Combined Liver-Pancreas Transplantation as Novel Treatment for Patient With Cystic Fibrosis: A Case Report.

BACKGROUND: A 21-year-old woman diagnosed with cystic fibrosis developed cirrhosis, exocrine pancreatic insufficiency, and insulin-dependent diabetes mellitus. The patient qualified for double organ liver-pancreas transplantation beyond typical indications. The respiratory symptoms of cystic fibrosis were moderate and well-treated. The patient was endangered mainly by liver insufficiency and recurrent hypoglycemia, which was due to the treatment of diabetes with high doses of insulin. Computed tomography showed mild bronchiectasis, cirrhotic liver, splenomegaly, and atrophy of the pancreas. Pseudomonas aeruginosa colonized the upper respiratory tract. Gastrointestinal complications were sufficient for the patient to be qualified for combined liver-pancreas transplantation. METHODS: First, a standard hepatectomy was performed. The liver was transplanted orthotopically. Subsequently, the team performed pancreas transplantation through a separate incision. The donor's duodenum was anastomosed to the recipient's jejunum, close to the ligament of Treitz. RESULTS: No serious complications were noted during the postoperative period. Transplanted organs started functioning without delay. The patient was discharged after 6 weeks in general good condition. Twenty months later, the patient felt well, and the grafts kept functioning properly. CONCLUSION: Combined liver-pancreas transplantation in patients with CF restores exocrine and endocrine pancreatic function and minimizes the risk of life-threatening complications associated with liver insufficiency. Improvement of life quality coincides with the possibility of discontinuing insulin and pancreatic enzyme supplementation. The combination of liver and pancreas transplantation may prevent advanced pulmonary complications, extend the prognosis of survival, and improve the long-term life quality.

Pregnancy after liver transplant: maternal and perinatal outcomes.

BACKGROUND: Liver transplantation is a life-saving and successful therapeutic procedure which is more and more frequent worldwide, also among women of reproductive age. Consequently, there is an increasing number of reports of pregnancy following liver transplantation, but doubts still exist regarding preconception counseling and the optimal method of managing pregnancy. The aim of this study was to report and evaluate pregnancy outcomes in women who had undergone liver transplantation. METHODS: We retrospectively analyzed female patients after orthotopic liver transplantation who reported pregnancy and were under medical care of a single transplant center. RESULTS: We identified 14 pregnancies in 10 women who had undergone liver transplantation (12 childbirths, one induced abortion due to fetal death in the first trimester, one pregnancy is still ongoing). Causes of transplantation include congenital or acquired disorders and the most common indication was autoimmune hepatitis (50%). The mean age at the point of transplantation was 28.5 (range 21-36), mean maternal age at pregnancy was 32 (range 26-43), and transplant-to-pregnancy interval was 4.07 years (range 1.5-7). The mean gestational week was 36.67 (range 31-40). Immunosuppression was maintained with combinations of prednisone (n = 11), tacrolimus (n = 13), and azathioprine (n = 8) prior to and during pregnancy. Two pregnancies were unintended, so women took mycophenolate mofetil in the first weeks of gestation. Another two women stopped taking azathioprine due to increasing anemia. Maternal complications included increase of aspartate transaminase and alanine transaminase (n = 2), anemia (n = 4) and hyperthyroidism (n = 2). Among the 12 childbirths, five (41.67%) were preterm. Only five women entered labor spontaneously, while seven (58,33%) had cesarean delivery. CONCLUSIONS: Pregnancy after liver transplantation can achieve relatively favorable outcomes. Liver transplantation does not influence women's fertility and, during pregnancy, we report low rates of minor graft complications. A multidisciplinary team should be involved in contraceptive, fertility and consequently pregnancy counseling of female transplant recipients.

Copeptin (CTproAVP) - A Biomarker of a Circulatory Impairment in Liver Transplant Recipients? A Prospective, Observational Study.

