Persistent hyperparathyroidism due to mediastinal parathyroid adenoma treated with selective arterial embolization with embosphere: first case in the literature.

Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia in the clinical setting and affects 0.3% of the population. Parathyroidectomy is the only definitive cure. Unfortunately, even in the most experienced hands, persistent primary hyperparathyroidism (P-PHPT) occurs in 4.7% of the patients. Ectopic adenomas are difficult to localize before and during operation and usually end up with P-PHPT. Herein, we presented a case with P-PHPT due to mediastinal parathyroid adenoma that was successfully ablated with selective arterial embolization. A 57-year-old female patient was admitted to our endocrinology clinic with persistent hypercalcemia 4 months after the initial surgery for PHPT that had been performed in another center. The patient did not accept the second operation, and serum calcium and parathyroid hormone (PTH) remained high despite medical treatment with cinacalcet and IV zoledronate. In the 99-m Tc-MIBI scintigraphy with SPECT, a 18 × 12-mm-sized lesion in the mediastinum at the paratracheal region was detected which was confirmed to be a possible parathyroid adenoma with fluorocholine PET and chest computed tomography (CT). The right bronchial artery that was detected to supply the mediastinal mass in CT angiography was selectively catheterized and embolized with embosphere. Right after the procedure, serum PTH and calcium levels were normalized and remained normal in 23 months of follow-up. Selective arterial embolization is a treatment option for ectopically located adenomas which are difficult to resect and in cases with certain comorbidities which constitute a contraindication for surgery.

Imaging of acute pancreatitis and its complications. Part 2: complications of acute pancreatitis.

The Atlanta classification of acute pancreatitis was introduced in 1992 and divides patients into mild and severe groups based on clinical and biochemical criteria. Recently, the terminology and classification scheme proposed at the initial Atlanta Symposium have been reviewed and a new consensus statement has been proposed by the Acute Pancreatitis Classification Working Group. Major changes include subdividing acute fluid collections into "acute peripancreatic fluid collection" and "acute post-necrotic pancreatic/peripancreatic fluid collection (acute necrotic collection)" based on the presence of necrotic debris. Delayed fluid collections have been similarly subdivided into "pseudocyst" and "walled of pancreatic necrosis". Appropriate use of the new terms describing the fluid collections is important for management decision-making in patients with acute pancreatitis. The purpose of this review article is to present an overview of complications of the acute pancreatitis with emphasis on their prognostic significance and impact on clinical management and to clarify confusing terminology for pancreatic fluid collections.

Factors influencing skin ageing in a Mediterranean population from Turkey.

BACKGROUND: Skin ageing is a continuous process, with intrinsic factors determining which extrinsic factors (chronic sun exposure and other environmental factors, particularly smoking) have the greatest effect. AIM: To investigate the effects of lifestyle and environmental factors on skin ageing in a Mediterranean population from Ankara, Turkey. METHODS: In total, 574 (337 women, 237 men; age range 18-89 years) were enrolled into the study. Data were collected on age, gender, weight, height, body mass index (BMI), skin phototype, smoking status, consumption of alcohol (> 3 units/week) and coffee (> 1 cup/day), sun exposure, use of sunscreen and sunglasses, and involvement in sports and physical activities. The Daniell skin-wrinkling grading system was used as a marker of skin ageing. RESULTS: We found that male gender, chronic sun exposure and number of pack-years of cigarette smoking significantly contributed to the formation of facial wrinkles. There was a negative correlation between facial wrinkling and the use of sunscreen and sunglasses and facial wrinkling (P < 0.001 for both). We did not find any significant association between wrinkling score and alcohol consumption, coffee consumption, sports participation or d skin phototype. Moreover, wrinkling score was significantly higher in patients with a BMI < 25 kg/m(2) than in patients with a BMI > 25 kg/m(2) (P < 0.018). Multiple logistic regression analysis was conducted after adjusting for age, gender, smoking status, alcohol consumption, skin phototype, sun exposure, and use of sunglasses and topical sun protection. We found that gender and age were significantly associated with skin ageing (P < 0.014 and < 0.001, respectively). CONCLUSION: In this study, older age, male gender, low BMI, smoking and chronic sun exposure had a negative influence on skin ageing in a Turkish population.

The incidence and management of acute and chronic rejection after living donor liver transplantation.

