Assessment of the Quality of Life in Patients After Liver Transplantation as an Important Part of Treatment Results.

INTRODUCTION: Organ transplantation for many patients with end-stage liver disease is a life-saving operation. Progressing at a time and usually irreversible damage to the organ directly leads to many life-threatening complications as well as to progressive deterioration in health and the quality of life (QOL). On the other hand, the assessment of QOL after liver transplantation, apart from the survival analysis, should take into account general health perception, physical activity, a place in the family and in the environment, as well as the patient's social and professional activity. MATERIAL AND METHODS: The study group included 238 patients (128 women and 110 men) who underwent transplantation in various transplantation centers in Warsaw due to chronic and acute liver failure. To measure the QOL the author's questionnaire was used, which was made especially for this study. RESULTS: There were no significant correlations found between the subjective QOL of the examined patients and socio-demographic and clinical variables, such as age, gender, education, marital status, occupational status, and time from the organ transplantation. However, a significant correlation was found between the perceived QOL of patients and the following variables: physical activity, pain and other symptoms, social and family life, sex life, and psycho-emotional state. It was also proved that the problems with maintaining a normal body weight after liver transplantation significantly affected the overall health of patients. CONCLUSIONS: Liver transplantation in the vast majority of patients, despite numerous complaints, facilitates functioning in various fields of life. On the other hand, the indicated discomfort in the area of mental and emotional health requires easier access to a psychologist. At the same time, there is a justified requirement for education and nutritional counselling for patients after liver transplantation because of the proven risk of occurrence of cardiovascular disease.

Salivary proteomics in bisphosphonate-related osteonecrosis of the jaw.

OBJECTIVE: The objective of this study was to identify differentially expressed salivary proteins in bisphosphonate-related osteonecrosis of the jaw (BRONJ) patients that could serve as biomarkers for BRONJ diagnosis. SUBJECTS AND METHODS: Whole saliva obtained from 20 BRONJ patients and 20 controls were pooled within groups. The samples were analyzed using iTRAQ-labeled two-dimensional liquid chromatography-tandem mass spectrometry. RESULTS: Overall, 1340 proteins were identified. Of these, biomarker candidates were selected based on P-value (<0.001), changes in protein expression (≥1.5-fold increase or decrease), and unique peptides identified (≥2). Three comparisons made between BRONJ and control patients identified 200 proteins to be differentially expressed in BRONJ patients. A majority of these proteins were predicted to have a role in drug metabolism and immunological and dermatological diseases. Of all the differentially expressed proteins, we selected metalloproteinase-9 and desmoplakin for further validation. Immunoassays confirmed increased expression of metalloproteinase-9 in individual saliva (P = 0.048) and serum samples (P = 0.05) of BRONJ patients. Desmoplakin was undetectable in saliva. However, desmoplakin levels tended to be lower in BRONJ serum than controls (P = 0.157). CONCLUSIONS: Multiple pathological reactions are involved in BRONJ development. One or more proteins identified by this study may prove to be useful biomarkers for BRONJ diagnosis. The role of metalloproteinase-9 and desmoplakin in BRONJ requires further investigation.

Design features of the Diabetes and Periodontal Therapy Trial (DPTT): a multicenter randomized single-masked clinical trial testing the effect of nonsurgical periodontal therapy on glycosylated hemoglobin (HbA1c) levels in subjects with type 2 diabetes and chronic periodontitis.

BACKGROUND: Evidence suggests that periodontitis is associated with prevalent and incident type 2 diabetes mellitus (T2DM), raising the question of whether periodontitis treatment may improve glycemic control in patients with T2DM. Meta-analyses of mostly small clinical trials suggest that periodontitis treatment results in a modest reduction in glycosylated hemoglobin (Hb) A1c. PURPOSE: The purpose of the Diabetes and Periodontal Therapy Trial (DPTT) was to determine if periodontal treatment reduces HbA1c in patients with T2DM and periodontitis. METHODS: DPTT was a phase-III, single-masked, multi-center, randomized trial with a planned enrollment of 600 participants. Participants were randomly assigned to receive periodontal treatment immediately (Treatment Group) or after 6 months (Control Group). HbA1c values and clinical periodontal measures were determined at baseline and 3 and 6 months following randomization. Medication usage and dosing were assessed at each visit. Periodontal treatment consisted of scaling and root planing for a minimum of two 90-minute sessions, plus the use of an antibacterial mouth rinse for at least 32 days afterwards. The primary outcome was change in HbA1c from baseline to 6 months and the trial was powered to detect a between-group difference of 0.6%. Secondary outcomes included changes in periodontal clinical measures, fasting plasma glucose, the Homeostasis Model Assessment (HOMA2) and the need for rescue diabetes or periodontal therapy. CONCLUSION: Dental and medical researchers collaborated to recruit, treat and monitor participants with two chronic diseases to determine if treatment of one condition affects the status of the other.