BACKGROUND: Copeptin, an easily measured and stable surrogate marker of arginine vasopressin, is a biomarker of a homeostasis disorder and a circulatory impairment in a wide spectrum of morbidities. The aim of this study was to evaluate the potential of copeptin as a biomarker of a circulatory impairment in patients undergoing liver transplantation (LT). METHODS: This was a prospective, observational study. Blood samples were obtained from 38 patients undergoing LT. Serum copeptin level was measured by means of a sandwich immunoassay pre-, intra-, and postoperatively up to 21 days after the operation. RESULTS: The mean concentration of copeptin remained in the range of values slightly below 1000 pg/mL during the analyzed observation period and remained higher than the values observed in healthy individuals. Intraoperative and immediately postoperative copeptin levels did not correlate with hemodynamic parameters. There was also no correlation between preoperative copeptin levels (C1) and preoperative Model for End-Stage Liver Disease scores, serum creatinine levels, plasma transaminase levels, international normalized ratio, or hematocrit (Spearman ρ, P > .05). CONCLUSIONS: Preoperative copeptin levels are elevated in most LT recipients and remain elevated for 21 days after surgery. There was no correlation between the concentration of copeptin and the Model for End-Stage Liver Disease-Sodium score or the cause of a hepatic failure. It cannot be concluded that copeptin is a biomarker of a circulatory impairment in patients with transplanted liver in the perioperative period. The secretion of vasopressin, as measured by copeptin concentration during and after LT, requires further study.

Cutaneous nocardiosis in a liver transplant recipient - case report.

Solid organ transplant recipients are specific group due to taken immunosuppressive agents. This can result in side effects including infections caused by rare opportunistic pathogens. A CASE REPORT: A 64-year old woman after orthotopic liver transplantation due to primary biliary cirrhosis and autoimmune hepatitis was admitted to hospital because of several infections. A painful lesion on left lower leg was noticed 3 months after surgery, while the patient was hospitalized with pneumonia. The Doppler ultrasound showed no signs of deep vein thrombosis. In the course of next month, the inflammatory infiltration has increased and the patient was readmitted to the hospital. After another ultrasound and MRI, which revealed solid-cystic character of the lesion, erythema nodosum was suspected. However, no pathogens were detected in blood and tissue cultures. After empiric antibiotic therapy regression of the lesion were observed. Recurrence of inflammation of the skin, the subcutaneous tissue and the knee joint resulted in readmission to the hospital after 3 months. Empiric antimicrobial therapy was administrated again and the dose of immunosuppressive agent was reduced. Since there was no bacterial growth in another routine culture of blood and synovial fluid, samples were cultured for opportunistic bacteria - Nocardia spp, Cryptococcus spp, Nontuberculous mycobacteria. Nocardia abscessus has grown after few weeks. Ceftriaxone, then trimethoprim-sulfamethoxazole (3x960 mg for 6 months) was administered according to antibiogram. Treatment resulted in regression of the lesion, pain alleviation and simultaneous liver function tests elevation. CONCLUSIONS: Cutaneous and subcutaneous nocardiosis is a rare infection. Solid organ transplant recipients are at risk of nocardiosis so it should be considered in differential diagnosis, especially when infections are hard to treat.

Impact of Blood Loss and Intraoperative Blood Transfusion During Liver Transplantation on the Incidence of Early Biliary Complications and Mortality.

Biliary complications are one of the most serious and dangerous complications following liver transplantation. Factors that may determine their occurrence are still being assessed. The retrospective analysis of 239 consecutive liver transplantations (LT) performed between January 2013 and December 2018 was conducted in compliance with the Helsinki Congress and the Istanbul Declaration. We divided recipients into 2 groups depending on whether biliary complications occurred. The first (biliary complication [BC group]) consisted of patients who developed biliary complications (n = 41) and the second (nonbiliary complications [NBC group]) without them (n = 198). Demographic and statistical data analysis showed no differences between the groups in terms of age, Model for End-Stage Liver Disease with sodium serum concentration (MELD-Na) score, and average cold or warm ischemia time. In comparison, estimated intraoperative blood loss, 1341 mL in the NBC and 1399 mL in the BC, was not significantly different, as were the number of transfused red blood cells (RBC) units, which were respectively 1.7 and 2.1 (P = ns). The recipients' hemoglobin levels just before surgery were (11.5 g/dL vs 11.6 g/dL; P = ns) and after transplantation (9.8 g/dL vs 9.8 g/dL; P = ns). Eleven patients died within 30 days of transplantation. This group was characterized by a higher MELD-Na score (25 vs 17; P = .01), lower pretransplant hemoglobin level (10 g/dL vs 11.6 g/dL; P = .02), and the number of transfused RBC units (3.3 vs 1.7; P = .01). However, there was no correlation between intraoperative blood loss, the number of transfused RBC units, pre- and postoperative hemoglobin levels, and the incidence of biliary complications after LT. Lower pretransplant hemoglobin levels and a higher amount of intraoperatively transfused blood products were associated with a higher fatality rate after LT.

