Disseminated adiaspiromycosis: case report of a liver transplant patient with human immunodeficiency infection, and literature review.

Disseminated adiaspiromycosis is a rare infection that is sometimes associated with immunocompromised situations. We report the case of a patient, infected with human immunodeficiency virus and receiving highly active antiretroviral therapy, who had a liver transplant for hepatocellular carcinoma. The patient presented skin and pulmonary lesions due to adiaspiromycosis during immunosuppressive therapy. A review of >60 cases in the literature shows that adiaspiromycosis is a rare infection and Emmonsia is a dimorphic fungus that is difficult to grow. It should be considered a possible diagnosis in case of fungal infection and pulmonary granulomatosis. We should be aware of emerging adiaspiromycosis in patients with risk factors of immunosuppression, particularly transplant recipients. In these patients in particular, liposomal amphotericin B therapy should be considered.

Usefulness of reagent strips for checking cure in spontaneous bacterial peritonitis after short-course treatment.

BACKGROUND: The usefulness of reagent strips to check cure of spontaneous bacterial peritonitis have not been evaluated to date. AIM: To assess the usefulness of ascitic fluid analysis by means of reagent strips to check cure after a 5-day antibiotic course. METHODS: We prospectively included all cirrhotic patients diagnosed with spontaneous bacterial peritonitis. On day 5, conventional and reagent strip ascitic fluid analyses were performed. RESULTS: Fifty-three episodes of spontaneous bacterial peritonitis in 51 cirrhotic patients were included. Five patients died before the fifth day and in two patients, the control paracentesis yielded no ascitic fluid. In nine out of 46 cases (19.6%), spontaneous bacterial peritonitis had not resolved by day 5. In 32 out of 33 cases in which the ascitic fluid polymorphonuclear count was <250/microL at day five, the reagent strips was negative. The negative predictive value of the reagent strip at fifth day was 97% and the LR- 0.13. CONCLUSIONS: Almost 20% of episodes of spontaneous bacterial peritonitis do not resolve with a short-course of antibiotic treatment. In view of the high negative predictive value and low likelihood ratio for a negative test, reagent strips analysis may be an alternative to conventional cytology if a 5-day antibiotic therapy is planned.

Risk of acute liver injury associated with the use of drugs: a multicentre population survey.

BACKGROUND: Acute liver injury of uncertain aetiology is often drug related and quantitative information about the associated risk is scarce. AIM: To estimate the risk of acute liver injury associated with the use of drugs. METHODS: In a population survey study, 126 cases of acute liver injury were prospectively assembled from January 1993 to December 1999, in patients over 15 years of age, in 12 hospitals in Barcelona (Spain). We estimated the relative risk for each drug as the ratio between the incidence of acute liver injury among the exposed population to the drug and the incidence of acute liver injury among those not exposed to it. Drug consumption data were used to estimate the exposed population. RESULTS: Isoniazid, pyrazinamide, rifampicin, amoxicillin with clavulanic acid, erythromicin, chlorpromazine, nimesulide, and ticlopidine presented the highest risk (point relative risk > 25). Amoxicillin, metoclopramide, captopril and enalapril, furosemide, hydrochlorothiazide, fluoxetine, paroxetine, diazepam, alprazolam, lorazepam, metamizole, low-dose acetylsalicylic acid and salbutamol showed the lowest risk (point relative risk < 5). CONCLUSIONS: This study provides a risk estimation of serious liver disease for various drugs that will be useful in its diagnosis and management, and when comparing with the drug therapeutic benefit in each indication. Some observed associations would be worth specific studies.

Clinical features and outcome of spontaneous bacterial peritonitis in HIV-infected cirrhotic patients: a case-control study.

