Combination Drug Products for HIV-A Word of Caution for the Transplant Clinician.

Modern-day treatment regimens for human immunodeficiency virus (HIV) are not only highly effective, but are now more often available as convenient fixed-dose combination products. Furthermore, as medication adherence is of utmost importance in this setting, national guidelines endorse the use of such products. Transplant providers of HIV-infected patients will undoubtedly encounter these products, some of which contain medications known to drastically alter the metabolism of certain immunosuppressants. Herein, we describe an instance of drug interaction-induced calcineurin inhibitor (CNI) nephrotoxicity in a renal transplant recipient being started on a cobicistat-containing combination product for HIV. CNI toxicity, in turn, was resolved with the aid of phenytoin as an inducer of drug metabolism. This case underscores the importance of familiarity with newer combination products on the market and constant communication with HIV-positive transplant recipients and their providers.

Liver transplantation in an adult with adenomatosis and congenital absence of the portal vein: a case report.

Congenital absence of the portal vein (CAPV) is a rare congenital anomaly in which the superior mesenteric veins (SMV) and splenic veins converge and bypass the liver, effectively draining directly into the systemic venous circulation via the inferior vena cava (IVC), or alternatively the renal or iliac vein, creating a native portosystemic shunt. Portosystemic shunting results in clinical manifestations of hepatic encephalopathy as well as a predisposition to focal nodular hyperplasia and tumors, including adenomas, hepatoblastoma, and hepatocellular carcinoma (HCC), by the disruption of enterohepatic blood flow. Historically, CAPV has been thought to be a rare condition found mainly at autopsy, however, in recent years due to advances in radiological techniques, CAPV detection has increased. Herein we describe a patient with known CAPV who initially underwent hepatic resection for HCC. During surveillance, additional masses were discovered and were identified as recurrent HCC. Unfortunately, this patient was not a candidate for further resection or locoregional therapy. We demonstrate that transplantation is a challenging but technically viable option for treatment of HCC complicating adenomatosis-associated CAPV.

Surgical complications of liver transplantation.

Surgical complications remain a frequent cause of morbidity after liver transplantation. A high index of suspicion, aggressive diagnostic testing, and a low threshold for re-exploration are necessary to ensure early treatment of these complications.

Liver transplantation. The last ten years.

8960741 10 years have witnessed a number of changes in the liver transplant process. Key among these changes are the longer preservation times allowed with UW solution, the development of the new techniques for the transplantation of pediatric patients, and the reintroduction of xenotransplantation for both permanent and temporary hepatic support. Early referral and prompt transplant of patients are among the most important keys to successful transplantation. However, owing to the present organ allocation system and the lack of suitable organ donors, potential liver transplant recipients will continue to experience a significant mortality rate on the waiting list. In addition, owing to the long waiting times for suitable donor organs, many patients who would have been excellent low-risk candidates will deteriorate as their liver disease progresses and become high-risk patients for liver transplantation. Expanding the donor pool and modifying the present liver allocation system to shift the flow of organs to the better-risk patients will do more to improve the results of liver transplantation than any other change in the management and transplantation of patients with severe liver disease.

The nature of complications following liver biopsy in transplant patients with Roux-en-Y choledochojejunostomy.

Liver biopsy is an important diagnostic tool in the management of patients following orthotopic liver transplant. We evaluated complications following percutaneous liver biopsy in a group of liver transplant patients who had Roux-en-Y choledochojejunostomies fashioned as part of their biliary reconstruction during liver transplantation. Complications were divided into two major groups: septic complications (including fever, symptomatic bacteremia, cholangitis, infected hematoma and hypotension related to sepsis) and bleeding (defined as hypotension requiring volume expansion greater than 500 cm3 or blood transfusion, hemothorax, intrahepatic or peritoneal hemorrhage and hemobilia occurring within 1 wk of liver biopsy). One hundred ninety-two biopsies were performed in 46 patients with choledochojejunostomies, and 118 biopsies were carried out in an age- and sex-matched control group of patients with choledochocholedochostomy biliary anastomosis. There were no septic complications in the choledochojejunostomy patients and one (0.32%) septic complication in the choledochocholedochostomy patients (NS). Eight bleeding complications occurred (2.6%) in eight patients (8.3%). Five (2.6%) occurred in five (10.8%) of the choledochojejunostomy patients, vs. three (2.5%) in three (6.5%) choledochocholedochostomy patients (NS). None of the bleeding complications required surgical intervention or was fatal. We conclude that liver biopsy in posttransplant patients with Roux-en-Y choledochojejunostomies is a safe procedure and that the incidences of complications were similar in our two groups. The negligible incidence of septic complications in the choledochojejunostomy patients does not appear to warrant the administration of prophylactic antibiotics, as has been previously suggested.

