Immunosuppression in Liver Transplant Recipients in the Setting of Sepsis.

Management of immunosuppression (IS) in liver transplant recipients in the setting of sepsis is an open stage for debate. The age-long practice of reduction or complete cessation of IS during sepsis has been followed by most centres across the world, although, their exact strategies are highly heterogeneous. On the other hand, the emergence of striking new evidence suggesting that there is, in fact, decreased mortality with the continuation of IS in sepsis, has raised doubts about our previously conceived intuitive notion that IS portends increased risk in sepsis. The theory postulated is that IS agents, perhaps reverse the state of dysregulated immune response in sepsis to that of an iatrogenically modulated immune response, thus dimming the inflammatory cascade and preventing its deleterious effects. Of note, none of these studies reported exaggerated rejection-related complications. These contrasting outlooks have made it rather onerous to formulate an evidence-based recommendation for liver transplant recipients afflicted with sepsis. Inclusion of transplanted patients in randomised controlled trials of sepsis-related interventions seems to be the need of the hour.

Quality of life 5 years following liver transplantation.

BACKGROUND: Data on quality of life (QOL) among liver transplant recipients from India is scarce. We conducted a prospective assessment of QOL and incidence of complications 5 years following liver transplantation (LT). METHODS: Demographic data of 130 patients (M:F = 98:32, mean age 38.4 ± 14.9 years) who had completed at least 5 years after LT were collected and the incidence of new onset metabolic complications and renal dysfunction was analyzed. Liver transplant database (LTD QOL) questionnaire was given to 100 patients and scoring was done on five QOL domains. This was compared to a historical cohort from the liver transplant database of three transplant centres from North America, who had completed the same questionnaire before and 1 year after LT. RESULTS: The incidence of new onset dyslipidemia, diabetes mellitus, renal dysfunction, hypertension and overweight/obesity was 43%, 26.7%, 25%, 16.4% and 15.4%, respectively. Although ethanol-related cirrhosis was the etiology for transplant in 38%, recidivism was not evident in any recipient in this cohort even after 5 years. Significant improvement in QOL was observed in all five domains, namely measures of disease (p=0.001), psychological status (p=0.001), personal function (p=0.001), social and role function (p=0.001) and general health perception (p=0.001) in our patients 5 years after transplant compared to historical data. CONCLUSION: Although metabolic disease is common after LT, there is significant improvement in long-term QOL. Recidivism appeared to be rare in our study population.

Bilious mask: parasite masquerading as malignant gall bladder polyp.

A 31-year-old woman, presenting with right upper quadrant pain, was suspected to have malignant gall bladder polyp based on MRI and CT scan findings. She underwent radical cholecystectomy with excision of bile duct and hepaticojejunostomy. Surprisingly, histology revealed parasitic remnants within the bile duct wall with no evidence of malignancy. A year later, this young woman suffers significant impairment of quality of life, perhaps an aftermath to the radicality of the surgery. Our case demonstrates a masquerade of 'malignant biliary polyp' by a parasite. This raises the need for extensive investigations such as endoscopic ultrasound guided biopsies, parasitic serology and positron emission tomography (PET) scans when patients present with probable malignant biliary lesions, even in difficult-to-access areas. A preoperative diagnosis might have averted an unnecessary major surgery in this young woman.