Etiologies Associated With Elevated Liver Enzymes After Renal Transplant.

OBJECTIVES: One of the most important causes of morbidity and mortality in renal transplant recipients is liver disease. Liver dysfunction is shown in 7% to 67% of kidney transplant recipients. Liver insufficiency accounts for death in up to 28% of kidney transplant recipients. We stratified various etiological factors responsible for elevated liver enzymes in kidney transplant recipients. MATERIALS AND METHODS: We enrolled all patients who fulfilled inclusion criteria. The principal investigator obtained and recorded demographic and clinical information via a standardized form. We reviewed clinical records of kidney recipients with hepatotoxicity during the course of illness, and we analyzed data with SPSS statistical software (version 22). Descriptive statistics were used for continuous and categorical variables. RESULTS: All recipients of living related renal transplants from January 2015 to December 2016 were included in the study (n = 496). We excluded 64 patients with positive serology for hepatitis B or hepatitis C before transplant. Of the remaining 432 patients, 74 (17.1%) had deranged liver enzymes. Forty-one patients (55.4%) had deranged liver enzymes 3 to 4 years after transplant, whereas 23 patients (31.1%) had deranged liver enzymes 4 years after transplant. Liver parenchymal biopsy was performed in 17 patients (23%) to evaluate the etiology. The most common cause of deranged liver enzymes was sepsis, which was seen in 21 patients (28.4%), followed by viral hepatitis, ie, cytomegalovirus hepatitis in 7 (9.5%) and hepatitis C in 6 (8.1%) patients. Other causes included antituberculosis treatment-induced liver injury, autoimmune hepatitis, sinusoidal obstruction syndrome, and nonalcoholic steatohepatitis, observed in 4 patients each (5.4%). CONCLUSION: The most common cause of deranged liver enzymes in patients who received living related renal transplants in our population was sepsis, which can have a substantial effect on graft survival.

Recurrence Rate of Early Hepatitis C Virus Infection After Renal Transplantation Following Successful Treatment of Patients on Dialysis With Direct-Acting Antiviral Agents.

OBJECTIVES: Recurrence of hepatitis C virus after organ transplant has dreadful complications. An excellent response has been shown with direct-acting antiviral agents in transplant recipients. Although a sustained virological response is considered as the virological cure, it requires patients to be on dialysis for 3 months more before undergoing renal transplant, thus increasing the risk of hepatitis C virus reinfection and associated complications. We aimed to determine hepatitis C virus recurrence in renal transplant recipients who had achieved endof-treatment response before transplant. MATERIALS AND METHODS: Per our institutional dialysis protocol, patients who do not achieve rapid virological response are treated with 6 months of direct-acting antiviral agents. All patients who achieve end-of-treatment response are then referred for renal transplant. Our study included kidney transplant recipients who were treated with directacting antiviral agents and had a hepatitis C virus polymerase chain reaction test 3 months after renal transplant. We obtained demographic and clinical data of patients and used SPSS version 20.0 for statistical analyses. RESULTS: Our study included 48 transplant recipients; most were males (81.1%) with mean age of 28.7 ± 9.4 years. All patients received sofosbuvir, daclatasvir, and ribavirin combination before transplant. Most patients (70%) received treatment for 3 months. The polymerase chain reaction test for hepatitis C virus was conducted after a mean of 8.3 ± 3.3 months posttransplant. Laboratory parameters showed total bilirubin of 3.6 ± 17.5 mg/day, alanine aminotransferase of 51.5 ± 80.2 IU/L, and gammaglutamyltransferase of 133.9 ± 220 IU/L. Two recipients (4.2%) had posttransplant recurrence of hepatitis C virus infection. CONCLUSIONS: To our knowledge, this study is the first to document excellent response of direct-acting antivirals in renal transplant recipients who had been referred early for transplant. Thus, dialysis patients can undergo transplant after achieving end-oftreatment response.