Living donor liver transplantation (LDLT) is a good alternative to cadaveric liver transplantation for end-stage liver disease. Herein we report the outcome of 132 LDLTs performed between 1999 and 2005, with special emphasis on the incidence and management of acute and chronic rejection. Among the LDLT population a first acute rejection episode (ARE) was clinically suspected in 24% and proven by liver biopsy in 11%. According to the Banff classification, 50% of AREs were grade 1, and 50%, grade 2. There was no grade 3 AREs. The first ARE occurred between 7 days and 23 months posttransplantation (mean 97 days, median 70 days). Ninety-seven percent (31/32) of the AREs occurred within the first year after transplantation and 3% (1/32) in the second year. Among the patients with ARE, 23% developed a second ARE between 4 and 11 months. A third ARE was detected in 8% of patients after month 18. All AREs responded to adjustment of immunosuppressive doses or steroid boluses. Chronic rejection (CR) was detected in 2%. In conclusion, the incidences of ARE and CR are consistent with the previously reported data. Acute and chronic rejections seem to be mild and easily manageable clinical conditions. Our results also showed a significant difference between clinically suspected and biopsy-proven ARE emphasizing the importance of indicated liver biopsies in the management of the LDLT population.

Does pharmaconutrition with L-arginine and/or alpha-tocopherol improve the gut barrier in bile duct ligated rats?

BACKGROUND/AIM: Nitric oxide supplementation and antioxidant therapy modulate gut barrier function, but the relationships between enhanced nitric oxide production, antioxidant administration, and biliary obstruction remain unclear. We evaluated the role of nitric oxide and alpha-tocopherol supplementation in bile duct ligated rats. METHODS: Fifty male Wistar albino rats underwent sham operation (group I; control animals) or bile duct ligation (groups II, III, IV, and V). The ligation groups received the following regimens: standard pellet diet (group II), pellet diet plus intramuscularly administered alpha-tocopherol (group III), and L-arginine-enriched pellet diet without (group IV) or with (group V) alpha-tocopherol. Nitric oxide, malondialdehyde, and alpha-tocopherol concentrations were assessed at the end of 3 weeks. Liver and intestinal samples were scored histologically. Mesenteric lymph node and liver cultures were assessed for bacterial translocation. RESULTS: The liver malondialdehyde concentration was highest in group III. The nitric oxide content in the liver was higher in groups III and V, as were the blood alpha-tocopherol levels. Bacterial translocation was evident following bile duct ligation, but did not differ among the treatment groups. Intestinal histology revealed that group III had the lowest villus height, that group V had the least villus count, and that group II had the highest mucous cell count. The fibrosis scores were higher in groups IV and V. CONCLUSIONS: An obvious effect of alpha-tocopherol (with or without L-arginine) on the gut barrier could not be demonstrated. Moreover, the L-arginine-enriched diet promoted fibrosis in the liver. Thus, while biliary duct obstruction triggers bacterial translocation, nitric oxide and/or alpha-tocopherol supplementation did not seem to improve the gut barrier in our model.

Primary cardiac lymphoma in a heart transplant recipient.

Posttransplantation lymphoproliferative disease (PTLD) is one of the most serious complications of chronic immunosuppression in transplant recipients. Involvement of the cardiac allograft or development of lymphoma in the heart is extremely rare. We report a primary cardiac lymphoma that developed about 14 months after the operation in a cardiac recipient. The patient presented with vague abdominal complaints. Multiorgan failure developed within a short period of time, and the patient died. The diagnosis of "diffuse large cell lymphoma of B cell type" was made on postmortem examination.

Primary hepatic marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type in a liver transplant patient with hepatitis B cirrhosis.

We describe the clinical, histological, and immunohistochemical features of primary hepatic low grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) in a liver transplant recipient with hepatitis B cirrhosis. MALT lymphomas arise in organs normally devoid of lymphoid tissue, which accumulates as a consequence of chronic antigenic stimulation associated with chronic infection or autoimmune disease. Primary hepatic MALT lymphoma is extremely rare; 13 cases have been reported worldwide to date. Our patient is the first case of primary hepatic MALT lymphoma associated with hepatitis B cirrhosis who was treated with orthotopic liver transplantation.

Pancreatic Castleman's tumour: an unusual case.

