Strongyloides stercoralis infection in kidney transplant recipients.

Strongyloides stercoralis is an uncommon infection in Saudi Arabia. It can establish latency and cause an autoinfection in humans that lasts for years. The infection can get reactivated during immunosuppression and can result in a life-threatening Strongyloides hyperinfection syndrome. We present three cases of renal transplant recipients who developed Strongyloides infection following transplantation. A bronchoalveolar lavage specimen, a duodenal biopsy and/or a stool specimen from these patients revealed evidence of S. stercoralis larvae. The first two patients received kidneys from the same deceased donor, a native of Bangladesh, an area that is highly endemic for S. stercoralis. The data suggest that the first two cases might be donor derived. High-risk donors and recipients should be screened for Strongyloides infection to initiate treatment before transplantation thus reducing morbidity and mortality.

Recurrence of hepatitis C virus genotype-4 infection following orthotopic liver transplantation: natural history and predictors of outcome.

BACKGROUND AND OBJECTIVES: There are few reports on hepatitis C virus genotype 4 (HCV-4) recurrences after orthotopic liver transplantation (OLT). Therefore, we undertook a study to determine the epidemiological, clinical and virological characteristics of patients with biopsy-proven recurrent HCV infection and analyzed the factors that influence recurrent disease severity. We also compared disease recurrence and outcomes between HCV-4 and other genotypes. PATIENTS AND METHODS: All patients who underwent OLT (locally or abroad) for HCV related hepatic cirrrhosis from 1991 to 2006 and had recurrent HCV infection were identified. Clinical, laboratory and pathological data before and after OLT were collected and analyzed. RESULTS: Of 116 patients who underwent OLT for hepatitis C, 46 (39.7%) patients satisfied the criteria of recurrrent hepatitis C. Twenty-nine (63%) patients were infected with HCV genotype 4. Mean (SD) for age was 54.9 (10.9) years. Nineteen of the HCV genotype 4 patients (65.5%) were males, 21 (72.4%) received deceased donor grafts, and 7 (24.1%) developed > or =1 acute rejection episodes. Pathologically, 7 (24.1%) and 4 (13.8%) patients had inflammation grade 3-4 and fibrosis stage 3-4, respectively. Follow-up biopsy in 9 (31%) HCV genotype 4 patients showed stable, worse and improved fibrosis stage in 5, 2 and 2 patients, respectively. Of the 7 patients in the recurrent HCV group who died, 6 were infected with genotype 4 and 4 of them died of HCV-related disease. CONCLUSION: This analysis suggests that HCV recurrence following OLT in HCV-4 patients is not significantly different from its recurrence for other genotypes.

A ruptured graft hematoma in the second day after deceased donor liver transplantation: a case report and review.

BACKGROUND: Ruptured liver after transplant is a rare complication. It can lead to graft or patient loss. Few reports are available in literature. CASE REPORT: A 58 y old male patient underwent a deceased donor liver transplant due to hepatitis B virus related cirrhosis. The donor was a 38 y old trauma victim. There were no obvious injuries involving the liver during organ recovery but multiple petechiae appeared on the surface of the right lobe after preservative solution infusion. The transplant procedure was uneventful. The patient recovered quickly. On the second day the patient developed severe hypotension and laparotomy showed a deep laceration in the right lobe separating the anterior and posterior sectors. Massive blood transfusion was needed. Homeostasis was extremely dif fi cult and partial right lobe resection needed to control bleeding. The patient recovered and was discharged two weeks after the transplant. CONCLUSIONS: Hematomas secondary to interventional procedures may be treated conservatively but spontaneous hematomas mostly will need surgery. The presence of petechiae on the surface of the graft may indicate a high energy injury and the possibility of intrahepatic hematoma that may rupture after implantation.

Experience with 122 consecutive liver transplant procedures at King Faisal Specialist Hospital and Research Center.

