Liver transplantation in patients with atrial fibrillation.

In this study we described survival and incidence of perioperative and postoperative complications in liver transplant recipients with known atrial fibrillation. A total number of 717 patients underwent liver transplantation between January 2005 and December 2008 at our institution. In this population, preoperative paroxysmal or chronic-persistent atrial fibrillation was diagnosed in 32 patients (4.5%). Of these, 12 patients died during follow-up and 4 patients required liver retransplantation. Perioperative cardiac complications occurred in 10 patients (31%) resulting in 3 cardiac-related deaths. Median patient survival was 1613 days (range, 22-2492) and median graft survival was 1524 days (range, 10-2492). Twenty patients are still alive with a median survival of 1861 days (range, 1189-2492) after liver transplantation.

Liver retransplantation in superobese patients: a single center experience.

A retrospective review of patients who had body mass indeces greater than 40 kg/m(2) who underwent liver retransplantation (LR) from February 1998 to December 2008 at our institution. There were 73 patients who had body mass indeces greater than 40 kg/m(2) and had orthotopic liver transplantation. Six of 73 patients required retransplantation. Median time between orthotopic liver transplantation and LR was 131 days (range, 2 to 2812 days). Indications for LR were ischemic cholangiopathy, hepatic necrosis, recurrent hepatitis C, and primary non-function. Four patients are still alive with median survival of 37 months after LR. Two patients had perioperative death.

Colorectal and anal neoplasms following liver transplantation.

OBJECTIVE: Liver transplantation (LT) is the treatment of choice for end-stage liver disease. The required immunosuppression increases the risk for developing malignancies. Some viruses play a crucial role. Data on neoplasms of the colon, rectum and anus in LT are limited. METHOD: A retrospective evaluation of the incidence and clinical course of colorectal and anal malignancies and colonic polyps in a series of 467 consecutive LTs in 402 individuals between 1998 and 2001 was performed. Standard immunosuppression included Tacrolimus, Mycophenolic acid and steroids. RESULTS: During a median follow up of 5.2 years, three colon adenocarcinomas, one EBV associated cecal posttransplant lymphoproliferative tumour and two HPV associated anal tumours were identified. Pre-LT colonoscopy was performed in 161 patients (40%), and of 153 evaluable individuals, 53 (34.9%) had polyps. Colonoscopy was performed in 186 patients (46.3%) median 14.8 (range 0.2-77.8) months post-LT and 55 (29.3%) had polyps. Post-LT adenomatous polyps were detected in 47.3% of patients with pre-LT polyps vs 6.7% of patients without pre-LT polyps (P < 0.001). Patients with alcoholic liver disease had a significantly higher rate of adenoma formation (50.0% vs 11.1%, P < 0.001). No patient died from colorectal/anal malignancy. CONCLUSION: The incidence of metachronous and new polyp formation in our study is similar to people who are not immunocompromised, but subgroups are at increased risk. Viral-associated malignancies, including post-transplant lymphoproliferative disorders and anal cancer, are important entities in the LT population suggesting that complete screening of the colon, rectum and anus including pre-LT and post-LT colonoscopy should be utilized.

Persistence of hepatitis C RNA in liver allografts is associated with histologic progression independent of serologic viral clearance.

Background. Hepatitis C virus (HCV) nondetectability in the liver may predict a sustained viral response (SVR) in patients with an end of treatment response. HCV RNA can be detected in liver tissue by in situ hybridization (ISH). Aim. To determine if HCV nondetectability in liver allografts by ISH can predict SVR in patients who cleared virus serologically on treatment. Methods. Twenty five patients with undetectable serum HCV on Interferon/Ribavirin therapy for HCV recurrence post liver transplant (LT) were studied. All had biopsies at 4 months post LT (baseline) and follow up with HCV ISH analysis performed. Results. 10 were ISH positive (group 1); 15 were ISH negative (group 2). Groups 1 and 2 had similar patient, donor, and viral characteristics at LT, as well as treatment duration at the time of the ISH assayed liver biopsy (13 +/- 16 versus 10 +/- 4 months P = .24). However, group 1 had longer total treatment duration (24 +/- 10 versus 14 +/- 5 months, P = .001). Eight (80%) group 1 and 9 (60%) group 2 patients achieved SVR. Mean grade and stage (modified Ishak score) were similar at 4 months, however, group 1 had higher grade (3 +/- 1.7 versus 1.6 +/- 1.3, P = .039) and stage (1.4 +/- 1.4 versus 0.5 +/- 0.6, P = .084) on the ISH assayed biopsy, after similar post LT intervals (23 +/- 10 versus 24 +/- 12 months, P = .91). Conclusion. Allograft HCV ISH nondetectability does not predict SVR in treatment responsive HCV recurrence, but is associated with less severe histologic disease.

Case report of lamivudine-resistant hepatitis B virus infection post liver transplantation from a hepatitis B core antibody donor.