Management of Tacrolimus-Induced Toxicity With Normal Serum Levels After Liver Transplant.

Drug-induced liver injury after liver transplant occurs in 1.7% of patients. Tacrolimus is an effective immunosuppressant that is used to treat acute rejection. Although rare, it can cause toxicity, which is demonstrated by cholestatic liver injury. Here, we present a case of a young male patient who was diagnosed with Wilson disease, had penicillaminechelating therapy, and underwent living related liver transplant. Within 1 month posttransplant, he developed deranged, predominantly cholestatic pattern liver function tests. Laboratory parameters showed total bilirubin of 1.12 mg/ dL, alanine aminotransferase of 553 IU/L, gammaglutamyltransferase of 624 IU/L, and tacrolimus level of 10.2 ng/mL. After thorough evaluation, a liver biopsy was performed. Liver biopsy showed hepatocellular necrosis with centrilobular cholestasis without any evidence of graft rejection. However, with normal level of tacrolimus, the biopsy was suggestive of drug-induced liver injury. Thus, tacrolimus dose was reduced, resulting in improved liver function tests and patient discharge from the hospital. Tacrolimus is an effective immunosuppressant after liver transplant and has the ability to treat early acute rejection. The patient's liver biopsy showed hepatocellular necrosis with centrilobular cholestasis without any evidence of graft rejection. Cholestatic liver injury after tacrolimus usually resolves after dose reduction or by switching to another agent. With demonstrated tacrolimus-induced toxicity in liver transplant recipients, despite normal serum levels, transplant physicians should keep high index of suspicion regarding toxicity in the posttransplant setting.

Hepatic manifestations of coronavirus disease 2019 infection: Clinical and laboratory perspective.

The novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2, has become a global challenge of unprecedented nature since December 2019. Although most patients with COVID-19 exhibit mild clinical manifestations and upper respiratory tract involvement, in approximately 5%-10% of patients, the disease is severe and involves multiple organs, leading to multi-organ dysfunction and failure. The liver and gastrointestinal tract are also frequently involved in COVID-19. In the context of liver involvement in patients with COVID-19, many key aspects need to be addressed in both native and transplanted organs. This review focuses on the clinical presentations and laboratory abnormalities of liver function tests in patients with COVID-19 with no prior liver disease, patients with pre-existing liver diseases and liver transplant recipients. A brief overview of the history of COVID-19 and etiopathogenesis of the liver injury will also be described as a prelude to better understanding the above aspects.

Revolution in the diagnosis and management of hepatitis C virus infection in current era.

Chronic hepatitis C virus (HCV) infection is a major global public health problem, particularly in developing part of the world. Significant advances have been made in the early diagnosis and treatment of the disease. Its management has been particularly revolutionized during the past two decades. In this review, we summarize the major advances in the diagnostic and management armamentarium for chronic HCV infection. The focus of the present review is on the newer directly acting anti-viral agents, which have revolutionized the management of chronic HCV infection. Management of uncomplicated chronic HCV infection and of specific complications and special at-risk populations of patients will be covered in detail. Despite the advent and approval of highly effective and well tolerable oral agents, still many challenges remain, particularly the affordability, the equitable distribution and access to later drugs. The World Health Organization aims to eliminate viral hepatitis including HCV by 2030 since its poses a major public health threat. There is an urgent need to ensure uniform and early access to diagnostic and therapeutic facilities throughout the world if the later goal has to be realized.

Successful response of intradermal hepatitis B vaccine in nonresponders of intramuscular hepatitis B vaccine in general and hemodialysis population.

