with hepatitis C in Iran. In the five-year study period, rapid development was made in the treatment of HCV patients. It led to the introduction of DAAs, which replaced interferon-based therapies. The results of this study indicated the high success rate of liver transplantation in patients with hepatitis C in Iran. The results of this study could be used to compare the efficacy of DAAs in future research.

Post liver transplant complications of Budd-Chiari syndrome.

Budd-Chiari syndrome (BCS) is a rare, life-threatening disease characterized by hepatic venous outflow obstruction. Liver transplantation (LT) is widely accepted as an effective therapeutic measure for irreversible liver failure due toBCS. There is debate on differences in the post LT course and complications in patients withBCS as compared to non-Budd-Chiari (NBC) patients. In this retrospective study, data on all patients who received a liver transplant for BCS at the Shiraz Organ Transplantation Center between January 1996 and September 2017 were reviewed and compared to data ofa control group who had received liver transplants over the same period but due to other causes (NBC). Out of 4225 patients who received liver transplants in the study period, 108 hadBCS and an age- and gender-matched control group consisted of 108NBCcases. The mean ± standard deviation (SD) of model for end-stage liver disease (MELD) scores were 19.1 ± 3 and 20 ± 3 for BCS and NBC groups, respectively (p = 0.33). One-, 3-, 5-, and 10-year survival rates in the BCS group were as follows: 82%, 78%, 76%, and 76% compared with the NBC rates of 83%, 83%, 83%, and 76%, respectively (p = 0.556). There was no difference between the two groups in complication ratesafter 6months. In the later period, vascular thrombosis was more common in BCS. Whole-organ LT from deceased donors in patients with BCS had comparable outcomes with LT due to other causes of end-stage liver disease. In most instances, these patients should receive lifelong anticoagulation.

Clinical Outcome of Vancomycin-Resistant Enterococcus Colonization Among Liver Transplant Recipients at Shiraz Organ Transplant Center.

Liver transplant recipients are more susceptible to vancomycin-resistant enterococci colonization than healthy individuals. We investigated the prevalence of vancomycin-resistant enterococci colonization and its effect on the outcomes of liver transplant recipients. Patients who had undergone primary liver transplant at the Shiraz Organ Transplant Center from 2015 to 2017 were enrolled in this study. Demographic characteristics, laboratory test results, duration of stay in the intensive care unit, total duration of hospital stay, and clinical outcome data were extracted from the Shiraz Organ Transplant Center database. Posttransplant outcomes such as graft rejection, mortality, hospital stay, and kidney function tests were included for the first 90 days after transplant. A total of 753 liver transplant recipients (470 males and 283 females) were included in this study. Vancomycin-resistant enterococci colonization was identified in 51 patients (6.8%) after transplant at the time of intensive care unit admission. Our study found no significant difference between outcomes for patients with vancomycin-resistant enterococci colonization and outcomes for patients without colonization, including graft rejection, mortality, hospital stay, and kidney function tests. Our study revealed that asymptomatic vancomycin-resistant enterococci colonization in liver transplant patients has no adverse effect on the duration of posttransplant hospital stay, early mortality rate, graft rejection rate, or kidney function compared with noncolonized patients.

Evaluation of High Oxygen Saturation Status in Cirrhotic Patients

Background: Cirrhosis, as the end stage of a variety of chronic liver diseases, can affect oxygenation in patients and make them hypoxic through hepatopulmonary syndrome or portopulmonary hypertension. However, we observed that some patients referring to our center for liver transplantation had high arterial oxygen saturation. Objectives: This study was designed to investigate the presence and association of hemoglobin oversaturation in cirrhotic patients candidate for liver transplantation. Methods: In a cross - sectional study, cirrhotic patients referring to Shiraz Organ Transplantation Center were included from 2013 to 2015. The exclusion criteria were other disorders that might affect O2 saturation and other causes of liver transplantation except for cirrhosis. Also, we excluded all patients with chest X - ray abnormality. Hemoglobin saturation was measured by arterial blood gas analysis. Patients were divided into two groups, oversaturated patients (Hb sat O2 ≥ 98%) as the case group and patients with Hb sat O2 < 98% as the control group. We compared the case and control groups for the cause of cirrhosis, sex, smoking status, age, spirometry, model for end - stage liver disease (MELD) score, and the place of residence’s altitude. After univariate analysis, logistic regression models were used for multivariate analysis and adjusted for significant and near significant (P value < 0.2) covariates. Results: Of 495 patients, 18.6% were oversaturated. Moreover, 64.5% of the control group patients were males versus 58.7% of the case group. The mean age of the control group (40.6 ± 14.7) was significantly higher than that of the case group (36.8 ± 15.7) in univariate analysis (P value = 0.02). Hemoglobin oversaturation was significantly higher in patients with auto - immune hepatitis (AIH) than in patients with other causes of cirrhosis (P value = 0.001). There was no significant difference between the case and control groups in other causes of cirrhosis or other factors. In multivariate analysis, just AIH remained statistically significant in the models (odds ratio = 2.03; 95% confidence interval = 1.13 - 3.65; P value = 0.01). After finding an association between AIH and oversaturation, the drugs routinely used for the treatment of AIH were compared between the case and control groups. No significant difference was found between them in using prednisone, azathioprine, and cyclosporine (P values = 0.5, 0.6, and 0.6, respectively). Conclusions: Based on our research, there was an association between oversaturation in cirrhotic patients and AIH. The association was not related to the drugs used for the treatment of AIH.