Colonoscopy Surveillance in Liver Transplant Recipients for Primary Sclerosing Cholangitis Associated With Inflammatory Bowel Disease.

OBJECTIVE: The aim of this study was to assess gastrointestinal (GI) monitoring in the group of patients who underwent orthotopic liver transplantation (OLTx) because of primary sclerosing cholangitis (PSC) concomitant with inflammatory bowel disease (IBD). METHODS: Analysis was performed of data collected from medical histories and telephone calls in 33 patients who underwent OLTx in the Department of General and Transplantation Surgery of the Medical University of Warsaw from 2001 through 2017 because of PSC concomitant with IBD. RESULTS: Only 52% of patients claimed they stayed under constant supervision of a GI clinic. The remaining 48% patients were exclusively under transplantation clinic supervision, which controlled graft function. Of 27 patients, 18 (67%) underwent regular colonoscopy examination. According to the American Society of Gastrointestinal Endoscopy and other international organizations' guidelines, patients with PSC and IBD should have yearly screening colonoscopy. Only 9 patients met these guidelines. The median of intervals between colonoscopies among the other 9 patients was 2 years. Among the remaining 9 patients who did not have regular colonoscopy, the gap between endoscopic examinations reached 10-14 years. Fifteen patients (55%) had at least 1 polyp resected during the colonoscopy examination. CONCLUSIONS: Fewer than half of patients follow the medical recommendations concerning their health condition and screening. The main reason for not performing regular colonoscopies was remission and/or lack of symptoms of IBD. According to the previously mentioned guidelines, the absence of symptoms of IBD does not exempt patients from annual colonoscopy. Some of the negligence was a result of lack of adequate access to gastroenterology specialists.

A deceptive case of emphysematous cholecystitis complicated with retroperitoneal gangrene and emphysematous pancreatitis: clinical and computed tomography features.

PURPOSE: Emphysematous cholecystitis (EC) is an uncommon, severe variant of acute cholecystitis caused by gas- forming bacteria - most often Clostridium perfringens and Escherichia coli. We present a deceptive case of EC associated with retroperitoneal gas gangrene and emphysematous pancreatitis. CASE REPORT: An 86-year-old, overweight woman was admitted to the emergency department with non-specific abdominal symptoms. Admission laboratory tests showed elevated diastase levels indicating acute pancreatitis. Computed tomography (CT) demonstrated a substantial amount of gas in the retroperitoneum and peritoneal cavity, which raised a suspicion of duodenal perforation. Primary diagnosis was not confirmed during emergency laparotomy, which revealed a gangrenous gallbladder adjacent to the duodenum and surrounded by purulent fluid. The final diagnosis established after laparotomy and rereading of CT scans was that of emphysematous cholecystitis associated with gangrenous pancreatitis and retroperitoneal gangrene. After surgery, the patient was transferred to the intensive care unit in septic shock. Shortly after, the second laparotomy was undertaken on suspicion of internal bleeding. During surgery, the patient experienced cardiac arrest and died despite immediate resuscitation. CONCLUSIONS: Emphysematous cholecystitis may be associated with a spread of infection both to the peritoneal cavity and retroperitoneum and result in a substantial amount of gas in those anatomic compartments. The knowledge of this rare complication may be helpful in establishing a correct diagnosis.