The aim of this study was to evaluate the clinical characteristics and outcome of spontaneous bacterial peritonitis, a serious complication in patients with cirrhosis and ascites, in an HIV-infected cirrhotic population. Thirty-five HIV-infected cirrhotic patients who developed spontaneous bacterial peritonitis during a 12-year period were compared with 70 non-HIV-infected cirrhotic subjects. Patients were matched according to the date of the first episode of spontaneous bacterial peritonitis. A bacteriological diagnosis was made in 37 of 47 (79%) and in 50 of 97 (52%) episodes in the HIV group and in the non-HIV group, respectively (p=0.003), and Streptococcus pneumoniae was isolated more frequently in the HIV group (22 vs. 8%, p=0.02). Median survival after the initial diagnosis of spontaneous bacterial peritonitis was 2.9 and 14.0 months in the HIV group and non-HIV group, respectively. Age (hazard ratio [HR] 1.04; 95%CI 1.01-1.07), male sex (HR 2.55; 95%CI 1.34-4.83), Child-Pugh score at first spontaneous bacterial peritonitis episode (HR 1.29; 95%CI 1.10-1.54), renal impairment at first spontaneous bacterial peritonitis episode (HR 2.61; 95%CI 1.49-4.62), and HIV infection (HR 9.81; 95%CI 4.03-23.84) were independently associated with higher long-term mortality after the first diagnosis of spontaneous bacterial peritonitis. In conclusion, HIV-infected cirrhotic patients with spontaneous bacterial peritonitis have a higher rate of bacteriological diagnosis and a more frequent pneumococcal etiology than non-HIV-infected subjects. Life expectancy in these patients, once spontaneous bacterial peritonitis has developed, is poor. These data are particularly relevant for determining the optimal time for liver transplantation in this population.

[Domino or sequential liver transplantation. Is it a feasible technique?]. / El trasplante hepático dominó o secuencial, es una técnica factible?

BACKGROUND: In domino liver transplantation (LT), the explanted liver of a patient with familial amyloidotic polyneuropathy (FAP) is donated to another patient. PATIENTS AND METHOD: Between February 1999 and March 2001 we performed 131 LT with 121 cadaveric donors in our unit. Ten domino LTs were performed. RESULTS: Patients with FAP were younger (37 years) than recipients of the second LT (64 years). The evolution of patients undergoing transplantation for FAP was excellent and all are currently alive and without complications. Among recipients of the second LT, one patient died in the postoperative period. A further two patients died from tumoral recurrence and hepatitis C virus recurrence 18 months and 9 months after transplantation, respectively. The remaining patients have shown no symptoms of FAP during the follow-up. CONCLUSION: The results of this study show that domino LT is technically feasible. The technique increases the number of grafts without apparent risk either to the recipient with FAP or to the recipient of the latter's explanted liver.

La resección es un buen tratamiento del hepatocarcinoma sobre el hígado cirrótico en pacientes seleccionados / Resection is an effective treatment for hepatocarcinoma in selected cirrhotic patients

Introducción. La resección quirúrgica del hepatocarcinoma sobre cirrosis es una indicación discutida debido a su alta morbilidad y recidiva tumoral. No obstante, debido a la edad de presentación del tumor y el alargamiento de las listas de espera de trasplante, es la única alternativa para muchos pacientes. El objetivo de este estudio es analizar la supervivencia, recidiva y factores pronóstico de la resección del hepatocarcinoma en pacientes seleccionados. Pacientes y métodos. Se analizó una serie de 53 pacientes con cirrosis durante un período de 11 años a los que se realizó una resección hepática por hepatocarcinoma. Se intervinieron 45 varones y 8 mujeres con una edad media de 65,4 (8,4 años). Se indicó la cirugía en tumores de 5 cm o menores, con función hepática óptima y sin evidencia de hipertensión portal. En el 55 por ciento de los casos se realizó una segmentectomía, en el 36 por ciento bisegmentectomía y en el 9 por ciento una resección hepática mayor. Resultados. La mortalidad perioperatoria fue del 2 por ciento. Se confirmó que la presencia de hipertensión portal está directamente relacionada con la aparición de descompensación ascítica y la mortalidad a los 12 meses. La supervivencia fue del 86, el 64 y el 59 por ciento al año, tres y 5 años respectivamente, objetivando que la biloburidad, los nódulos satélite y la ausencia de cápsula son factores de mal pronóstico. La tasa de recidiva fue del 17, el 42 y el 60 por ciento a uno, tres y 5 años, siendo los nódulos satélite y la invasión vascular micro y macroscópica factores directamente relacionados con la recidiva. Conclusiones. La resección es un buen tratamiento del hepatocarcinoma sobre hígado cirrótico en pacientes seleccionados (AU)

Risk factors for development of de novo neoplasia after liver transplantation.