Quality of life among liver transplantation recipients before and after surgery: A single-center longitudinal study

Background: Liver transplantation has improved patients' survival rates and quality of life (QoL). This study investigated the effect of liver transplantation and model for end-stage liver disease (MELD) score on patients' QoL at Shiraz Organ Transplantation Center. Materials and Methods: This perspective longitudinal study was conducted among 40 liver transplant candidates at Shiraz Organ Transplant Center. Inclusion criteria were patients who were 12 years or older, able to answer the questions and willingness to participate. If they had received multi-organ transplant and had mental or physical disabilities, we excluded them from the study. They were interviewed by the same researcher in the transplant clinic before transplantation, 1 and 6 months after transplantation. The participants completed the data collection form and Short Form-36 questionnaire via face-to-face interview. The data collecting form consist of demographic and medical information. Medical information was collected from Shiraz Organ Transplant Center. Results: Mean age of participants was 41.18 ± 14. By comparing QoL dimensions, a significant difference was found between before and after transplantation (P 0. 05). Conclusion: Liver transplantation improves patients' quality life with end-stage liver disease. MELD scores do not depict QoL after liver transplantation.

Nonalcoholic Steatohepatitis Is the Most Rapidly Growing Indication for Liver Transplantation in Iranian Patients.

Nonalcoholic fatty liver disease is a rapidly growing disease and is hypothesized to become the most common cause of liver cirrhosis in the near future. This study aimed to investigate trends of nonalcoholic steatohepatitis as an indication for liver transplant in Iranian patients. Liver transplant data from all adult patients (age > 18 y) who had undergone liver transplant between 1993 and 2017 at the Shiraz Organ Transplant Center (Shiraz, Iran) were reviewed. Underlying liver diseases leading to liver transplant were stratified according to year of transplant, and trends of increase or decline were analyzed. Kaplan-Meier curves were used for analysis of posttransplant survival of patients with nonalcoholic steatohepatitis and patients with modified nonalcoholic steatohepatitis. We evaluated 3184 liver transplant patients. Of these, 112 patients with biopsy-proven nonalcoholic steatohepatitis underwent liver transplant up to the end of 2017. Mean age of patients was 52.86 ± 9.01 years in those with nonalcoholic steatohepatitis and 51.73 ± 7.91 years in those with modified nonalcoholic steatohepatitis (P > .05).The prevalence of nonalcoholic steatohepatitis as an indication for liver transplant was 0.8% in 2011, 0.36% in 2012, 1.9% in 2013, 4.01% in 2014, 2.89% in 2015, 6.65% in 2016, and 9.97% in 2017. The prevalence of modified nonalcoholic steatohepatitis was 2.4% in 2011, 2.88% in 2012, 2.71% in 2013, 2% in 2014, 2.17% in 2015, 2.13% in 2016, and 2.28% in 2017. We found that nonalcoholic steatohepatitis as a cause of liver transplant increased significantly during recent years (P < .001). Nonalcoholic steatohepatitis is a rapidly growing indication for liver transplant among Iranian patients. Health care providers should consider programs for prevention and early diagnosis of patients with nonalcoholic steatohepatitis for proper treatment.