A pilot study of the association between cariogenic oral bacteria and preterm birth.

OBJECTIVES: We examined the associations between preterm birth and low birth weight and maternal caries history, maternal periodontal status, and salivary levels of mutans streptococci and Lactobacilli. DESIGN: This study was a matched case-control study in women during their pregnancy or up to 8 weeks after delivery. SUBJECTS AND METHODS: Thirty-four women delivering before 37 weeks gestation were recruited along with 73 term controls matched for age and race/ethnicity. Demographic and obstetric information was collected from questionnaires and medical records and oral examinations along with commercial salivary tests were completed within the study groups. MAIN OUTCOME MEASURES: The main outcome variables were the preterm birth and low birth weight status. The independent variables measured were the salivary levels of Lactobacilli and mutans streptococci and the caries and periodontal status of the subjects. RESULTS: The odds ratio comparing low levels of bacteria in preterm mothers and controls was statistically significant for Lactobacilli (odds ratio (OR) = 3.45, 95% confidence interval (CI) = 1.27 to 10.00) and almost significant for mutans streptococci (OR = 2.63, 95% CI = 0.95 to 8.33). Clinical caries and periodontal disease measures did not differ significantly between groups. CONCLUSION: Within the limitation of our study, low levels of Lactobacilli in saliva were found to be associated with preterm birth.

Biliary complications in relation to the technique of biliary reconstruction in adult liver transplant recipients.

UNLABELLED: Biliary complications are known as a weak point of liver transplantation. Their occurrence can be related to the practice of draining the biliary anastomosis performed at the time of transplantation. At our institution, routine of anastomotic biliary drainage was abandoned in June 2004. AIM: We sought to assess the occurrence and character of biliary complications following orthotopic liver transplantation in relation to the technique of anastomosis. MATERIALS AND METHODS: In two groups of transplantees: last 100 transplantations with biliary drainage (48 females and 52 males aged 17 to 64 years) and last 100 transplantations without drainage (52 females and 48 males aged 18 to 67 years). The results of treatment were compared, for biliary complications and their influence on further management. In both groups, the main indications for transplantation were various types of cirrhosis as well as cholestatic diseases. In most cases (167) we performed a cholangiojejunal Roux-en-Y (CBD) end-to-end anastomosis, less commonly (33 cases) hepaticojejunal anastomoses. RESULTS: In the first group, biliary complications (bile leak at the site of drainage, bile leak after T-tube removal, CBD strictures) requiring surgical or endoscopic intervention, occurred in 17% recipients. In one case, the biliary complication resulted in retransplantation. In the second group, biliary complications occurred in 11% patients. None of them caused organ loss. CONCLUSION: Abandoning drainage of the biliary anastomosis has reduced the occurrence of early biliary complications after orthotopic liver transplantation.

The use Prometheus FPSA system in the treatment of acute liver failure: preliminary results.

UNLABELLED: The preliminary outcomes of patients with acute liver failure treated with the Prometheus Fractionated Plasma Separation and Absorption (FPSA) system are presented herein. PATIENTS AND METHODS: The procedures were performed in 13 patients (4, intoxication by Amanita phalloides; 4, unknown reason; 3, acetaminophen intoxication; 1, Wilson disease, and 1, liver insufficiency after hemihepatectomy owing to metastases of colon adenocarcinoma). The patients were qualified for the procedure according to the King's College Hospital criteria. The patients' general status was assessed on basic of GCS, UNOS, and the 4-grade encephalopathy classifications. The procedures were performed with the Prometheus 4008H Fresenius Medical Care unit. RESULTS: The 29 procedures were of mean duration 6.5 hours. There were statistically significant reductions in total bilirubin, ammonia, and aminotransferase levels. In addition, the procedures corrected water, mineral, and carbohydrate disorders. One patient did not require liver transplantation. Seven patients received liver transplants: three patients with positive outcomes; two died due to septicemia within 30 days perioperatively, one died at 6 months after OLT owing to respiratory failure; and one, owing to hemorrhagic diathesis. Four patients did not receive a liver transplant because of lack of a organ, no consent for the surgery, or neoplastic disease with metastases. CONCLUSIONS: The Prometheus FPSA-System was an effective detoxication method for patients with acute liver failure. The system was useful as a symptomatic treatment before liver transplantation allowing a longer wait for a graft.