Liver transplant recipients are at greater risk for de novo neoplasia, especially lymphoma and nonmelanoma skin cancer; however, risk factors for this complication have not been well studied. Clinical and pathological records of 137 consecutive liver transplant recipients who had survived for at least 1 year were reviewed to register de novo neoplasia. Ten variables were analyzed for their association with the development of de novo malignancies by means of a log-rank test and stepwise selection in a multivariate analysis using the Cox proportional hazard model. Thirty de novo neoplasias appeared in 22 of 137 transplant recipients between 12 and 104 months after orthotopic liver transplantation (OLT; median follow-up, 69 months): 14 patients had 21 skin cancers, 6 patients had solid-organ cancer, and 3 patients developed a lymphoproliferative disease. Probabilities of de novo neoplasia were 13% at 5 years post-OLT and 26% at 8 years post-OLT. The only associated risk factor for any neoplasia was age. Age and hepatocarcinoma were independent risk factors associated with skin cancer. That hepatocarcinoma in the explanted liver is an independent risk factor for skin cancer suggests there is individual susceptibility to both neoplasias.

Complicaciones de la toracentesis en pacientes cirróticos con derrame pleural / Complications of thoracentesis in cirrhotic patients with pleural effusion

Objetivo : estudiar las complicaciones de la toracentesis, diagnóstica o terapéutica, en pacientes cirróticos con derrame pleural. Diseño experimental: estudio prospectivo de cohortes. Se practicó una toracentesis diagnóstica al ingreso o cuando tuvo indicación clínica y una toracentesis evacuadora a aquellos pacientes con disnea que no mejoraron con tratamiento médico. A todos los pacientes se practicó una radiografía de tórax en las 24 horas siguientes al procedimiento y un seguimiento clínico cuidadoso. Se han estudiado los factores de riesgo para presentar un neumotórax y la probabilidad actuarial de sufrir un neumotórax en el subgrupo de pacientes con toracentesis evacuadoras sucesivas. Pacientes: todos los pacientes cirróticos con derrame pleural ingresados durante un periodo de 4 años. Se incluyeron en el estudio 69 pacientes. Resultados: durante el periodo de estudio se practicaron 245 toracentesis,150 diagnósticas y 95 evacuadoras. La complicación más grave fue el neumotórax que se presentó en 10 ocasiones (4 por ciento); tras de 2 de 150 (1,3 por ciento) toracentesis diagnósticas y tras 8 de 95 (8,4 por ciento) toracentesis terapéuticas (RR, IC 95 por ciento; 6,8, 1,4132,77, p<0,01). El riesgo actuarial de sufrir neumotórax tras toracentesis evacuadoras repetidas ha sido del 7,7 por ciento, 25,3 por ciento y 34,7 por ciento tras la primera, segunda y cuarta toracentesis, respectivamente. Conclusiones : la toracentesis diagnóstica en pacientes cirróticos tiene baja morbilidad. Las toracentesis terapéuticas son un factor de riesgo para el desarrollo de un neumotórax y el riesgo aumenta con la práctica de sucesivas toracentesis. La práctica de una radiografía de tórax no está justificada tras una toracentesis diagnóstica; sin embargo, es recomendable tras una toracentesis terapéutica (AU)

Influence of donor post-reperfusion changes on graft evolution after liver transplant.

INTRODUCTION: The increase in indications for liver transplantation has meant that waiting lists are growing ever longer. For this reason, broadening the donor pool is a priority for most groups. OBJECTIVE: The objective of this study was to analyze the predictive value of post-reperfusion biopsy in the evolution of graft function after liver transplantation. PATIENTS: One hundred and forty-eight liver biopsies, obtained after graft reperfusion, were analyzed. Eight pathological variables and thirty-seven clinical variables of the donors were recorded. Risk factors for presenting primary graft non-function or dysfunction were studied with logistic regression models. Factors associated to the long-term graft failure were studied using Cox analysis and actuarial survival curves. RESULTS: Microvesicular steatosis greater than 50% was the only risk factor associated to graft dysfunction in the multivariate logistic regression model. Microvesicular steatosis greater than 30%, severe hepatocyte necrosis and presence of abundant neutrophilic leukocytes were risk factors associated to graft failure in the univariate study. Only steatosis remained as an independent risk factor in the multivariate study. These grafts also presented poorer long-term survival. Abundant polymorphonuclear infiltrate was associated to a higher frequency of biliary complications. CONCLUSIONS: Microvesicular steatosis implies a better evolution than macrovesicular steatosis. Neutrophilic infiltrate and hepatocellular necrosis lead to poorer initial graft function and reduced long-term survival.