BACKGROUND: Hepatitis B infection is one of the most common infections worldwide, with its vaccination being an effective preventive measure. Nonresponse to hepatitis B vaccination increases population susceptibility to virus dissemination along with detrimental complications. Despite twice intramuscular vaccination series, 14.3% in the general population and 50% in hemodialysis patients fail to mount a response against hepatitis B. We aimed to evaluate the effectiveness of intradermal (ID) vaccination in the nonresponders amongst the general and hemodialysis population. METHODS: A total of 5 doses of 10 µg of hepatitis B vaccine was given intradermally, 2 weeks apart, to both the study groups: patients who were on hemodialysis and the general population group who previously had failed to achieve satisfactory antibody titers with the IM administration of the vaccine. A hepatitis B surface antibody (HBsAb) titer of ≥10 IU/mL and ≥100 IU/mL were considered "responder" and "good responder," respectively. RESULTS: Out of a total of 95 participants, 49 (51.6%) were hemodialysis-dependent. Most of the participants were females 49 (51.6%). The mean age of all the participants was 39.02 ± 13.5 years (range: 18-70 years). Overall, 75.8% of the participants responded to the ID vaccination with a mean HBsAb titer of 263.5 ± 350.1 IU/L. Almost similar vaccination response was observed in both the hemodialysis and general population i.e., 75.5% and 76.1%, respectively (P = 1.00). In the hemodialysis group, the absence of hypertension (P = 0.04) and age ≥36 years (P = 0.016) were associated with an ID vaccination response. CONCLUSION: For those not responding to the conventional IM route of the hepatitis B vaccine, the ID route is an effective way of immunization in this group and this approach would lead to a decrease in infection rates in the vulnerable population such as those on hemodialysis.

Safety and Efficacy of Extracorporeal Shock Wave Lithotripsy for Difficult-to-retrieve Common Bile Duct Stones: A Ten-year Experience.

BACKGROUND AND OBJECTIVE: Extracorporeal shock wave lithotripsy (ESWL) for common bile duct (CBD) stones has been used in the past, but experience is limited. We report our experience of ESWL in the management of difficult CBD stones. METHODS: Patients with difficult-to-retrieve CBD stones were enrolled and underwent ESWL. Fluoroscopy is used to target the stones after injection of contrast via nasobiliary drain. CBD clearance was the main outcome of the study. RESULTS: Eighty-three patients were included (mean age 50.5 ± 14.5 years); these patients were mainly females (43; 51.8%). Large stones >15 mm were noted in 64 (77.1%), CBD stricture in 22 (26.5%) and incarcerated stone in 8 (9.6%) patients. Patients needed 2.1 ± 1.2 sessions of lithotripsy and 4266 ± 1881 shock waves per session. In 75 (90.3%) patients, the fragments were extracted endoscopically after ESWL, while spontaneous passage was observed in 8 (9.6%). Total CBD clearance was achieved in 67 (80.6%) patients, partial clearance in 5 (6%) and no response in 11 (13.2%). Failure of the treatment was observed in large stone with size ≥2 cm (P = 0.021), incarcerated stone (P = 0.020) and pre-endoscopic retrograde cholangiopancreatography cholangitis (P = 0.047). CONCLUSION: ESWL is a noninvasive, safe and effective therapeutic alternative to electrohydraulic lithotripsy and surgical exploration for difficult biliary stones.

Use of sofosbuvir based regimen in patients with end-stage renal disease and chronic hepatitis C; an open label, non-randomized, single arm, single center study from Pakistan.