Pediatric living-related and cadaveric liver transplantation: a single center experience.

Living-related liver transplantation is becoming more commonplace worldwide in the treatment of end-stage liver disease in the pediatric age group. Our LRD experience has resulted in patient and graft survival rates comparable to our cadaveric donor recipients. The incidence and severity of acute rejection episodes were similar. This differs from the clear immunologic advantage of living-related donation in kidney transplantation. It may, however, reflect the relatively small numbers in our LRD group. Overall, however, the technical complications are manageable with early intervention, yielding acceptable results.

Endoscopy in the diagnosis of gastrointestinal Mycobacterium avium-intracellulare infection.

Two cases of mycobacterium avium-intracellulare (MAI) infection in association with acquired immunodeficiency syndrome (AIDS) are presented to highlight the distinctive upper gastrointestinal endoscopic appearances: 2 X 4 mm diameter, white nodules with intervening erythema and hemorrhagic erosions covered the mucosa of the second part of the duodenum. Histological evaluation of these nodules revealed diffuse expansion of the lamina propria by macrophages that contained numerous intracellular and extracellular acid-fast organisms. We conclude that endoscopy with endoscopic biopsy may represent the most rapid and sensitive diagnostic tool available in this disease.

Effect of sucralfate on theophylline absorption in healthy volunteers.

The effect of oral administration of sucralfate concurrently with a single oral dose of non-sustained-release theophylline was studied in eight healthy male volunteers. A two-way, randomized, cross-over study design was used. During the control phase, each subject received a single 5-mg/kg dose of a non-sustained-release theophylline product. During the treatment phase, a 1-g sucralfate tablet was ingested four times a day for two days before the theophylline dose, with the theophylline dose, and six hours after the dose. Plasma samples were collected at frequent intervals for 24 hours after theophylline dosing. Plasma theophylline concentrations, determined by high-performance liquid chromatography, were similar in the absence and presence of sucralfate. No significant differences in theophylline half-life or mean residence time between the control and treatment phases were observed. A significant decrease in the area under the plasma drug concentration-time curve was observed in the presence of sucralfate. However, the magnitude of this change was minimal and unlikely to be clinically important. In these healthy subjects, the concomitant administration of sucralfate with a single dose of non-sustained-release theophylline did not alter the rate or extent of theophylline absorption to a clinically important degree.

Elevation of chemotactic factor inactivator in alcoholic liver disease.

Defective regulation of neutrophil chemotaxis occurs in patients with alcoholic liver disease. One potent mediator of neutrophil chemotaxis is the complement-derived neutrophil chemoattractant, C5a, which can be inhibited by a serum protein, chemotactic factor inactivator. We hypothesized that chemotactic factor inactivator elevation might, in part, explain the defective neutrophil chemotaxis seen in patients with alcoholic hepatitis. To test this hypothesis, sera were collected from 22 patients with alcoholic hepatitis and 9 normal controls, and evaluated for the antigenic presence of chemotactic factor inactivator using an ELISA test. Chemotactic factor inactivator levels were found to be markedly elevated in patients with alcoholic hepatitis (162 +/- 24 micrograms per ml) compared to normals (60 +/- 3 micrograms per ml, p less than 0.01). Subdividing the hepatitis patients revealed that the elevation of chemotactic factor inactivator was found to be greatest in those patients with mild alcoholic hepatitis (prothrombin time within normal limits and bilirubin less than or equal to 5 mg per dl, 256 +/- 44 micrograms per ml, p less than 0.001), while the group with the severest hepatic dysfunction (prolonged prothrombin time and bilirubin greater than 5 mg per dl) did not differ significantly from controls (71 +/- 11 micrograms/ml, p less than 0.2). Importantly, the inhibition of C5a-induced chemotactic activity by partially purified chemotactic factor inactivator correlated with antigenic amounts of chemotactic factor inactivator in serum (r = 0.63, p less than 0.05). The C5a inhibitory activity in sera obtained from patients with alcoholic hepatitis coprecipitated with chemotactic factor inactivator when serum was precipitated by ammonium sulfate precipitation (45 to 64% saturation).(ABSTRACT TRUNCATED AT 250 WORDS)