The impact of donor age on liver transplantation: influence of donor age on early liver function and on subsequent patient and graft survival.

BACKGROUND: The urgent need to increase the organ donor pool has led to the expansion of criteria for donor selection. The aim of this study was to analyze the influence of donor age on early graft function, subsequent graft loss, and mortality after liver transplantation (LT). METHODS: Data on LT were evaluated retrospectively in a population-based cohort of 400 LTs in 348 patients. Of these, 21 (5%) were from donors >70 years old. Pretransplantation donor and recipient characteristics and the evolution of recipients were analyzed. The influence of donor age as a risk factor was assessed using univariate and multivariate analyses. RESULTS: Actuarial graft survival was 89% at 1 month after LT, 81% after 6 months, and 59% after 60 months. Multivariate analysis demonstrated that only donor age (>70 years old) was associated with a higher risk of long-term graft loss (relative risk [RR]=1.4, 95% confidence interval [CI]=1-1.9; P=0.03) and mortality (RR=1.7, 95% CI=1.2-2.3; P=0.01). Graft survival of septuagenarian livers was 80% at 1 month after LT, 56% after 6 months, and 25% after 54 months. Actuarial survival analysis (Kaplan-Meier curves) also demonstrated worse evolution in recipients of livers from old donors (log-rank test, P<0.001). CONCLUSIONS: Advanced donor age is associated with lower graft and recipient survival.

Postreperfusion biopsies are useful in predicting complications after liver transplantation.

Biliary complications after orthotopic liver transplantation (OLT) may occur because of preservation injury (PI). In this study, we examine findings on routine reperfusion biopsy specimens in relation to the occurrence of biliary complications and graft outcome. From 1997 to 2000, a total of 193 OLTs were performed in our center. Postreperfusion biopsy specimens were analyzed and histological lesions were graded. For analysis, grafts were grouped into 2 categories: the presence or absence of PI (severe to moderate lesions versus mild or no lesions). Histological evidence of PI was present in 17% of the biopsy specimens. The incidence of grafts with PI and ischemia time longer than 12 hours was 38% compared with 14% in PI and short ischemia time (P =.02). Biliary complications were also more frequent in the PI group (28% v 14%; P =.03). Study of risk factors by means of logistic regression analysis confirmed that the PI group had a greater risk for biliary complications (relative risk, 2.8; 95% confidence interval, 1 to 7.4; P =.03). Moreover, moderate macrovesicular steatosis was found in 6% of the grafts, resulting in a 40% graft loss rate. We found that an increased presence of neutrophilic infiltrates in the postreperfusion biopsy specimen, indicating PI, was related to an increased incidence of biliary complications. Moreover, moderate macrovesicular steatosis was associated with increased graft loss. Therefore, postreperfusion biopsies are useful in anticipating post-OLT complications.

Influencia de los hallazgos de la biopsia post-reperfusión en la evolución del injerto tras el trasplante hepático / Influence of donor post-reperfusion changes on graft evolution after liver transplant