BACKGROUND: Saudi Arabia is a leading country in the Middle East in the field of deceased-donor liver transplantation (DDLT) and living-donor liver transplantation (LDLT). We present out experience with DDLT and LDLT at King Faisal Specialist Hospital and Research Center (KFSHRC) for the period from April 2001 to January 2007. PATIENTS AND METHODS: We performed 122 LT procedures (77 DDLTs and 45 LDLTs) in 118 patients (4 re-transplants) during this period of time. RESULTS: The number of adult and pediatric procedures was 107 and 11, respectively. The overall male/female ratio was 66/52 and the median age of patients was 43 years (range, 2-63 years). In the DDLT group, the median operating time was 8 hours (range, 4-19), the median blood transfusion was 6 units (range, 0-40), and the median hospital stay was 13 days (range, 6-183). In the DDLT group, after a mean follow-up period of 760 days (range, 2-2085), the overall patient and graft survival rate was 86%. In the LDLT group, the median operating time was 11 hours (range, 7-17), the median blood transfusion was 4 units (range, 0-65), and the median hospital stay was 15 days (range, 7-127). In the LDLT group, and after a mean follow-up period of 685 days (range, 26- 1540), the overall patient and graft survival rates were 90% and 80%, respectively with no significant difference in patient and graft survivals between groups. Biliary complications were significantly higher in LDLT compared to DDLT (P<0.05). Vascular complications were also significantly higher in LDLT compared DDLT (P<0.05). CONCLUSIONS: Both DDLT and LDLT are being successfully performed at KFSHRC with early experience indicating a higher rate of biliary and vascular complications in the LDLT group.

The Kidney Transplant Program at King Faisal Specialist Hospital and Research Center.

More than 1,000 kidney transplants were performed at King Faisal Specialist Hospital and Research Center (KFSH&RC) between 1981-2005. The majority were from living donors. The renal transplant program at KFSH&RC was fundamentally transformed in 2001 with the introduction of renal transplant physicians and the emphasis on multidisciplinary teamwork. This fundamental change has resulted in tripling of the size of the program and in expanding its scope of services to include high-risk patients (highly sensitized with a positive crossmatch). These achievements were coupled with excellent outcome data. The 5-year patient and graft survival rates for adult transplants performed during 2000-2005 were 97% and 94%, respectively, for 268 living donor transplants and 97% and 76%, respectively, for 73 deceased donor transplants. The kidney transplant program at KFSH&RC is now a leading center in the Region and it ranks among the leading kidney transplant centers in the world in terms of size, scope of services and outcomes.

Improving organ donation in Central Saudi Arabia.

OBJECTIVE: Organ transplantation is successful. The main challenge in the Kingdom of Saudi Arabia (KSA) and elsewhere continues to be organ shortage. This shortage was not resolved by utilization of living donors. Previous studies indicate that there is underreporting of brain death cases, lack of completion of documentation process, poor medical care in some instances and finally high refusal rate for consent. In order to put this problem in perspective and find a solution, we initiated a collaborative project between 4 hospitals in Riyadh, KSA and The Saudi Center for Organ Transplantation. The initial result of this project is presented in this article. METHODS: A donor team was formed to deal and facilitate the logistical aspect of donation in the 3 main Ministry of Health hospitals in Riyadh. Data with regard to the number of donors reported, documentation and success rate were recorded over 3-months (October 2003 to December 2003) and compared with the preceding 9 months. RESULTS: During the period from January 2003 to September 2003, the total number of case reported to the Saudi Center for Organ Transplantation in Riyadh region, was 94. Only 53% were fully documented. Families were approached in 45 of these 50 cases in terms of donation and consent was obtained in 15. However, the number harvested was only 10 (11% yield from total number reported). During the period from October 2003 until the end of December 2003, the total number of cases reported from 3 hospitals was 19. Seventeen (90%) of them were documented. The families were approached in 16 cases and consent was obtained in 6. All 6 (32%) donors were harvested. CONCLUSION: The above result clearly indicates that a donor team supporting the intensive care unit (ICU) can improve the donation. It is expected that application of a similar project to more ICUs in KSA will have a substantial positive impact on the rate of organ donation.

Sirolimus-based immunosuppression for liver transplantation in the presence of extended criteria for hepatocellular carcinoma.