Liver Transplantation for a Metastatic Pancreatic Solid-Pseudopapillary Tumor (Frantz Tumor): A Case Report.

d_abstr_CB Solid-pseudopapillary neoplasms (SPN) of the pancreas, first described by Frantz in 1959, are a very rare entity and account for 0.13-2.7% of all pancreatic neoplasms. They are seen predominantly in young women in their second and third decade of life. d_abstr_CCR We report a case of a 51-year-old female first diagnosed with a pancreatic tumor in 2010 following a computed tomography (CT) scan of the abdomen. The lesion was originally thought to be a neuroendocrine tumor subsequently treated with chemotherapy, which delayed the appropriate treatment. The tumor was rediagnosed as a SPN only after pancreatectomy was performed. Due to the fact that the neoplasm metastasized to the liver, the patient underwent an orthotopic cadaveric liver transplantation (OLTx) in 2013. During the postoperative period lymph node metastases were identified in the abdomen. The patient received surgical treatment and palliative radiotherapy. Presently no signs of recurrence are found either in the bed of pancreatic resection or in the transplanted liver. The function of the transplant organ has demonstrated no abnormalities over the 4-year follow-up. d_abstr_CC SPN of the pancreas is a rare disease associated with heterogeneous clinical course ranging from benign to metastatic. Choosing appropriate treatment requires individual clinical assessment of the disease's spread. Partial living donor liver transplantation or cadaveric liver transplantation might prove an effective therapeutic option for patients with multiple SPN metastases in the liver. It ought to be remembered, however, that the experience in this area is quite limited.

Negative Correlation Between Hepatitis C Virus (HCV) and Let-7 MicroRNA Family in Transplanted Livers: The Role of rs868 Single-Nucleotide Polymorphism.

BACKGROUND Genetic alterations of TGF-ß pathway members, including its transmembrane receptor, TGFBR1, may influence the course of HCV infection. Rs868 is a single-nucleotide polymorphism of the 3'UTR region of TGFBR1, located in a binding site for the conserved let-7/miR98 microRNA family. Previously, we demonstrated a favorable course of hepatitis C recurrence after liver transplantation in rs868 AG genotype of the transplanted liver when compared to rs868 AA. The aim of the present study was to confirm the biological effect of rs868. MATERIAL AND METHODS HepG2 cell line was transfected with luciferase vectors cloned with 3'UTR of TGFBR1 gene encompassing different rs868 alleles. Post-transplant liver biopsies from 61 patients with HCV-related end-stage liver disease were evaluated histopathologically and analyzed for the expression of TGFBR1 mRNA, let-7/miR98 microRNAs, HCV RNA load, and rs868 genotype. RESULTS Luciferase expression was significantly lower in the A allele-containing vector. TGFBR1 mRNA and HCV RNA load were correlated negatively with let-7/miR98 microRNAs and this correlation was significantly stronger for rs868 AG compared to AA genotype. A strong positive correlation was demonstrated between TGFBR1 and HCV in both genotypes. In AG heterozygotes, let-7/miR98 microRNAs showed a strong negative correlation with periportal or periseptal interface hepatitis (Ishak A score). CONCLUSIONS There is a negative correlation between let-7/miR98 microRNAs and HCV viral load and TGFBR1 mRNA after liver transplantation. In the rs868 AG heterozygotes, this correlation was stronger and there was a negative correlation between let-7/miR98 and Ishak A score, which is in concordance with the previously demonstrated protective role of this genotype in post-transplant hepatitis C recurrence.

The impact of the recipient and donor interferon lambda-3 polymorphism on the course of HCV infection following liver transplantation.