AIM: we aimed to determine the virological response and safety of Sofosbuvir-based direct-acting antiviral agents (DAAs) in chronic hepatitis C (CHC) patients on long-term hemodialysis (HD). BACKGROUND: With the advent of interferon-free DAAs, the treatment of CHC has been revolutionized. Pakistan is among the countries where novel sofosbuvir (SOF)-free antiviral agents are not available. METHODS: This non-randomized, single-arm, open-label study enrolled all HD patients with chronic HCV infection after informed consent. They were treated with SOF in combination with Ribavirin (RBV) with either interferon (IFN group) or daclatasvir (DAC group), with the virological response assessed according to standard guidelines. Data were analyzed using SPSS version 20.00. RESULTS: Out of 133 patients, the majority (72.9%) were males with the mean age of 31.92 ± 9.88 years. Most patients (50.3%) had HCV genotype (GN) 1, followed by GN 3 in 42.9%, 4 in 1.48% and 2 in 0.7%, while mix GN was documented in 6 (4.4%) patients. Among these, 60 (45.1 %) patients received standard SOF, IFN, and RBV (IFN group) and 73 (54.9 %) received SOF, DAC and RBV (DAC group). End of treatment and sustained virological response at 12 weeks post-treatment were achieved in 133 (100%) and 129 (97 %) patients, respectively. The adverse effects were anemia in 58 (43.6 %) patients and elevated alanine transaminases in 11 (8.1%) patients. CONCLUSION: SOF in combination with either IFN or DAC is an equally efficacious and effective treatment regimen for patients on maintenance HD, especially in resource-poor countries.

To determine the prognostic value of the albumin-bilirubin grade (ALBI) in patients underwent transarterial chemoembolization for unresectable hepatocellular carcinoma.

AIM: We aimed at determining the prognostic value of the albumin-bilirubin grade (ALBI) in patients undergoing transarterial Chemoembolization for unresectable Hepatocellular carcinoma. BACKGROUND: Various noninvasive liver reserve markers are used to predict the severity of liver injury. The role and probability of these markers in predicting the prognosis of patients with hepatocellular carcinoma (HCC) is still unknown. METHODS: Patients who underwent TACE from 2013 to 2017 were included. Patient's age, gender, cause of cirrhosis, ALBI Grade along with the site, size and number of tumors were recorded. Radiological response to TACE was assessed by CT scan at 1 and 3 months after the procedure, respectively. Survival assessment was performed and all patients were assessed for survival until the last follow-up. RESULTS: A total of 71 patients were included. Majority of them were male (80.3 %). The mean tumor size of 6 ± 3.9 cm. Majority of patients (54.9 %) had a single lesion and it was mostly localized to the right lobe (60.5 %). The most common cause of chronic liver disease was HCV (65.3%). Median Child class score (CTP) and MELD score were 7 and 10, respectively. Ascites was treated prior to TACE in 12 patients (16.9 %).Mean ALBI score in the study population was -1.59 ± 0.69, with the majority (49. 2 %) falling in grade 2. The mean duration of survival at the last follow up was of 12.1 ± 12.14 months (1- 49).Univariate analysis showed serum albumin (p = 0.003), serum bilirubin (p = 0.018), CTP score (p = 0.019), ALBI grade (p = 0.001) and presence of varices (p = 0.04) to be the main predictors of 6 months survival after TACE. On Cox analysis, only ALBI score (p = 0.038) showed statistical significant association. CONCLUSION: ALBI grade may serve as a surrogate marker in predicting the prognosis of HCC patients undergoing Transarterial Chemoembolization.

The use of Karnofsky Performance Status (KPS) as a predictor of 3 month post discharge mortality in cirrhotic patients.

AIM: Is Karnofsky Performance Status (KPS) a predictor of 3 month post discharge mortality in cirrhotic patients? BACKGROUND: Cirrhotic patients often experience an abrupt decline in their health, which often leads to frequent hospitalization and can cause morbidity and mortality. Various models are currently used to predict mortality in cirrhotics however these have their limitations. The Karnofsky Performance Status (KPS) being one of the oldest performance status scales, is a health care provider-administered assessment that has been validated to predict mortality across the elderly and in the chronic disease populations. METHODS: We used the KPS performance status scale to envisage short-term mortality in cirrhotic and HCC patients who survive to be discharged from hospital. RESULTS: Our study showed that KPS one week post-discharge, child pugh score, hospital stay, international normalized ratio, serum albumin, total bilirubin and serum creatinine showed statistical significance on univariate analysis. On multivariate analysis, KPS was found to be statistical significant predictor of 3-month mortality. CONCLUSION: Hence KPS can be utilized to identify cirrhotic patients at risk of 3-month post discharge mortality.