We present an uncommon case of hyaline vascular type Castleman's disease mimicking a pancreatic tumour. A 56-year-old woman with constitutional symptoms was investigated. Pre-operative interventions failed to produce a definitive diagnosis. Surgical excision was performed and the tumour was diagnosed to be the hyaline vascular type of Castleman's disease histopathologically. Pancreatic Castleman's disease should remain a consideration in the differential diagnosis of a pancreatic mass.

Hepatocellular carcinoma in liver transplant era: a clinicopathologic analysis.

Hepatocellular carcinoma (HCC) is one of the most common tumors in the world, and the prognosis is usually poor. Today, liver transplantation (LT) is a radical but frequently curative treatment modality for HCC. In selected patients, it cures HCC and the underlying cirrhosis at the same time. The present clinicopathological study examined the importance of tumor characteristics for their effects on recurrence and survival rates after LT for HCC. Forty-two native hepatectomy specimens among 250 consecutive orthotopic liver transplantations contained HCC. Patients were predominantly men (30 men, 12 women), ranging in age from 1 to 61 years (median 51). While 20 patients received cadaveric organs, 22 were transplanted from living donors. In 14 patients (33%) HCC presented as a solitary nodule, 5 (12%) as two nodules; 2 (5%) as three nodules; and 21 patients (50%) as more than three nodules. The maximal diameter of the largest tumor not larger than 3 cm in 28 patients (66%), exceeding this size in 14 patients (34%). There was a significant correlation between nodule number and tumor size (r = 0.36, P = 0.05). While 23 patients had no sign of vascular involvement, 17 tumors showed microscopic invasion and two large vessel involvement. There was a positive correlation between vascular invasion and nodule number (r = 0.41, P = 0.05). The histopathological grade of differentiation of the tumors was assessed as "well" in seven patients (14%), moderate in 28 (72%), and poor in 7 (14%). The differentiation was significantly poorer when vascular invasion was observed (r = 0.43, P =.01). According to the TNM classification, 11 patients (26%) were stage I, 6 (14%) stage II, 13 (31%) stage III, and 12 (29%) stage IV. After a median follow-up of 10 months (1-50 months), the overall mortality was 18% (n = 8). Patient survival at 6 month, 1, and 4 years was 88%, 80%, and 60%, respectively. The outcome was significantly poorer for TNM stage IV versus stage I,II, and III tumors to (P =.02). Tumor recurred in three patients at 4,6, and 50 months after liver transplantation. The sites of recurrence were bone, lung, and adrenal glands. In conclusion, liver transplantation represents a safe and feasible treatment for hepatocellular carcinoma with excellent outcomes compared with other treatment modalities. Liver transplantation offers excellent survival rates and chance for cure in stages I, II, and III hepatocellular carcinoma in cirrhotic patients.

An experimental model of hemolysis-induced acute pancreatitis.

The literature indicates that acute pancreatitis is a complication of massive hemolysis with a prevalence of about 20%. We describe an experimental model of hemolysis-induced acute pancreatitis. Hemolytic anemia was induced in rats by a single ip injection of 60 mg/kg of 20 mg/ml acetylphenylhydrazine (APH) in 20% (v/v) ethanol on the first experimental day (day 0). One hundred and fifty Wistar albino rats weighing 180-200 g were divided into three groups of 50 animals each: groups 1, 2 and 3 were injected ip with APH, 20% ethanol, and physiological saline, respectively. Ten rats from each group were sacrificed on study days 1, 2, 3, 4 and 5. Serum amylase, lipase levels and pancreatic tissue tumor necrosis factor-alpha (TNF-alpha) and platelet-activating factor (PAF) contents were determined and a histological examination of the pancreas was performed. No hemolysis or pancreatitis was observed in any of the rats in groups 2 and 3. In group 1, massive hemolysis was observed in 35 (70%) of 50 rats, moderate hemolysis in seven (14%), and no hemolysis in eight (16%). Thirty-three of 35 (94.2%) rats with massive hemolysis had hyperamylasemia, and 29 of these rats (82.8%) had histologically proven pancreatitis. The most severe pancreatitis occurred on day 3, as demonstrated by histology. Tissue TNF-alpha and PAF levels were statistically higher in group 1 than in groups 2 and 3. Acute massive hemolysis induced acute pancreatitis, as indicated by histology, in almost 80% of cases. Hemolysis may induce acute pancreatitis by triggering the release of proinflammatory and immunoregulatory cytokines.