AIM OF THE STUDY: Aim of the study was to assess the impact of the recipient and donor interferon lambda-3 (IFNL3) single-nucleotide polymorphisms (SNPs) rs12979860 and rs8099917 on the course of hepatitis C virus (HCV) reinfection following liver transplantation. MATERIAL AND METHODS: The study involved 141 subjects after liver transplantation for HCV-induced cirrhosis, performed between 2000 and 2015. It assessed the impact of both SNPs on the outcomes of interferon/ribavirin (IFN/RBV) treatment following transplantation, HCV viral load, laboratory test results, histological lesions in the liver graft, the risk of acute rejection, and the development of hepatocellular carcinoma (HCC) in patient's own liver. RESULTS: In the case of rs12979860, SVR was achieved in 58.8% of recipients with the CC genotype, and only 12% of recipients with the TT genotype (p = 0.016). Recipients with the rs12979860 CC variant had lower viral load and lower alanine transaminase (ALT) activity than recipients with a non-CC variant. Opposite effects were demonstrated in the analysis of the donors' genotype. Recipients with the unfavorable variants (rs12979860 TT and rs8099917 GG) had a lower risk of graft rejection and tended to have a higher risk of developing HCC in their own liver. CONCLUSIONS: The IFNL3 rs12979860 polymorphism may be considered a predictor for IFN/RBV effectiveness following liver transplantation. The course of HCV reinfection following liver transplantation may be more aggressive if an unfavorable variant in the recipient coexists with a promising variant in the donor. Particularly careful monitoring for HCC in recipients with unfavorable IFNL3 variants is warranted.

Prognostic value of perioperative assessment of plasma cardiac troponin I in patients undergoing liver transplantation.

An elevation in plasma cardiac troponins is an indicator of increased perioperative risk in orthopaedic and vascular surgery, however, data on liver transplantation (LTx) are scarce. The aim of the study was to evaluate the prevalence of cardiac troponin I (cTnI) elevation in the perioperative period of LTx, and its potential relationship with 1-year mortality. MATERIAL AND METHODS: Analysis included 79 patients with liver cirrhosis. During LTx all patients underwent hemodynamic measurements. cTnI level was determined before the operation, 24, 48 and 72 hours afterwards. One-year mortality was assessed. RESULTS: 12.7% patients died, all during in-hospital period. cTnI level on day 1. was identified as the most promising marker of increased death risk with optimal cut-off value of 0.215 ng/mL (the sensitivity of 60.0%, specificity of 87.0%, positive predictive value of 40.0%, negative predictive value of 93.8%). The most important predictor of cTnI increase was the duration of the LTx procedure followed by amount of packed red blood cells transfused, basic stroke volume index, and cardiac output index. IN CONCLUSION: value of cTnI level assessed 24 hours post-surgery was a reliable predictor of death following LTx with optimal cut-off value of 0.215 ng/mL. The surgery time was the most important predictor of cTnI elevation.

Nursing Problems in Care of a Patient with Very Early HCV Infection Recurrence After Liver Transplantation: A Case Report.

BACKGROUND Recurrent HCV infection following liver transplantation is a common problem, and usually has a more aggressive course than primary infection. The aim of the paper was to present nursing problems in the care of a 22-year-old female patient after liver transplantation (Ltx) with a rapid recurrence of HCV infection shortly after Ltx. CASE REPORT Ltx was performed 22 July 2012 due to chronic cirrhosis secondary to HCV infection with viremia (HCV PCR 3.5×107 IU/mL). Graft function worsened 14 days following transplantation. Acute cholestatic hepatitis related to HCV reinfection was diagnosed based on biopsy. During a period of 20 months the patient received 3 different antiviral treatment regimens, beginning with a dual therapy (Interferon and Ribavirin), followed by the inclusion of Telaprevir, then Daclatasvir; however, these treatments were not successful. The fourth-line regimen with sofosbuvir (EU medical experiment) led to viremia elimination (HCV PCR) after 5 weeks of treatment. However, hepatic failure stabilization was unsuccessful, there was an increase in encephalopathy, and the MELD score was 25. Therefore, the patient underwent liver retransplantation. In the post-transplantation period, the patient was in good condition, with no viremia. CONCLUSIONS The most common nursing problems in the care of the patient were associated with the diagnostic process, therapies used (including experimental treatment), and progressive liver failure. The therapeutic success should be attributed to the intensive supervision and monitoring of viremia, immediate inclusion of adequate treatment methods, adequate patient preparation for diagnostic tests, and careful care after diagnostics, as well as psychological support and education.