Dyspepsia Amongst End Stage Renal Disease Undergoing Hemodialysis: Views from a Large Tertiary Care Center.

BACKGROUND AND OBJECTIVES: Gastrointestinal symptoms are common in patients with end stage renal disease (ESRD) among which dyspepsia is frequently observed. The aim of the study was to determine the frequency and associations of dyspepsia in ESRD patients using the Leeds questionnaire. METHODS: All ESRD patients on maintenance hemodialysis were consecutively enrolled in the study. Leeds questionnaire was used to interrogate the patients for the assessment of dyspepsia. Mean and standard deviation were calculated for age, body mass index (BMI), disease duration and number of hemodialysis sessions. Independent t-test and Chi square tests were used for statistical analysis. RESULTS: Total number of patients was 200, out which 118 (59.3%) were male. The mean age was of 41.4 years. According to the Leeds questionnaire, dyspepsia was present in 62 (63.9%) patients. Younger patients (age 20-40 years) more frequently had dyspeptic symptoms (61.5% patients), retrosternal pain (156 patients, 78.0%), regurgitation (127 patients, 63.5%), dysphagia (67 patients, 33.5%), and nausea (142 patients, 71.0%). Patients presented with intermittent pattern of symptoms in 179 (89.5%) cases, while continuous symptoms in 6 (3.0%). Dyspepsia was associated with aspartate aminotransferase (AST) levels > 25 U/L (P = 0.001), alanine aminotransferase (ALT) levels > 28U/L (P = 0.000) and gamma glutamyl transferase (GGT) levels > 34 U/L (P = 0.002). On multivariate analysis, urea, creatinine, and presenting symptoms of dysphagia and belching showed significant statistical association with dyspepsia. CONCLUSION: Dyspepsia is a common problem affecting patients with end stage renal disease and is associated with raised serum AST, ALT and GGT in such patients.

Correlation Between MELD and UNa/K Ratio in Predicting Renal Dysfunction in Cirrhotic Patients.

BACKGROUND: Renal dysfunction is one of the dreaded complications of cirrhosis. MELD is a validated chronic liver disease (CLD) severity scoring system. Urinary (U) Na/K ratio closely correlates with renal dysfunction in terms of low GFR in cirrhotic patients. PATIENTS AND METHODS: All consecutive patients with decompensated cirrhosis between the age of 18 to 70 years, of either gender, presenting in the outpatients' department of Sindh Institute of Urology and Transplantation, Karachi, from June 2015 to June 2017 were included. The MELD score was calculated and the UNa/K ratio less than 1 was taken as surrogate marker of renal dysfunction. Statistical analysis was performed by SPSS (version 20.0). RESULTS: A total of 71 patients were enrolled. The mean age was 43.79 years and majority were male (67.6%). The most common cause of liver cirrhosis was HCV, found in 42 (59.2%) patients. The mean CTP score was 10.48 ± 2.069 (range: 6-14) with majority of the patients following in class C, that is, 48 (67.6%). Mean MELD score was 21.75 ± 8.96 (range: 8-43). In 57 patients (80.3%), MELD score was > 15.The mean serum creatinine and mean serum sodium were 1.5 ± 1.1 mg/dl (range: 0.37-5.3) and 133.79 ± 6.9 mmol/L (range: 112-152), respectively. Mean urinary sodium and urinary potassium were 38.60 ± 46.64 mmol/L (range: 5-181) and 38.15 ± 23.9 mmol/L (range: 4.3-112), respectively. In majority of study population, UNa/K ratio was below 1, that is, in 52 patients (73.2%). Statistically significant correlation was documented between MELD score and UNa/K ratio (ɤ = 0.34, P = 0.004). CONCLUSION: The inverse correlation between MELD scores and UNa/K ratio indicates that patients with CLD and higher MELD scores might have renal dysfunction. This finding however should be corroborated by large scale studies.