Introducción: el incremento de las indicaciones de trasplante hepático ha comportado el alargamiento de las listas de espera. Por este motivo la ampliación en la utilización de los donantes marginales es una prioridad para la mayoría de grupos. Objetivo: el objetivo de este estudio es analizar el valor predictivo de la biopsia post-reperfusión en la evolución de la función del injerto tras el trasplante hepático. Pacientes: se analizaron 148 biopsias hepáticas obtenidas tras la reperfusión del injerto. Se recogieron ocho variables anatomopatológicas y treinta y siete variables clínicas del donante y receptor. Se estudiaron los factores de riesgo de presentar no-función primaria o disfunción del injerto, mediante modelos de regresión logística. Los factores asociados a la pérdida del injerto a largo plazo fueron calculados mediante análisis de Cox y curvas de supervivencia actuarial. Resultados: la esteatosis microvesicular superior al 50 por ciento fue el único factor de riesgo de presentar disfunción del injerto, en el modelo de regresión logística multivariante. La esteatosis macrovesicular superior al 30 por ciento, la necrosis hepatocitaria severa y la presencia de abundantes leucocitos neutrófilos fueron factores de riesgo de pérdida del injerto en el estudio univariante. Únicamente la esteatosis se mantuvo como factor de riesgo independiente en el estudio multivariante comportando además peor supervivencia del injerto. El infiltrado polimorfonuclear abundante se asoció a mayor aparición de complicaciones biliares. Conclusiones: la esteatosis microvesicular comporta mejor evolución que la macrovesicular. La infiltración por polimorfonucleares y la presencia de necrosis son también predictores de disfunción y tienen peor evolución a largo plazo (AU)

Complications of thoracentesis in cirrhotic patients with pleural effusion.

OBJECTIVE: To study the complications of thoracentesis, either diagnostic or therapeutic, in cirrhotic patients with pleural effusion. EXPERIMENTAL DESIGN: A cohort prospective study. A diagnostic thoracentesis was performed at admission or when spontaneous bacterial empyema was suspected; a therapeutic thoracentesis was conducted in patients with dyspnea that did not improve with medical treatment. A chest radiography and a careful clinical follow up were performed in all patients within 24 hours after the procedure. We studied the risk factors for developing pneumothorax and the actuarial probability of pneumothorax after consecutive therapeutic thoracentesis. PATIENTS: All cirrhotic patients admitted with pleural effusion over a 4-year period. The study included 69 patients. RESULTS: During the study period, we performed 245 thoracentesis, 150 diagnostic and 95 therapeutic ones. The most severe complication was pneumothorax in 10 cases (4%), after 2 out of 150 (1.3%) diagnostic thoracentesis and after 8 out of 95 (8.4%) therapeutic thoracentesis (RR, 95% CI 6.8, 1.41-32.77, p < 0.01). The actuarial risk of pneumothorax after the first, second and fourth therapeutic thoracentesis was 7.7%, 25.3% and 34.7%, respectively. CONCLUSIONS: Diagnostic thoracentesis in cirrhotic patients is associated to a low morbidity. Therapeutic thoracentesis is a risk factor for pneumothorax and the risk increases after consecutive thoracentesis. A chest radiograph is not justified after a diagnostic thoracentesis, but should be done after a therapeutic thoracentesis.

[Analysis of 500 liver transplantations at Bellvitge Hospital, Spain]. / Análisis de 500 trasplantes hepáticos en el Hospital de Bellvitge.

BACKGROUND: We present the experience of the liver transplantation program at the Hospital of Bellvitge with 500 transplantations performed during 15 years, to describe changes in liver transplantation observed throughout the time and to analyze the long term results. PATIENTS AND METHOD: Five groups each one including 100 consecutive transplantations are studied. RESULTS: The main indications were hepatocellular carcinoma (23%), alcoholic cirrhosis (22.8%), and post-hepatitis C cirrhosis (18.8%). Sixty-five retransplantations were performed in 59 patients (13%), being the more frequent indications arterial thrombosis (13 patients) and primary nonfunction of graft (10 patients). In 10 patients a hepatorenal transplantation was performed. In group I, the most frequent donor cause of death was cranial traumatism (80%), while in group V it was the vascular pathology (52%). There were other significative differences between these groups of patients (I vs V): patients with stage 2 or 3 from UNOS status (45 vs 19%), blood use (29.6 [26] vs 4.6 [5.3] PRBC), ICU stay (13 [13] vs 7.4 [11] days), hospital stay (40 [52] vs 23.7 [17] days), rejection rate (46 vs 20%) and primary graft nonfunction (9 vs 3%). However, the infection rates (48 vs 54.5%) and biliary tract complications (26 vs 20%) have not shown statistically significant differences. Actuarial one and 5-year survival are 83 and 70% respectively. CONCLUSIONS: An important and progressive improvement of liver transplantation results has been observed. However, de novo tumours, hepatitis C virus recurrence and chronic rejection can limit long term results.