An increasing number of patients with hepatocellular carcinoma (HCC) are undergoing evaluation for listing for liver transplantation. Criteria for selection require ongoing review for suitability. A consecutive series of 40 patients with HCC within the standard Milan criteria (single tumors n = 19 < 5 cm, or up to 3 tumors < 3 cm) and beyond (Extended Criteria; single tumors n = 21 < 7.5 cm, multiple tumors < 5 cm) underwent liver transplant with a sirolimus-based immunosuppressive protocol designed to minimize exposure to calcineurin inhibitors and steroids. At 44.3 +/- 19.3 months (mean +/- standard deviation) follow-up, 1- and 4-year survivals (Kaplan-Meier) are 94.1 +/- 5.7% and 87.4 +/- 9.3%, in the Milan group, respectively, and 90.5 +/- 6.4% and 82.9 +/- 9.3% in the Extended Criteria group, respectively. Five patients died during follow-up, only 1 from recurrent HCC. Five tumor recurrences have occurred at median 17 (mean 22 +/- 17) months posttransplant, 1 in the Milan group and 4 in the Extended Criteria group. Median survival in the patients with recurrent tumor is 42 months (mean 45 +/- 25), and the median postrecurrence survival is 15.5 months (mean 23 +/- 16). The rate of patients who were alive and free of tumor at 1 and 4 years is 94.1 +/- 5.7% and 81.1 +/- 9.9%, respectively, in the Milan group and is 90.5 +/- 6.4% and 76.8 +/- 10.5%, respectively, in the Extended Criteria group. Five patients had sirolimus discontinued for toxicity, while 24 of 35 surviving patients have sirolimus monotherapy immunosuppression. In conclusion, the Milan criteria for liver transplantation in the presence of HCC can be carefully extended without compromising outcomes. This sirolimus based immunosuppression protocol appears to have beneficial effects on tumor recurrence and survival with an acceptable rate of rejection and toxicity.

Steroid avoidance in liver transplantation.

Corticosteroids have always played a valuable role in transplantation. Unfortunately, they are subject to a wide range of side effects, such as hyperlipidemia, hypertension, diabetes mellitus, osteoporosis, growth retardation and Cushingoid appearance. Steroids may also exacerbate problems that existed before surgery, including malignancy, hepatitis B and hepatitis C. New, powerful immunosuppressants have allowed steroid use to be reduced or avoided altogether, but use of these regimens is not simple and may be associated with late acute rejection and recurrence of autoimmune disease. The present review examines the rationale for steroid avoidance in liver transplantation and assesses the new regimens that are currently being developed.

Human small bowel storage: the role for luminal preservation solutions.

BACKGROUND: Graft injury incurred during periods of cold storage remains a factor affecting the success of small bowel (SB) transplantation. No one preservation solution, including the gold standard University of Wisconsin (UW) solution, has been able to maintain graft integrity for storage periods paralleling that of other commonly transplanted intra-abdominal organs. We investigated the role for the luminal administration of preservation solutions in a small animal model, documenting significantly improved graft quality. The current study addresses direct clinical applicability using human SB. METHODS: Human SB was obtained at the time of standard multiviscera procurement. After a common intra-arterial UW flush, the SB was immediately removed from the abdomen, randomly divided into three segments, and treated as follows (n=6-9): group 1, no luminal flush; group 2, luminal flush with UW solution; and group 3, luminal flush with an amino acid- enriched solution. Analysis of cellular energetics, permeability, and histologic injury was performed throughout 24 hr of cold storage. RESULTS: Mucosal barrier function, measured by mannitol permeability, was significantly better overall in groups 2 and 3, with 24-hr values measuring 31 and 34 nmol/cm2/hr versus 57 nmol/cm2/hr, respectively (both P<0.05). Significantly less morphologic injury was also noted in the luminally treated specimens (groups 2 and 3) compared with the clinical standard (vascular flush with UW solution). Damage in group 1 reached gross villus denudation with an obvious elevated risk of villus tissue loss, whereas groups 2 and 3 only exhibited epithelial clefting to varying degrees. CONCLUSION: This study supports luminal administration of preservation solutions for improvement of human SB graft quality during clinically relevant periods of cold storage.