The frequency and risk factors of low bone mineral density one year after liver transplantation in children: a study in Shiraz Organ Transplant Center

Objective: Osteoporosis is a severe epiphenomenon that follows liver transplantation (LT). There is an inconsistency regarding risk factors of developing osteoporosis in LT children. In this article, we address the frequency of low bone mineral density (BMD) in LT children.&#x0D; Methods: This is a prospective study performed on children aged &lt;18 years old, referred to the Shiraz Organ Transplant Center. The study was conducted from March 2009 until March 2014. Those with at least one year passed from the transplantation were included. Lumbar and hip bone densities were checked by Dual-Energy Radiograph Absorptiometry.&#x0D; Results: From the total of 84 included children, 32 (38.1%) and 52 (61.9%) were males and females respectively. The underlying diseases included cryptogenic (32, 28.1%), biliary atresia (18, 21.4%), Wilson disease (9, 10.7%), autoimmune hepatitis (9, 10.7%), tyrosinemia (6, 7.1%), acute liver failure (5, 6%), and hypercholesterolemia (5, 6%). Overall, 53 children (63.1%) had normal BMD, while 31 (36.9%) revealed lower than normal BMD. The means of lumbar and hip z scores were -1.04+/-1.47 (median of -0.75) and -0.98+/-1.92 (median of -0.60), respectively. There was no significant association between bone density and the age of transplantation, sex, weight, height, or underlying diseases (P&gt;0.05). None of the immunosuppressive drugs were associated with low BMD. The patients who received pulse therapy showed a significantly higher rate of low BMD respective to the patients who did not receive pulse therapy (P=0.03).&#x0D; Conclusion: The frequency of low BMD is relatively high in LT children. Pulse therapy may increase the risk of low BMD and osteoporosis in LT children.&#x0D;

Identifying Factors That Affect Patient Survival After Orthotopic Liver Transplant Using Machine-Learning Techniques.

Survival after liver transplant depends on pretransplant, peritransplant, and posttransplant factors. Identifying effective factors for patient survival after transplant can help transplant centers make better decisions. Our study included 902 adults who received livers from deceased donors from March 2011 to March 2014 at the Shiraz Organ Transplant Center (Shiraz, Iran). In a 3-step feature selection method, effective features of 6-month survival were extracted by (1) F statistics, Pearson chi-square, and likelihood ratio chi-square and by (2) 5 machine-learning techniques. To evaluate the performance of the machine-learning techniques, Cox regression was applied to the data set. Evaluations were based on the area under the receiver operating characteristic curve and sensitivity of models. (3) We also constructed a model using all factors identified in the previous step. The model predicted survival based on 26 identified effective factors. In the following order, graft failure, Aspergillus infection, acute renal failure and vascular complications after transplant, as well as graft failure diagnosis interval, previous diabetes mellitus, Model for End-Stage Liver Disease score, donor inotropic support, units of packed cell received, and previous recipient dialysis, were found to be predictive factors in patient survival. The area under the receiver operating characteristic curve and model sensitivity were 0.90 and 0.81, respectively. Data mining analyses can help identify effective features of patient survival after liver transplant and build models with equal or higher performance than Cox regression. The order of influential factors identified with the machine-learning model was close to clinical experiments.

Evaluation of Underlying Liver Disease and Its Severity in Children Referred for Liver Transplant: a Single-Center Report From Nemazee Hospital of Shiraz.

Liver transplant has been used as a curative approach for children with end-stage liver diseases. Here, we describe the underlying causes for pediatric liver transplant performed at the Shiraz Organ Transplantation Center, Nemazee Hospital, Shiraz, Iran. In this cross-sectional descriptive study, children < 18 years old who were candidates for liver transplant from 2007 to 2010 at the Shiraz Organ Transplantation Center were included. Patients were evaluated for their underlying diseases leading to liver failure. Disease severity was assessed and compared with Pediatric End-Stage Liver Disease model and the Model for End-Stage Liver Disease scores. Of 107 patients, 60.8% were males and 39.2% were females. The mean age was 11.6 ± 4.9 years. Thirteen patients (12.5%) were < 2 years old, 26 (24%) were 2 to 6 years old, 33 (30.8%) were 6 to 12 years old, and 35 (32.7%) were 12 to 18 years old. Underlying liver diseases comprised biliary atresia (27.1%), cryptogenic cirrhosis (21.5%), autoimmune cirrhosis (13.1%), familial intrahepatic cholestasis (11.2%), Wilson disease (9.3%), tyrosinemia (7.4%), neonatal hepatitis (4.7%), congenital hepatic fibrosis (3.7%), and Caroli disease (1.9%). Jaundice (83.2%), ascites (57%), and esophageal varices (43%) were the most common clinical findings. Mean serum direct bilirubin, total bilirubin, international normalized ratio, and serum creatinine values were 3.6 ± 0.8 mg/dL, 9.3 ± 9.1 mg/dL, 2.1 ± 1.1, and 0.6 ± 0.2 mg/dL, respectively. The mean Pediatric End-Stage Liver Disease score in children < 12 years old was 11.4 ± 9.1. The mean Model for EndStage Liver Disease score in children > 12 years old was 13.7 ± 5.9. There were no differences in scores among sex, age groups, or different etiologies. Scores for disease severity were not significantly different with regard to different causes of underlying diseases for liver transplant in Iranian children.