Bone Mineral Density and Bone Turnover Markers Under Bisphosphonate Therapy Used in the First Year After Liver Transplantation.

BACKGROUND Rapid bone loss occurs early after liver transplantation (Tx), concomitantly with intensified bone turnover. In the present study we investigated the effect of bisphosphonates (bisph) added to vitamin D (vitD) and calcium on bone mineral density (BMD) and bone biomarkers in liver graft recipients in the first posttransplant year. MATERIAL AND METHODS In 28 patients BMD was determined at the third month after Tx. In case of osteopenia (Tscore ≤-1.0) and no contraindications, oral bisph was started for 1 year (group BP, n=14); other patients served as controls (CON, n=14). The changes in BMD and biomarkers of bone formation were osteocalcin (OC), bone alkaline phosphatase (BAP), and resorption. Study endpoints were active isoform 5b of the tartrate-resistant acid phosphatase (TRACP5b), serum pyridinoline crosslinks (PYD), and urine excretion of deoxypyridinoline (Dpd) crosslinks. RESULTS In 19 (68%) patients, reduced BMD (T-score ≤1.0) was observed at baseline. The changes in lumbar BMD in BP and CON groups were 5.2% and 1.5%, respectively, not reaching statistical significance. Baseline PYD, Dpd/creat, and OC were elevated in all patients, indicating high bone turnover. We observed decrease in PYD and Dpd/creat in both groups; however, OC decreased only under bisph therapy. Increase in BAP was observed in the control group but not in the BP group. The changes in BAP and OC were significantly different (p<0.01). CONCLUSIONS Combining bisph with vitD and calcium is an effective bone- sparing strategy in liver transplant recipients in the first posttransplant year. Bisph more efficiently decreased the rate of bone turnover than vitD and calcium alone.

Liver Failure Impairs the Intrahepatic Elimination of Interleukin-6, Tumor Necrosis Factor-Alpha, Hepatocyte Growth Factor, and Transforming Growth Factor-Beta.

The strategic location of the liver and its metabolic activity make it a key organ regulating homeostasis. Our purpose was to examine its participation in removal of cytokines: interleukin-6 (Il-6), tumor necrosis factor-alpha (TNF-α), hepatocyte growth factor (HGF), and transforming growth factor-beta (TGF-ß) from the portal circulation in human. 20 liver donors and 20 patients with end-stage liver failure were included in the study. Their blood was collected during liver transplantation from the portal, hepatic, and peripheral vein, and the hepatic artery and cytokines' concentrations were determined. Using the results the mathematical model of cytokine elimination by the liver was developed. In donors significantly lower levels of IL-6, TNF-α, HGF, and TGF-ß were detected in portal blood compared to hepatic vein. In patients with cirrhosis there were no significant differences of IL-6, TNF-α, and TGF-ß levels between portal and hepatic veins. Significantly higher level of HGF in hepatic compared to portal vein was observed. In healthy liver elimination of the cytokines prevailed over their synthesis, as reflected by the positive values of the elimination ratios. In the cirrhotic liver elimination ratios of Il-6, HGF, and TGF-ß were negative indicating the prevalence of intrahepatic synthesis of cytokines over their removal.

The first Polish liver transplantation after Roux-en-Y gastric bypass surgery for morbid obesity: a case report and literature review.