Noninvasive Clinical Predictors of Portal Hypertensive Gastropathy in Patients with Liver Cirrhosis.

BACKGROUND AND OBJECTIVES: Portal hypertensive gastropathy (PHG) is described endoscopically as "mosaic-like appearance" of gastric mucosa with or without the red spots. It can only be diagnosed by upper gastrointestinal (GI) endoscopy. The aim of this study was to determine the diagnostic accuracy of platelet count to spleen diameter ratio (PSR) and right liver lobe diameter to albumin ratio (RLAR) in the detection of PHG using upper GI endoscopy as a gold standard in patients with liver cirrhosis. MATERIAL AND METHODS: This cross-sectional study was conducted in the Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi. All consecutive patients with ages 18-65 years who were screened using esophagogastroduodenoscopy (EGD) to exclude esophageal varices were enrolled. At the same time, findings related to PHG were noted. After informed consent, all the patients had blood tests including platelet count and albumin and abdominal ultrasound determining spleen diameter and right liver lobe diameter. RESULTS: Out of 111 patients, 59 (53.15%) were males with a mean age of 44 ± 12.61 years. Rate of PHG was observed in 84.68% (94/111) cases confirmed by EGD. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of PSR were 87.23%, 5.88%, 83.67%, 7.69%, and 74.7%, respectively, and those of RLAR were 28.72%, 70.59%, 84.38%, 15.19%, and 35.14%, respectively. CONCLUSION: PSR is better predictor of PHG than RLAR but at the expense of relatively lower specificities and NPV likely because of underlying pathophysiology (portal hypertension) which is similar for esophageal varices, PHG, and ascites.

Upper Gastrointestinal Bleeding in Patients with End Stage Renal Disease: Causes, Characteristics and Factors Associated with Need for Endoscopic Therapeutic Intervention.

BACKGROUND AND OBJECTIVES: The risk of upper gastrointestinal bleeding (UGIB) is increased among the end-stage renal disease (ESRD) patients. The aim of the current study was to describe the causes and characteristics of UGIB in ESRD patients at our center and to assess the need for endoscopic therapeutic intervention (ETI) using Rockall (RS) and Glasgow Blatchford scores (GBS). MATERIAL AND METHODS: All patients with ESRD and UGIB with age ≥14 years were included. Frequencies and percentages were computed for categorical variables. Chi square test or Fischer's exact test was used for statistical analysis. RESULTS: A total of 59 subjects had a mean age of 47.25 ± 15 years.The most common endoscopic findings seen were erosions in 33 (55.9%) patients, followed by ulcers in 18 (30.3%) patients. ETI was required in 33 (55.9%) patients, which included adrenaline injection in 19 (32.3%), hemoclip in 9 (15.2%) and argon plasma coagulation in 5 (8.4%) patients. Factors associated with the need of ETI were identified as: a combined presentation of hematemesis and melena (P=0.033), ulcer (P=0.002) and associated chronic liver disease (P=0.015). Six (10.1%) patients died. Death was more common if ETI was not performed (P=0.018). CONCLUSION: ETI was more commonly required in patients on maintenance hemodialysis with UGIB, who had presence of combined hematemesis and melena, ulcers and associated chronic liver disease. A Glasgow Blatchford score of >14 was helpful in assessing the need for ETI in these patients.

Living-Donor Liver Transplant Follow-Up: A SingleCenter Experience.