Evolution of Liver Transplantation Program in Shiraz, Iran

Background: Liver transplantation (LT) is the only approved treatment for patients with end stage liver disease (ESLD). Shiraz organ transplantation center (SOTC) was the first center in Iran to provide LT. This report is on the evolution of LT program in this center. Methods: We report the clinical features and outcomes of all those who received LT between May 15, 1993 to December 31, 2015 as well as donor features. All LT were performed at Namazi hospital in Shiraz, Iran. The Kaplan-Meier and multivariate Cox proportional hazards regression analyses were performed to determine prognostic factors and the overall long-term survival after liver transplantations. Results: During this period, 3191 recipient patients received LT from 3110 donors. Overall patient survival rates were 84% at 1 year, 80% at 5 years, and 73% at 10 years. The survival rates for recipients from living donors were 74.0% at 1 year and 70.0% at 5 years compared to 86.0% at 1 and 81.0% at 5 years for recipients from deceased donors (P < 0.0001). The survival rates of LT for 2 different Era I (1993 - 2005) and II (2006 - 2015) were estimated to be 76.0% vs. 85.0% at one year, 69.0% vs. 81% at 5 years, and 60.0% vs. 78.0% at 10 years, respectively (P < 0.0001).The most common indications for LT were cryptogenic cirrhosis, hepatitis B, primary sclerosing cholangitis, autoimmune hepatitis, and metabolic liver diseases during this period. Conclusions: LT is now an affordable treatment for patients with ESLD in Iran with acceptable survival, which has further been improved in recent years.

Biliary reconstruction in liver transplant patients with primary sclerosing cholangitis, duct-to-duct or Roux-en-Y?

Roux-en-Y choledochojejunostomy and duct-to-duct (D-D) anastomosis are biliary reconstruction methods for liver transplantation. However, there is a controversy over which method produces better results. We have compared the outcome of D-D anastomosis vs. Roux-en-Y hepaticojejunostomy in patients with primary sclerosing cholangitis who had undergone liver transplant in Shiraz Organ Transplant Center. The medical records of 405 patients with primary sclerosing cholangitis (PSC) who had undergone liver transplant from 1996 to 2015 were reviewed. Patients were divided into two groups: Roux-en-Y group and D-D group. Morbidity, disease recurrence, and graft and patient survival rates were compared between the two groups. Total of 143 patients underwent a D-D biliary reconstruction, and 260 patients had a Roux-en-Y loop. Biliary complication involved 4.2% of patients from the D-D group, and 3.9% from the Roux-en-Y group (P=. 863). Actuarial 1-, 3-, and 5-year patient survival for D-D and Roux-en-Y group was 92%, 85%, and 74%; and 87%, 83%, and 79%, respectively (P=.384). The corresponding 1-, 3-, and 5-year probability of biliary complication was 97%, 95%, and 92%; and 98%, 97%, and 94%, respectively (P=.61). Duct-to-duct biliary reconstruction in liver transplantation for selected patients with PSC is a good alternative instead of Roux-en-Y biliary reconstruction.

Risk Factors for Portal Vein Thrombosis in Patients With Cirrhosis Awaiting Liver Transplantation in Shiraz, Iran.

Background:Portal vein thrombosis is a fairly common and potentially life-threatening complication in patients with liver cirrhosis. The risk factors for portal vein thrombosis in these patients are still not fully understood.Objectives:This study aimed to investigate the associations between various risk factors in cirrhotic patients and the development of portal vein thrombosis.Patients and Methods:In this case-control study performed at the Shiraz organ transplantation center, Iran, we studied 219 patients (> 18 years old) with liver cirrhosis, who were awaiting liver transplants in our unit, from November 2010 to May 2011. The patients were evaluated by history, physical examination, and laboratory tests, including factor V Leiden, prothrombin gene mutation, Janus Kinase 2 (JAK2) mutation, and serum levels of protein C, protein S, antithrombin III, homocysteine, factor VIII, and anticardiolipin antibodies.Results:There was no statistically significant difference in the assessed hypercoagulable states between patients with or without portal vein thrombosis. A history of previous variceal bleeding with subsequent endoscopic treatment in patients with portal vein thrombosis was significantly higher than in those without it (P = 0.013, OR: 2.526, 95% CI: 1.200 - 5.317).Conclusions:In our population of cirrhotic patients, treatment of variceal bleeding predisposed the patients to portal vein thrombosis, but hypercoagulable disorders by themselves were not associated with portal vein thrombosis.