An experimental model of hemolysis-induced acute pancreatitis

The literature indicates that acute pancreatitis is a complication of massive hemolysis with a prevalence of about 20 percent. We describe an experimental model of hemolysis-induced acute pancreatitis. Hemolytic anemia was induced in rats by a single ip injection of 60 mg/kg of 20 mg/ml acetylphenylhydrazine (APH) in 20 percent (v/v) ethanol on the first experimental day (day 0). One hundred and fifty Wistar albino rats weighing 180-200 g were divided into three groups of 50 animals each: groups 1, 2 and 3 were injected ip with APH, 20 percent ethanol, and physiological saline, respectively. Ten rats from each group were sacrificed on study days 1, 2, 3, 4 and 5. Serum amylase, lipase levels and pancreatic tissue tumor necrosis factor-alpha (TNF-alpha) and platelet-activating factor (PAF) contents were determined and a histological examination of the pancreas was performed. No hemolysis or pancreatitis was observed in any of the rats in groups 2 and 3. In group 1, massive hemolysis was observed in 35 (70 percent) of 50 rats, moderate hemolysis in seven (14 percent), and no hemolysis in eight (16 percent). Thirty-three of 35 (94.2 percent) rats with massive hemolysis had hyperamylasemia, and 29 of these rats (82.8 percent) had histologically proven pancreatitis. The most severe pancreatitis occurred on day 3, as demonstrated by histology. Tissue TNF-alpha and PAF levels were statistically higher in group 1 than in groups 2 and 3. Acute massive hemolysis induced acute pancreatitis, as indicated by histology, in almost 80 percent of cases. Hemolysis may induce acute pancreatitis by triggering the release of proinflammatory and immunoregulatory cytokines

Allopurinol hypersensitivity syndrome as a cause of hepatic centrilobular hemorrhagic necrosis.

Extensive and severe hepatic centrilobular hemorrhagic necrosis is a common finding in hepatic vein obstruction and Budd-Chiari syndrome. Some drugs, including allopurinol, can also cause this histopathologic appearance but to our knowledge in this setting the lesions are not so massive. Here we report a case of a 41-year-old female who developed fever, pruritic skin rash, jaundice, eosinophilia, abnormal liver function tests, and acute renal failure 3 weeks after the beginning of allopurinol treatment, complicated with severe hepatocyte necrosis around most terminal hepatic venules suggesting Budd-Chiari syndrome.

Nitroimidazole-induced chronic hepatitis.

Drug-induced chronic hepatitis is a rare pathological condition. There is no reported case with chronic hepatitis secondary to nitroimidazole use. We report a patient who developed nitroimidazole-induced chronic hepatitis following acute exacerbation of hepatitis three times after nitroimidazole use.

Serum zinc status in chronic hepatitis B and its relationship to liver histology and treatment results.

BACKGROUND: It is known that cytotoxic T lymphocytes are responsible for viral clearance in chronic hepatitis B (HBV) infection. Zinc deficiency affects development of acquired immunity by preventing certain functions of T lymphocytes. We investigated the serum zinc levels and the relationship to liver histopathology and response to interferon alpha (IFN-alpha) and lamivudine combination therapy in 28 children with chronic HBV infection. METHODS: A course of IFN-alpha was injected as 5 million U/m2 subcutaneously, thrice a week for 6 months and lamivudine 4 mg/kg per day orally, for 1 year. Normalization of alanine aminotransferase (ALT), loss of HBV DNA, hepatitis B e antigen (HBeAg) seroconversion altogether was considered as end of therapy response (ETR). RESULTS: The ETR was achieved in eight (30.7%) patients. Serum zinc concentrations of 20 healthy children and patients was not significantly different (P>0.05). While pretreatment serum ALT, zinc, histological activity index (HAI) and portal inflammation scores were statistically higher in children who had ETR (P<0.005, P<0.05, P<0.05 and P<0.05, respectively), pretreatment serum HBV DNA was lower (P<0.005). Serum zinc level was correlated with HAI and portal inflammation scores (P<0.01 and P<0.01). CONCLUSION: This study showed the relationship of serum zinc status to liver histopathology and to the ETR and may be a preliminary study leading new studies focusing on zinc status in patients with chronic HBV infection.

