Outcomes of liver transplantation in simultaneously hepatitis B surface antigen and hepatitis C virus RNA positive recipients: the deleterious effect of donor hepatitis B core antibody positivity.

BACKGROUND: Recent data from Italian studies have shown excellent results of liver transplantation (LT) in hepatitis B virus (HBV)-infected patients with grafts from hepatitis B core antibody (HBcAb)-positive donors, whereas such grafts in hepatitis C virus (HCV)-infected recipients have displayed poorer outcomes. We investigated the results of LT with HBcAb-positive grafts in patients with ongoing HBV and HCV coinfections. METHODS: From August 1999 to December 2009, we performed 27 adult primary LTs from deceased heart-beating donors into recipients showing hepatitis B surface antigen (HBsAg)- and HCV-RNA-positivity simultaneously: 12 patients received a graft from an HBsAg-negative HBcAb-positive donor (core+D group) and 15 from an HBcAb-negative donor (core-D group). Immunosuppression included a calcineurin inhibitor, antimetabolite and steroids which were suspended at 6 months. Anti-HBV prophylaxis was always perfomed with anti-HBs immunoglobulins and nucleos(t)idic analogues. RESULTS: The groups were similar regarding variables of donor, recipient, donor-recipient match, LT procedure, and acute rejection treatment. Median follow-up for surviving grafts was 67 months (range, 16-141). Among all patients, HCV-RNA remained positive after LT. The prevalence of histologically proven recurrent HCV hepatitis was similar in the 2 groups: 83% core+D vs 73% core-D. No recurrent HBV hepatitis occurred during the follow-up. Graft survival at 5 years was significantly lower in the core+D group (core+D 48% vs core-D 87%; P = .018), in which a significantly higher prevalence of graft loss was caused by HCV recurrence (core+D 5/12, 42% vs core-D 1/15, 7%; P = .03). All of the 5 core+D patients who lost their grafts due to HCV recurrence did not receive anti-HCV therapy (4 owing to an aggressive disease and 1 because of patient refusal). CONCLUSIONS: Outcomes of LT in patients with ongoing HBV and HCV coinfection are adversely affected by donor HBcAb positivity, an effect that is mainly mediated by the dismal course of HCV recurrence after LT.

Outcomes of liver transplantation from hepatitis B core antibody-positive donors in viral cirrhosis patients: the prevailing negative effect of recipient hepatitis C virus infection.

BACKGROUND: Liver transplantation (LT) with grafts from hepatitis B core antibody (HBcAb)-positive donors has been the object of recent studies, suggesting different outcomes depending on the etiology of viral cirrhosis in the recipient. METHODS: From November 2002 to December 2009, we transplanted 124 livers from hepatitis B surface antigen (HBsAg)-negative HBcAb-positive deceased heart-beating donors to adult recipients with viral cirrhosis, classified as: HBsAg positive (group 1; n = 63); hepatitis C virus (HCV) RNA positive (group 2; n = 52); and simultaneously HBsAg and HCV-RNA positive (group 3; n = 9). Immunosuppression included a calcineurin inhibitor, mycophenolate, and steroids (tapered to suspension in 6 months). In all groups, anti-HBV prophylaxis was performed with anti-HBs immunoglobulins and nucleos(t)idic analogues. RESULTS: The groups were similar regarding donor, recipient, donor-recipient match, transplant procedure, variables, and treatment of acute rejection, except for younger recipient age in group 1 (P = .009), lower recipient body mass index in group 3 (P = .03), and longer cold ischemia time in group 2 (P = .003). Median follow-up for surviving grafts was 63 (range, 16-102) months. No case of recurrent or de novo hepatitis B occurred. The prevalence of histologically proven recurrent HCV hepatitis was similar in groups 2 and 3 (65% vs 78%). Graft survival at 5 years was 86% in group 1, 35% in group 2, and 31% in group 3 (P < .0001 for group 1 vs 2; P < .01 for group 1 vs 3). On multivariate analysis, independent predictors of worse graft survival were HCV infection in the recipient (HR 8.08, 95% CI 3.36-17.97; P < .0001) and MELD at LT ≥25 (HR 3.72, 95% CI 1.12-12.37; P = .032). CONCLUSIONS: The presence of HCV infection in the recipient is the factor which most negatively influenced the outcome of LT using grafts from HBcAb-positive donors. Allocation of such grafts should consider the type of viral cirrhosis among LT candidates.