Recurrence of primary sclerosing cholangitis in patients after liver transplantation.

BACKGROUND: Primary sclerosing cholangitis (PSC) is a chronic cholestatic disease that progresses to end-stage liver disease. There are several specific problems related to the posttransplantation period in these patients. The aim of this study was to analyze a single center experience with 17 orthotopic liver transplantations (OLT) due to PSC. PATIENTS AND METHODS: Seventeen patients were included (10 men, 7 women). Actuarial patient and graft survival rates and the incidence of recurrent sclerosing cholangitis were determined at 1, 5, and 7 years. RESULTS: Fifteen patients received single grafts, whereas two patients required retransplants. Patients received either cyclosporine (n = 7) or tacrolimus (n = 10) based immunosuppression. The 1-, 5-, and 7-year patient survival rates were 80%, 60%, and 60%, respectively, whereas the graft survival rates were 88%, 65%, and 65%, respectively. Two patients had cholangiocarcinomas (CCA) diagnosed during OLT; both recurred within 6 months and had a fatal outcome. Two patients (12%) developed recurrent sclerosing cholangitis, as assessed by liver histology and imaging of biliary tree. CONCLUSIONS: Liver transplantation provides good patient and graft survival rates in cases affected with PSC. CCA is associated with poor recipient survival. Recurrent PSC occurs in approximately 12% of cases but does not significantly affect patient survival.

Assessment of early biliary complications after orthotopic liver transplantation and their relationship to the technique of biliary reconstruction.

INTRODUCTION: Biliary complications are known as the weak point of liver transplantation. Their occurrence can be related to the practice of drainage of the biliary anastomosis, the routine use of which was abandoned in June 2004. The aim of the study was to assess the incidence and type of biliary complications following orthotopic liver transplantation in relation to the technique of biliary anastomosis. MATERIAL AND METHODS: We compared the results of two groups of adult liver transplant recipients: group I, recent 50 transplantations with biliary drainage (25 women: 25 men of age range: 17 to 63 years), and group II, first 50 transplantations without drainage (19 women and 31 men of age range, 20 to 65 years). We examined the problem of biliary complications and their influence on the further management of the patients. In both groups the main indications for transplantation were various types of cirrhosis as well as cholestatic diseases. In the majority of cases (n = 86) an end-to-end common bile duct anastomosis was performed and in 14 cases, hepaticojejunal anastomosis. RESULTS: In group I, biliary complications requiring surgical or endoscopic intervention occurred in 10 (20%) recipients. In one case, biliary complications resulted in the need for retransplantation. In group II, biliary complications occurred in only four (8%) patients, none of which caused organ loss. CONCLUSION: Cessation of biliary anastomosis drainage has reduced the occurrence of early biliary complications following orthotopic liver transplantation.

Biochemical assessment of the early liver graft function in relation to selected donor parameters.

The aim of this study was to assess the usefulness of liver grafts procured from "marginal donors." Among 62 liver transplants in 2002, almost half were harvested from donors who were not deemed acceptable by other transplant units. The authors compared the data concerning the donor's status with the function of the transplanted liver. The relations between individual parameters were estimated, as well as the differences between two groups of recipients: those who received a graft from the "poorer" donors versus those who received "better" grafts. Regardless of the relations between particular parameters a statistical analysis revealed that differences of liver function that were detected during the first 5 days after transplantation disappeared thereafter.

Comparison of the results of liver transplantation for elective versus urgent indications.

The authors present an analysis of early and remote liver transplantation outcomes related to the presence of emergent indications among 196 of the 209 operations performed from 1989 to April 2003; namely 178 elective and 18 emergent transplantations. Perioperative mortality was 15%. The survival rate during the first 12 months was 79.8% and within 3 years 73.5% among patients operated on an elective basis (UNOS 3 and 2B). In contrast, patients with acute liver failure (UNOS 1 and 2A) showed rates of 45%, 50%, and 47%, respectively. Liver transplant outcomes depend primarily on the urgency of an operation. Longterm results are much better among patients operated on electively. Liver transplantation in patients with acute hepatic insufficiency is burdened with a high 45% mortality.

Results of liver transplantation according to indications for orthotopic liver transplantation.