OBJECTIVES: Liver transplant is a definite treatment of decompensated liver disease. Because of the shortage of livers from deceased donors, living-donor liver transplant is becoming more common. Here, we analyzed our clinical experience in the follow-up care of these patients. MATERIALS AND METHODS: Liver transplant recipients seen at the Sindh Institute of Urology and Transplantation (Karachi, Pakistan) were included in this analysis. Baseline characteristics and follow-up events were recorded. RESULTS: Our study population included 76 liver transplant patients registered at our clinic. Median age was 42 years, with 62 patients (81.6%) being males. The most common indication of transplant was hepatitis C virus-related cirrhosis (42 patients; 55%), followed by hepatitis B-hepatitis D virus coinfection (8 patients; 10.5%). Anastomotic biliary stricture developed in 16 patients (21.1%),which required biliary stenting. Biliary leak developed in 5 patients (6.6%), and renal cell carcinoma developed in 1 patient. Two recipients died due to hepatitis C virus-related fibrosing cholestasis hepatitis and pulmonary com plications. Posttransplant diabetes mellitus developed in 36 (47.1%), hypertension in 17 (38.6%), and dyslipidemia in 19 patients (25%). Of 42 patients with hepatitis C virus infection, 26 were treated with pegylated interferon and ribavirin, of which 65.3% achieved sustained virologic response at 24 weeks. The other 16 patients received sofosbuvir com - bined with ribavirin for 24 weeks. A sustained virologic response at 12 weeks was achieved in 5 patients, with not yet determined results in the remaining patients. Seven patients were lost to follow-up. CONCLUSIONS: Hepatitis C-related cirrhosis was the most common indication for liver transplant, and infection recurrence was observed in our patients. Biliary anastomotic stricture formation was the most prevalent complication after transplant. As liver transplants are becoming more widely available for Pakistani patients at home and abroad, gastroenterologists and trainees in our country should be sensitized, educated, and skilled in the posttransplant care of these patients.

Posttransplant De Novo Hepatitis C Virus Infection in Renal Transplant Recipients: Its Impact on Morbidity and Mortality.

OBJECTIVES: The clinical effects of hepatitis C virus infection acquired after transplant have not been thoroughly studied. We aimed to study hepatitis C virus-related morbidity and mortality with de novo hepatitis C virus infection after renal transplant. MATERIALS AND METHODS: Data from mortality files were retrospectively collected from January 2011 to January 2015. Patients were divided into 2 groups: hepatitis C virus positive (group A) and hepatitis C virus negative (group B). RESULTS: Eighty-one patients were included, with median duration of survival of 39 months after transplant. In group A (32 patients), 78.1% of patients were males, with mean age of 36.83 ± 9.15 years. The mean survival duration was better in group A than in group B (67.59 ± 67.1 vs 58.10 ± 59.6 mo; P = .58). Acute cellular rejection was 25% in group A versus 20.4% in group B, whereas chronic allograft nephropathy was 20.4% for group A versus 18.4% for group B. Hepatitis C virus-related death was observed in 7 patients (21.9%). Infection was the main cause of death, with 40.6% of patients in group A versus 53% of patients in group B. On multivariate analyses, better patient survival was associated with greater interval of acquiring HCV after transplant (P = .038). CONCLUSIONS: HCV infection acquired after renal transplant is not associated with increased HCV-related mortality, and prognosis is related to the time interval of acquiring infection after transplant.

Prevalence and Characteristics of Duodenal Villous Atrophy in Renal Transplant Patients Presenting With Persistent Diarrhea in a Developing Country.