BACKGROUND: Morbid obesity is associated with liver pathology, most commonly non-alcoholic steatohepatitis (NASH) leading to cirrhosis. However, the morbid obesity impedes qualification for organ transplantation. CASE REPORT: We present a case report of a 56-year-old woman who underwent bariatric procedure followed by liver transplantation (LTx). Her initial weight was 130.2 kg (BMI 50.9 kg/m2). The patient had a history of arterial hypertension, diabetes, gonarthrosis, and obstructive sleep apnea syndrome and no history of alcohol abuse. She underwent Roux-en-Y gastric bypass (RYGB) procedure. The routine intraoperative liver biopsy revealed fibrosis (III°), steatosis (II°), and intra-acinar inflammation. The operation led to a substantial loss of weight. Two years after the surgery the patient was referred to the Transplantation Clinic of Department of General Surgery and Transplantology with suspicion of liver failure due to advanced cirrhosis, which could be a result of previously diagnosed NASH and, probably, excessive alcohol use after bariatric surgery. The patient was qualified for elective LTx, which was performed 3 years after the RYGB. Immediately before LTx, the patient's weight was 65 kg (BMI 25.4 kg/m²). The postoperative period was complicated by bleeding into the peritoneal cavity, which required reoperation. She also had renal failure, requiring renal replacement therapy. One year after LTx, she showed stable liver function with normal transaminases activity and bilirubin concentration, remission of diabetes, and good renal function. CONCLUSIONS: Steatohepatitis in morbidly obese patients may lead to cirrhosis. Bariatric procedure can be a bridge to liver transplantation for morbidly obese patients with advanced liver fibrosis.

Liver transplantation for nonresectable metastatic solid pseudopapillary pancreatic cancer.

BACKGROUND: Solid pseudopapillary tumor (SPT) of the pancreas, also known as Franz tumor, Hamoudie tumor, solid-cystic-papillary epithelial neoplasm, or solid and cystic tumor, is a neoplasm of transitory (potential) malignancy, seen predominantly in young women. CASE REPORT: This report presents a female patient treated for a solid pseudopapillary tumor of the pancreas with hepatic metastases. The tumor was first diagnosed in 2006. Non-specific abdominal pain was the first presenting symptom. The patient underwent distal pancreatic resection and splenectomy in July 2006. Multifocal metastatic disease seen at surgery precluded radical resection. Following definitive pathology confirmation and the exclusion of extrahepatic metastases, the patient was referred to our transplant centre 18 months after pancreatic surgery, to be considered for orthotopic liver transplantation (OLTx). The extent of the disease was once again evaluated by imaging studies, followed by exploratory laparotomy. The patient underwent cadaveric liver transplantation in March 2008, with triple immunosuppression (tacrolimus, MMF, and steroids) following surgery. Presently, more than 5 years post-transplant, the patient has no signs of recurrent neoplasmatic disease. CONCLUSIONS: This is the first liver transplantation for a metastatic pancreatic pseudopapillary tumor in Poland, with the longest follow-up period described in the literature. Follow-up suggests a cautiously optimistic prognosis despite primary unresectability of hepatic metastases and the necessity for immunosuppressive therapy.

Liver transplantation for HCV cirrhosis; cautious optimism after 10 years of experience.

BACKGROUND: Currently, HCV (hepatitis C virus) cirrhosis is one of the most common indications for liver transplantation (LTx) in Europe and North America among adults. Very early after LTx, histological examinations of liver biopsies in a group of HCV-positive recipients show important differences compared to other indications for transplantation. MATERIAL/METHODS: We described results of 121 primary LTx for HCV cirrhosis. HCV-RNA PCR was positive in 94% of primary graft recipients prior to LTx. Co-existing HCC was diagnosed in 20.66% of recipients. RESULTS: One-year, 5-year, and 10-year survivals in the HCV-positive recipient group were 87.6%, 85.9%, and 84.3%, respectively. Symptomatic recurrent hepatitis was diagnosed in 58/121 (47.54%) recipients, and 41.3% presented with recurrence within the first 6 months. None of the PCR-negative recipients developed recurrent hepatitis prior to LTx. The rescue therapy for recurrent HCV hepatitis consist of Interferon and Ribavirin; the sustained virologic response (SVR) was obtained in 50% and 41% of recipients at 24 and 48 weeks, respectively, after treatment cessation. CONCLUSIONS: Despite almost universal recurrence of HCV after LTx, results of transplantation are relatively good. Modification of immunosuppression, younger organ selection, and avoiding steroid pulses for rejection improve the results. Inclusion of combination therapy with interferon and Ribavirin allows for more than 40% SVR.

Invasive fungal infections following liver transplantation - risk factors, incidence and outcome.