OBJECTIVE: This study assessed the results of liver transplantation in patients with a variety of different indications. METHODS: From 1989 to April 2003, 209 orthotopic liver transplantations (OLTx) were performed on 196 patients, including 178 cases. The diagnoses were: PBC (n = 34); PSC (n = 13); elective postinflammatory cirrhosis in the course of hepatitis C (n = 29); hepatitis B (n = 16); postalcoholic cirrhosis (n = 23), autoimmune cirrhosis (n = 11); Wilson's disease (n = 6); cirrhosis of unknown etiology (n = 10); secondary biliary cirrhosis (n = 5); Budd-Chiari syndrome (n = 6); and benign liver neoplasms (n = 7). RESULTS: The 3-year survival rate in the group of patients transplanted electively was 74.1%. In other groups it was: PBC, 91.4%; PSC, 69.2%; hepatitis C, 69.6%; hepatitis B, 55.5%; postalcoholic cirrhosis, 80%; autoimmune cirrhosis, 81.8%; Wilson's disease, 57.1%; secondary biliary cirrhosis, 40%; Budd-Chiari syndrome, 66.6%; hemochromatosis, 100%; benign neoplasms of the liver, 87.5%; and liver cysts, 100%. CONCLUSIONS: Results of liver transplantation were closely related to the urgency of the procedure. Better results were achieved in patients operated upon routinely compared with in those operated upon emergently (74.1% vs 50%). The best results of liver transplantation were achieved in patients transplanted on a routine basis with a diagnosis of PBC (91.4%), autoimmunologic cirrhosis (81.1%), postalcoholic cirrhosis (80%), or hemochoromatosis (100%). Patients with liver insufficiency due to hepatitis B and Wilson's disease have an increased risk of graft destruction, and the rate of survival in these patients is significantly lower than in other patients.

The impact of experience of a transplantation center on the outcomes of orthotopic liver transplantation.

The so-called learning factor has been disregarded for many years in analyzing the causes of surgical complications and post-operative mortality; it is also the case for OLT. In our center until April 2003, 209 OLT were performed in 196 patients. We evaluated the impact of experience of the transplantation team on the outcomes of liver transplantation. Thirty-four patients died (mortality rate, 16%) and 1-year survival rate, 64%. Mortality rates varied during different periods of observation due to increasing experience of the transplantation team. The causes of mortality were assessed for a series of 34 patients: it was 75% at the beginning of transplantation procedures while recent deaths have not recently exceeded 10% of cases.

Vascular complications after liver transplantation.

Vascular complications following liver transplantation is reviewed based upon literature data and our own results. Our study conclusions are mostly based on literature data, because our center does not have the liver transplantation experience of other centers worldwide. Thus, we may conclude, that the number and character of complications does not differ from those reported by other centers. The enbloc technique used in liver harvesting minimizes the risk of arterial damage in case of vascular anomalies. Recipient retransplantation is the most effective treatment method in cases of hepatic arterial occlusion. Doppler ultrasound examinations are effective to monitor vascular blood flow in the transplanted liver.

Biliary tract complications following liver transplantation.

INTRODUCTION: Biliary tract complications, which occur in 5.8% to 24.5% of adult liver transplant recipients, remain one of the most common problems following transplantation. The aim of this study was to evaluate these problems and analyze methods of treatment. MATERIAL AND METHODS: From 1989 to 2003, 36 (18.7%) among 193 patients who underwent orthotopic liver transplantations in our center developed biliary complications. Biliary strictures that developed in 18 cases (9.3%) were the most common complications. Clinical manifestations of strictures developed at 2 to 24 months after transplantation. Bile leaks occurred in 10 patients (5.2%), and were diagnosed in along the T-tube 4 cases and was not accompanied by any clinical manifestation. Bile leak to the peritoneum after T-tube removal occurred in 2 patients (1.1%). Solitary gallstone formation in one case (0.5%) was removed with the use of ECPW. One patient required retransplantation within 3 months after transplantation, because of the most severe complication-ischemic necrosis of biliary tract. RESULTS: Uneventful recovery was achieved in 34 patients in the analyzed group (94.4%). There was no case of recurrence during outpatient follow up. Two patients died in late follow-up of unrelated causes: namely, gastrointestinal bleeding due to a duodenal ulcer and multi-organ failure (MOF) due to a third severe episode of acute liver transplant rejection. CONCLUSIONS: Biliary complications remain an important problem in liver transplantation. Endoscopic and radiologic management are effective in the majority of cases. Surgical intervention is obligatory in selected cases.