Proctocolectomy for ulcerative colitis after liver transplantation for primary sclerosing cholangitis.

BACKGROUND: Sclerosing cholangitis is a chronic cholestatic liver disease of unknown etiology. Immunologic and genetic factors may be involved in the pathogenesis of the disease, characterized by fibrosis involving bile ducts, which can progress to biliary cirrhosis and cholangiocarcinoma (8%-30%). Sclerosing cholangitis is frequently associated with inflammatory bowel diseases, especially ulcerative colitis (60%-80%), which may require a proctocolectomy with ileal pouch anal anastomosis if there is no response to therapy or the appearance of colonic carcinoma. PATIENTS AND METHODS: Among 1629 liver recipients from 1990 to 2008, 47 (2.9%) had sclerosing cholangitis as the cause of cirrhosis. Forty two percent of these also had associated inflammatory bowel disease with 34% displaying ulcerative colitis. Eight patients died after liver transplantation (OLT) in the absence of recurrence of sclerosing cholangitis. Among the remaining 39 patients, 17 (43.6%) developed recurrent of sclerosing cholangitis; three required re-OLT, and among these three patients, one developed another recurrence. After OLT, ulcerative colitis persisted in an active state in eight patients, requiring proctocolectomy with ileal pouch-anal anastomosis for three patients (median time after OLT was 78.6 months). RESULTS: One of the three patients who had proctocolectomy had an immediate complication, a pelvic hematoma, which required a surgical approach. One patient developed acute pouchitis 15 months after OLT, medically treated with antibiotics and corticoids. Histology of the colectomy specimen demonstrated colorectal cancer in two patients (pT3N0 and pT2N0) and high-grade dysplasia in the remaining subjects. All patients displayed a cure of their colonic disease (median follow-up 14 months) despite two patients developing recurrence of the liver disease. CONCLUSION: Proctocolectomy with ileal pouch anal anastomosis is safe in patients who underwent OLT for sclerosing cholangitis in association with ulcerative colitis. If not surgically treated, patients may receive immunosuppression to prevent rejection and disease recurrence, avoiding at the same time the occurrence of "de novo" neoplasms. Mammalian target or rapamycin inhibitors may have an important role but this must be established with randomized controlled trials.

[Cholecystectomy by video celioscopy in the elderly. An obligatory choice?]. / La colecistectomia per via videocelioscopica negli anziani. Scelta obbligata?

The videocelioscopic technique is becoming increasingly widely used in the treatment of cholelithiasis. In view of the results obtained, the authors underline the advantages of this method in geriatrics.

[The diagnosis and treatment of renal oncocytoma. Our experience]. / Diagnosi e trattamento dell'oncocitoma renale. Nostra esperienza.

Personal experience of the treatment of renal oncocytoma is compared with reported data. Furthermore the problems relating to the diagnosis and treatment of this tumour, characterised, in many cases, by its lack of symptoms and tricky histopathological classification, are examined in greater depth.

[Effect of somatostatin and salmon calcitonin on carcinoid syndrome. A clinical case]. / Effetto della somatostatina e della calcitonina di salmone nella sindrome da carcinoide. Caso clinico.

In carcinoid syndrome, calcitonin administration proved to have an effective action in reducing symptomatology. During the perioperative period, treatment with somatostatin, thanks to the ease of administration of the drug and the reductive action of gastroenteric secretion, demonstrated its usefulness in countering the action of serotonin. In the present case, the data reported in the most recent literature on the use of the two drugs in the carcinoid syndrome are confirmed.

[Human sparganosis. A clinical case]. / Sparganosi umana. Caso clinico.

After reviewing the international literature, the Authors report an uncommon case of sparganosis localized in a submandibular gland.