Severe toxic hepatitis associated with amoxycillin and clavulanic acid.

Toxic hepatitis secondary to amoxycillin-clavulanic acid is an infrequent clinical picture. Most of the cases are reported to have a benign course. We report two cases of severe hepatic failure following amoxycillin-clavulanic acid use. One of the cases had cholestatic features primarily, and the other had hepatocellular injury prominently. The first case had also findings of trombotic trombositic purpura and had a fatal course.

The effect of trimetazidine on intrahepatic cholestasis caused by carmustine in rats.

This study investigated the effect of trimetazidine (TMZ), known as an anti-oxidant agent, on intrahepatic cholestasis caused by Carmustine (BCNU) in rats. Rats were assigned into four groups. The first group (Saline) consisted of 12 rats, which were injected with 2 ml/kg of saline intraperitoneally (IP) 48 h before the study. The second group (corn oil group, n=15), which were injected with 2 ml/kg of corn oil IP 48 h before the study. The third group (BCNU group, n=16), which were injected with 2 ml/kg of corn oil+25 mg/kg BCNU IP 48 h before the study. The fourth group (TMZ group, n=12), which were injected with 2.5 mg/kg per day of TMZ IP, administered at the same hour of the day as a single-dose. Twelve hour after the first dose of TMZ, corn oil 2 ml/kg+BCNU 25 mg/kg IP were injected, and the rats were included in the study 48 h after the administration of corn oil+BCNU. Following a pentobarbital anaesthesia, abdomen was opened with incision, a cannula was placed into the channel of choledocus, and the amount of bile was measured per hour. Then intracardiac blood sample was taken, and consequently centrifuged to obtain the plasma. Finally, the rats were killed with cervical dislocation, and their livers were removed and weighted. In addition to histopathological examination of liver, the levels of malon dialdehyde (MDA), oxidised glutation (GSSG), and reduced glutation (GSH) were detected. Also the osmolality of bile and plasma was estimated in mOsm/kg. As a result, the biliary flow was seen to decrease in BCNU group (P<0.005), but to be normal in TMZ group. The serum level of conjugated biluribin was higher in BCNU group compared to other groups (P<0.05 for each). Although the level of total glutation was lower (P<0.005) in TMZ group, GSH/GSSG ratio was normal. These findings suggest that TMZ has a protective effect on intrahepatic cholestasis caused by BCNU.

Effects of mast-cell stabilization in cerulein-induced acute pancreatitis in rats.

AIM: In this study we aimed to clarify the role of mast cells in the development and progression of inflammation in cerulein-induced acute pancreatitis (AP) in rats. We have also examined the effects of ketotifen; a mast-cell stabilizing agent in the treatment of acute pancreatitis and its relation with nitric oxide (NO) synthesis. METHODS: In the first part of the study we planned to examine the effects mast cell stabilization in acute pancreatitis, while the second part was focused on examining the relation between NO synthesis and the potential effects of ketotifen in AP. Wistar albino rats were randomly divided into 6 groups (n: 10). In the first part of the study, AP was induced by four subcutaneous (sc) injections of 20 microg/kg body weight of cerulein at hourly intervals in Groups A and B while Group C was treated with saline as the control group. Group B was pretreated with ketotifen 1 mg/kg (ip). In the second part, the study design was similar except for the inhibition of nitric oxide synthesis by N-nitro L-arginine methyl ester (L-NAME) 30 mg/kg (ip) in Groups D, E and F. Group D was treated with L-NAME and cerulein and Group E was treated with ketotifen, L-NAME and cerulein. Group F was treated with L-NAME and saline as the control group. Serum amylase activity and pancreatic myeloperoxidase activity (MPO) were measured. Pancreatic histology and mast-cell count in pancreatic tissue were evaluated. RESULTS: Mast cell count was found to be increased in the pancreatic tissue in cerulein-induced AP. (2.93+/-0.26 vs 1.98+/-0.26; p<0.001). Ketotifen treatment significantly reduced cerulein induced edema (1.30+/-0.21 vs 0.70+/-0.15; p<0.001), neutrophil infiltration (1.50+/-0.16 vs 0.60+/-0.16; p<0.001) and attenuated the increase in amylase (4394.0+/-149.5 U/L vs 3350.5+/-216.9 U/L; p<0.05) and MPO activity (1.14+/-0.13 U/gr tissue vs 0.54+/-0.08 U/gr tissue; p<0.001). Mast-cell count in pancreatic tissue was also decreased significantly with ketotifen pretreatment (2.93+/-0.26 vs 1.70+/-0.21; p<0.05). Inhibition of NO synthesis with L-NAME treatment decreased the beneficial effects of ketotifen. CONCLUSION: It seems likely that mast cell activity may play an important role in the initiation and progression of acute pancreatitis. Ketotifen treatment may reduce the severity of AP in rats. The protective action of ketotifen in cerulein-induced acute pancreatitis is most probably owing to mast cell stabilization and stimulation of NO synthesis.