BACKGROUND: The incidence of invasive fungal infections (IFIs), particularly candidiasis and aspergillosis, following solid organ transplantation vary from 1.4% to 42%. IFIs most commonly occur after orthotropic liver transplantation (OLT), lung/heart and pancreas transplantation. Mortality related to IFIs depends on the type of transplant and vary from 3% to 100% of cases. The results largely depend on early initiation of specific treatment for IFIs. Therefore, the diagnosis has to be prompt and based on known risk factors - time of surgical procedure, type of biliary anastomosis, blood loss, rate of rejection and re-transplantation. MATERIAL/METHODS: We evaluated the incidence of fungal infections in patients after liver transplantation in our center. The retrospective analysis of 175 consecutive OLT patients was undertaken to estimate incidence, risk factors and clinical courses of IFIs in the last 6 years at our center. RESULTS: Infections involving Aspergillus (6 cases), Candida (24 cases) and Cryptococcus (1 case) were observed in 17.7% of our recipients. Except for 1 case (Cryptococcus encephalitis), all of the episodes developed during the first month post-transplantation. All cases of lung aspergillosis developed in patients with autoimmune cholestasis prior to transplantation. In 1 case after transplantation, in a patient with bile duct necrosis requiring reoperation, pneumonia developed. In 3 cases, pulses of steroids were used to treat acute rejection. Apart from that, none of the potential risk factors of IFIs described by other authors were noted. Five out of 6 cases of aspergillosis survived on combined antifungal therapy. The recipient diagnosed with cryptococcal encephalitis died. All cases with urinary tract (n=18; 8.6%) or respiratory (n=6; 3.4%) candidiasis survived. CONCLUSIONS: Early diagnosis and prompt treatment is fundamental for patient survival.

Unexpected fatal right ventricular rupture during liver transplantation: case report.

BACKGROUND: The pulmonary artery catheter provides most hemodynamic informations, which are necessary for the patient monitoring during liver transplantation. However, its application may be associated with complications. CASE REPORT: Authors present a case of unexpected right ventricular rupture during liver transplantation in a 53-year-old male, with end-stage liver disease secondary to hepatitis C virus and alcohol abuse. The most likely cause of this complication was myocardial scarification of right ventricle during introducer sheath inserting. There was six hours period between vessel cannulation and the first signs of heart failure, which occurred in the final anhepatic phase. Attempts to surgical repair of damaged heart wall failed and the patient died. CONCLUSIONS: Based on the present case analysis we suggest to restrict the introduction depth of dilatator and possibly shorten it 2-3 cm by the manufacturer. We should also note that time elapsed from the vessel cannulation to cardiac tamponade first signs does not preclude this procedure as a cause of this fatal complications.

The use of thromboelastometry in the assessment of hemostasis during orthotopic liver transplantation reduces the demand for blood products.

BACKGROUND: Bleeding due to fibrinolysis is a serious intraoperative complication during orthotopic liver transplantation (OLT). For a number of years aprotinin was used to minimize risk of this complication. This drug was however banned in 2007 and substituted with other antifibrinolytics. The aim of the study was to assess the potential of intraoperative thromboelastometry to evaluate hemostasis and channelize antifibrinolytic therapy. MATERIAL/METHODS: Since ban on aprotinin, 39 patients underwent OLT in our center with no monitoring of fibrinolysis (NMF). Severe disturbances of hemostasis assessed clinically only as a need for blood and blood products transfusion and were treated with transfusion of fresh frozen plasma only. In 2008 we started to use thromboelastometry (ROTEM group, n=39), which allowed for targeted treatment of hyperfibrinolysis with tranexamic acid. RESULTS: The need for blood transfusion in ROTEM group was insignificantly a lower than in NMF group (4.1±4.76 vs 5.53±4.89 units, p=0.2). Patients from ROTEM group required also less plasma transfusions (10.01±7.47 vs 13.15±6.62, p=0.06). Severe fibrinolysis was found in 3 patients from ROTEM group (7.7%) and was treated with tranexamic acid. CONCLUSIONS: Thromboelastometry provides an immediate diagnosis of fibrinolysis, justifies implementation of targeted treatment and confirms effectiveness of the therapy. In a larger study group it can also result in significant minimization of blood products transfusion during OLT.