OBJECTIVES: Persistent diarrhea is a common complication after solid-organ transplant, including kidney transplant. Data on duodenal villous atrophy as a cause of persistent diarrhea in renal transplant recipients are scarce. MATERIALS AND METHODS: We conducted a prospective analysis of 207 patients who received renal transplants from 2009 to 2012 with persistent diarrhea and who underwent upper gastrointestinal endoscopy and duodenal biopsies. Duodenal biopsies were examined for duodenal villous atrophy. Age, sex, transplant duration, and drugs were compared between patients with and without duodenal villous atrophy. After exclusion of known causes of duodenal villous atrophy, a 3-month course of antibiotics was given and outcomes were analyzed. RESULTS: Of 207 renal transplant recipients, 104 patients (49.8%) displayed duodenal villous atrophy. Of these, 92 (88.5%) were male patients. The mean age of patients with duodenal villous atrophy was 34.9 ± 10.3 years. The mean onset of persistent diarrhea in DVA-positive patients posttransplant was 2.16 ± 0.8 years. Celiac disease serology was positive in 18 (17.3) patients. Giardiasis was demonstrated in 11 patients (10.7%), whereas immunoproliferative small intestinal disease was shown in 7 patients (6.8%). The remaining 68 patients (65.38%) received antibiotics, with 50 recipients (74.6%) showing complete response, although 13 of these patients (26%) relapsed. Among the remaining 18 patients (26.47%), 9 (50%) had other causes and 9 (50%) had no cause found. Isoniazid prophylaxis showed statistically significant negative association with duodenal villous atrophy. CONCLUSIONS: Duodenal villous atrophy is highly prevalent in renal transplant recipients irrespective of age, sex, and posttransplant duration. We found tropical sprue, giardiasis, immunoproliferative small intestinal disease, and celiac disease to be important causes of duodenal villous atrophy. Therefore, duodenal biopsy is recommended in renal transplant recipients with persistent diarrhea.

Early, non-refractory celiac disease associated with microscopic colitis and splenomegaly.

Celiac Disease (CD), also known as non-Tropical sprue, and Celiac sprue is an immune-mediated disorder, triggered by gluten containing grains in genetically susceptible people. The disease may be diagnosed at any age and can affect many organ systems. Its diagnosis and management can often be challenging. A high index of suspicion is required to diagnose this disease at an early stage in patients presenting with atypical symptomatology and delayed onset. Although serological tests are widely used, duodenal biopsy remains the gold standard for diagnosis of CD. Even though CD affects various body systems, Microscopic Colitis (MC) and refractory sprue are among the main gastrointestinal complications of CD, which are resistant to Gluten-Free Diet (GFD). A thorough and appropriate evaluation is mandatory for an early and accurate diagnosis of these complications. Herein, we report a case of a young female with CD in early phase in concordance with MC and splenomegaly.

Clinical presentation of extrahepatic portal vein obstruction: 10-year experience at a tertiary care hospital in Pakistan.

OBJECTIVE: To evaluate the clinical presentation, possible etiological factors, management and outcome of patients in our hospital with extrahepatic portal vein obstruction (EHPVO). MATERIALS AND METHODS: This study included patients with EHPVO followed up in our department during last 10 years. Patients of cirrhosis with EHPVO were excluded. Patients' clinical presentation, etiology of EHPVO, management and outcome results were analyzed. RESULTS: Of 30 patients, 19 (67.9%) were males. Median age was 12 years. Of 14 patients who underwent liver biopsy 9 had histological activity index stage of 1/6. History of omphalitis and pulmonary tuberculosis was present in one case each. Of 22 patients with the available thrombophilia profile, nine patients had a deficiency of protein C, five patients had a deficiency of protein S, one each had reduced level S of anti-thrombin III and factor V mutation. The predominant presenting symptom was hematemesis (15 patients, 53.6%). Seven patients (25%) had splenomegaly. Three patients (10.7%) had no esophageal varices on endoscopy. Three patients underwent splenectomy due to severe pancytopenia. Endoscopic retrograde cholangipancreatography was performed in four patients (14.3%) due to portal biliopathy. Common bile duct stenting was performed in all four patients. Of them, one patient underwent splenorenal shunt operation for indication of hemobilia. One patient died at the age of 40 years, due to cholangitis and sepsis. CONCLUSIONS: Results from this study show that the anticoagulant deficiency is a common cause of EHPVO in our setup. Hematemesis is a common presenting symptom. Some of these patients have symptomatic portal biliopathy.