Efficacy of interferon-alpha2b treatment in children with chronic hepatitis B who have previously undergone therapy for cancer.

BACKGROUND: The aim of the present study was to evaluate the efficacy of treatment with recombinant interferon (IFN)-alpha2b in 12 children with chronic hepatitis B who had previously undergone therapy for cancer. METHODS: Nine children had acute leukemias and the other three children had solid tumors. The mean (+/-SD) age of the children was 8.4+/-3.8 years (range 4-16 years). All cases were hepatitis B virus (HBV)-DNA positive and 11 were hepatitis B e antigen (HBeAg) positive. One was anti-HBe positive (mutant strain). Four cases were anti-delta IgG positive. Liver biopsy revealed chronic hepatitis B in 11 patients and cirrhosis in one patient. Interferon-alpha2b was given at a dose of 5 MU/m2 three times a week, subcutaneously, for 12 months. RESULTS: Elimination of serum HBV-DNA was obtained in three cases, but a further three patients demonstrated a marked decrease in HBV-DNA levels after therapy. Three of 11 patients seroconverted from HBeAg to anti-HBe. Alanine aminotransferase (ALT) levels returned to normal in three of nine cases in whom the ALT levels were high before treatment. At the end of therapy, the mean histologic activity index score was significantly diminished (P = 0.0039). CONCLUSIONS: In conclusion, a 12 month course of IFN-alpha2b induces some beneficial effects on virologic, biochemical and histologic indices in children with chronic hepatitis B who have previously undergone therapy for cancer.

Intramural hydatid cyst of descending aorta complicated by false aneurysm.

Hydatid disease is caused by the larval stage of Echinococcus granulosus, and the resultant fluid-filled cysts almost invariably affect the liver. Primary involvement of the aortic wall is very rare. We report a case of hydatid disease presenting as a huge cyst invading the wall of the descending aorta and complicated by a false aneurysm. Diagnostic problems and operative management are reviewed.

Clinicopathological features of rapidly progressive hepatitis C virus infection in HCV antibody negative renal transplant recipients.

BACKGROUND: Hepatitis C virus (HCV) infection acquired during dialysis treatment generally shows a relatively benign course after renal transplantation (RTx). However, less is known about the course of HCV infection acquired during or after RTx. METHODS: Clinical and histopathological assessment of 15 renal transplant recipients who acquired HCV infection during or after RTx. RESULTS: Alanine aminotransferase levels rose for the first time 1-19 weeks after RTx. HCV RNA was found positive in all patients, but anti-HCV became positive in only nine of them. During a mean follow-up of 21 +/- 12 months, jaundice appeared in 12 patients while ascites and/or hepatic encephalopathy occurred in six. Azathioprine was stopped in all patients. Cyclosporin was also stopped in four patients and in two of them prednisolone was also interrupted for a period of 3-7 weeks. Following this, ascites, hepatic encephalopathy and biochemical disturbances improved, while no deterioration was seen in graft function. Nine of the 15 patients had undergone two consecutive liver biopsies (LB). The first LB revealed cirrhosis in three and chronic hepatitis in six patients; the second LB showed cirrhosis in seven patients. The histological activity index (Knodell's score) progressed from 11.8 +/- 3.5 to 13.8 +/- 3.8. CONCLUSIONS: The results suggest that HCV infection acquired during or after RTx may run an unusual and rapidly progressive clinical and histopathological course at least in some of these patients. Decrease or withdrawal of immunosuppressive drugs may improve early hepatic failure without detrimental effect on graft function during that period.