The use of allografts from donors with hepatitis B core antibody in liver transplantation (LT) is associated with the risk of de novo hepatitis B virus (HBV) infection. Prophylaxis using hepatitis B Immune globulin (HBIg) and lamivudine alone or in combination has been reported. Yet, there are no standardized regimens and long-term efficacy is not known. We report a case of a patient who underwent LT for alcoholic liver disease who received an allograft from a donor with Hepatitis B core antibody. The patient had no previous exposure to HBV, was vaccinated against HBV, and had demonstrated Hepatitis B surface antibody present in serum before and 6 months after transplantation. Prophylaxis with short-term HBIg (1 week) and indefinite lamivudine was given. De novo HBV infection developed more than 3 years after LT with a lamivudine-resistant polymerase mutant containing the rtM204I and rtl180L/M mutations. We reviewed the risk of de novo post-LT HBV infection in recipients of livers from hepatitis B core antibody positive donors. High risk were HBV naïve recipients, moderate risk recipients had isolated hepatitis B surface antibody (anti-HBs) or hepatitis B core antibody (anti-HBc), while low-risk recipients had both anti-HBs and anti-HBc. We reviewed prophylaxis protocols reported in the literature and made recommendations for management.

Nutrition in hepatic failure and liver transplantation.

Protein-energy malnutrition (PEM) is a common problem in patients with end-stage liver disease, and it is universally present in patients undergoing orthotopic liver transplantation. Although PEM is an independent risk factor for morbidity and mortality, it need not be considered an absolute contraindication for liver transplantation. The etiology of PEM in liver disease is multifactorial and includes decreased nutrient and calorie intake, alterations in intestinal malabsorption and/or maldigestion, and diverse abnormalities of carbohydrate, fat, and protein metabolism. This article reviews the prevalence of malnutrition, its pathophysiology, different modalities for assessment of body composition, and general guidelines for nutritional support in patients with liver disease and liver transplantation.

Histochemical and immunohistochemical characterization of foamy histiocytes (muciphages and xanthelasma) of the rectum.

Despite being relatively common in the rectum, foamy histiocytes have received scant attention as to the antecedent lesion that causes them to form or their histologic characterization on the types of muco-substances they accumulate. One-hundred consecutive tissue sections of the rectum from an equal number of patients were reviewed for the presence of foamy histiocytes, evaluated for their associated histologic features, and examined histochemically for five types of mucin. Immunohistochemical and electron microscopic studies were performed. Forty (40%) of the rectal biopsy tissues contained foamy histiocytes. Patients presented with diarrhea, hematochezia, intestinal habit change, constipation, hemorrhoids, and abdominal pain. Endoscopically, 19 patients were thought to have rectal nodules or polyps. Histologically, 25 of the patients had regenerative changes in the adjacent mucosa and 14 had hyperplastic changes. In 36 patients (90%), the foamy histiocytes were located superficially in the lamina propria. Associated changes indicated that they are found in areas that are subject to an injury that is in a healing phase. These changes included mild fibrosis and chronic inflammation of lamina propria with mild architectural distortion. Thirty-five (88%) cases showed staining for D-PAS, Alcian blue stain pH 2.5, and the cocktail Alcian blue stain/PAS. Mucicarmine was positive in 25 (63%) cases. The Alcian blue stain pH 1.0 was positive in 19 (59%) of 32 cases. Ultrastructural studies showed electron-dense globules. Two cases were histologically identical to the other 38 but they did not stain for any mucin. Ultrastructural features disclosed clear vacuoles and thus represent a xanthelasma of the rectum. The foamy cells in all cases were confirmed to be histiocytes by immunohistochemistry and electron microscopy. Although muciphages and xanthelasma of the rectum may mimic polyps endoscopically, they are not related to any specific symptom or clinical finding, despite the fact that they probably represent remnants of a previous injury. Muciphages contain neutral, weakly acidic or strongly acidic mucin. The main type of acidic mucin is sialomucin with a smaller component of sulfated mucin.

Acute diarrhea: a practical review.

This review provides a practical, simple, and logical approach to the diagnosis and management of patients with acute infectious diarrhea, one of the most common diagnoses in clinical practice. Diarrhea in the immunocompromised host, traveler's diarrhea, and diarrhea in the hospitalized patient are also discussed. Most episodes of acute diarrhea are self-limited, and investigations should be performed only if the results will influence management and outcome. After an adequate history and physical examination, the clinician should be able to classify the acute diarrheal illness, assess the severity, and determine whether investigations are needed. Most patients do not require specific therapy. Therapy should mainly be directed at preventing dehydration. Various home remedies frequently suffice in mild, self-limited diarrhea. However, in large-volume, dehydrating diarrhea, oral rehydration solutions should be used, as they are formulated to stimulate sodium and water absorption. Antidiarrheal agents can be useful in reducing the number of bowel movements and diminishing the magnitude of fluid loss. The most useful agents are opiate derivatives and bismuth subsalicylate. Antibiotic therapy is not required in most patients with acute diarrheal disorders. Guidelines for their use are presented.

Nefazodone-induced liver failure: report of three cases.

BACKGROUND: Liver failure is a rare but devastating result of drug toxicity. OBJECTIVE: To describe three cases of subfulminant liver failure that were probably caused by nefazodone, a new antidepressant that is a synthetically derived phenylpiperazine. DESIGN: Case series. SETTING: Two university medical centers and a children's hospital. PATIENTS: Three women 16 to 57 years of age. INTERVENTION: Two patients underwent liver transplantation; the third was listed for transplantation but subsequently improved. MEASUREMENT: Liver biopsy. RESULTS: Nefazodone was administered for 14 to 28 weeks before the onset of symptoms. The duration of jaundice before onset of encephalopathy ranged from 4 to 6 weeks. All cases of liver failure had similar histologic appearance, with prominent necrosis in the centrolobular areas (zone 3). One patient had successful liver transplantation, one underwent transplantation but died, and one improved without transplantation. The temporal onset of disease after the start of nefazodone therapy suggested severe hepatocellular injury caused by the drug. CONCLUSIONS: Because nefazodone seems to cause severe hepatocellular injury in an idiosyncratic manner, routine liver chemistries should be performed before starting nefazodone therapy and patients should be monitored regularly. Therapy should be discontinued if liver enzyme concentrations become abnormal.

Rimantadine for treatment of hepatitis C infection in liver transplant recipients.

Hepatitis C recurrence after liver transplantation is a serious problem, leading to increased graft loss and morbidity in some individuals. Treatment with interferon and other agents is controversial and not highly efficacious. The use of an effective antiviral agent to reduce or eliminate viral burden is desirable. To this end, we performed an open-label pilot trial to determine if rimantadine would show antiviral activity against hepatitis C virus (HCV) in the posttransplantation setting. Eleven patients with recurrent post-liver transplantation disease, characterized by transaminase level abnormality and HCV RNA in serum and liver biopsy specimens consistent with HCV infection were offered enrollment onto the study. Patients were treated for 12 weeks with rimantadine, 100 mg orally twice daily, and followed up after treatment for up to 8 additional weeks. Serum was collected at 2-week intervals to assess transaminase and HCV RNA levels. Nine patients completed the planned course of therapy. There was no significant change in serum alanine aminotransferase levels during treatment. No patients cleared HCV RNA from the serum, and fluctuations in the viral titer were not clearly associated with the initiation and completion of the active-treatment phase. Rimantadine was well tolerated, with only one patient who stopped therapy for perceived side effects. We conclude that rimantadine monotherapy has no role in the management of recurrent hepatitis C after liver transplantation.

Tests of the liver: use and misuse.

Physicians frequently order batteries of tests that are used to assess liver injury or function. These tests are frequently ordered to screen for disease. However, a lack of understanding of the nature of the assays and the laboratory assignment of normal versus abnormal often leads to unnecessary workup or missed disease. We attempt to describe the nature of the most commonly used laboratory tests for liver disease, including alanine and aspartate aminotransferases, alkaline phosphatase, bilirubin, and gamma glutamyl transpeptidase. In addition, the role of functional tests of the liver, including prothrombin time, and metabolite clearance tests, such as aminopyrine and monoethylglycinexylidine, are examined.

Helicobacter pylori.

Helicobacter pylori is an important cause of chronic active gastritis and is strongly associated with peptic ulcer disease and gastric cancer. H. pylori colonizes the surface of the gastric epithelium with production of a number of factors, resulting in inflammation and an altered mucosa. H. pylori infection occurs world-wide and the mode of transmission most likely is from human to human via the fecal-oral and/or the oral-oral route. Treatment and, in the future, prevention of this infection may result in a marked diminution of upper gastrointestinal tract disease.

The pharmacokinetic characteristics of a hepatobiliary 99mTc-radiopharmaceutical: comparison of the imported and national kits.

In nuclear medicine, the search for the perfect hepatobiliary agent started in 1955 with the rose bengal dye labeled with 131I. With the advent of technetium-99m, many ligands were labeled and Tc-99m-PG and 99mTc-HIDA were among the best suited for this purpose. Both were synthesized at the radiopharmacy laboratory during 1977-1980 and have been used at INNSZ for clinical studies. For the last three years, a new ligand with a bromine atom and an extra methyl radical has been reported as being one of the best third generation HIDAs. We received the gift of several kits of trimethyl-Br-IDA from Sorin Biomedica, Italy, (A) and of Mebrofenin from ININ, Mexico, (B) to be labeled and tested in order to select one of them for clinical work. For a comparative study on the radiopharmacodynamic characteristics of the two labeled ligands, six healthy women volunteered to undergo two tests with a 72 hour hour rest period to assure complete washout. After the I.V. dose of 111 MBq (3 mCi) the dynamic study was started and a total of 127 16-second images were acquired with a Siemens Digitrac 750 scintillation camera coupled to a Scintiview computer. Static images were taken at the end of the dynamic study and after breakfast. Blood and urine samples were collected for 24 hours and the amount of radioactivity was measured with a well type scintillation detector. The radiopharmacokinetic results are listed in tables 1-4.(ABSTRACT TRUNCATED AT 250 WORDS)