Antithymocyte Globulin Use for Corticosteroid Nonresponsive Rejection After Liver Transplantation.

BACKGROUND AND AIMS: Acute cellular rejection after liver transplantation usually responds to intravenous corticosteroids, yet some episodes are corticosteroid-nonresponsive. We report our experience using antithymocyte globulin therapy for corticosteroid-nonresponsive acute cellular rejection in liver transplant recipients. METHODS: From January 1, 2002 to January 1, 2010, 1436 patients underwent 1548 liver or liver with other organ transplantations at our institution. We identified all patients treated with antithymocyte globulin during this timeframe for corticosteroid-nonresponsive rejection. RESULTS: Twenty patients required antithymocyte globulin for 21 episodes of corticosteroid-nonresponsive rejection. Antithymocyte globulin was started a median (range) of 27 (7-2434) days post-transplantation, and median total antithymocyte globulin dose and duration was 10.5 (7.5-26.25) mg/kg and 7 (5-13) days, respectively. Resolution or marked histological improvement of rejection on Day 7 liver allograft biopsies occurred in 90% of rejection episodes treated with antithymocyte globulin. Three-year graft and patient survival rates were 60% and 65%, respectively, compared with 79% and 84% in patients not requiring antithymocyte globulin. CONCLUSIONS: Antithymocyte globulin was an effective therapy for corticosteroid-nonresponsive rejection, with excellent short-term outcomes. Some liver transplant recipients failed to respond, and long-term survival was reduced, even in those who responded to antithymocyte globulin.

Hypertrophic Cardiomyopathy in Liver Transplantation Patients.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) is an autosomal dominant disorder that presents with a hypertrophied nondilated left ventricle. In the absence of other known causes of cardiomyopathy, it is often associated with left ventricular outflow tract obstruction during systole, systolic anterior motion of the mitral valve, mitral regurgitation, and increased risk of sudden cardiac death. When HCM coexists with end-stage liver disease, it can be further complicated by cirrhosis-associated cardiovascular abnormalities, including hyperdynamic circulation, systolic and diastolic dysfunction, and electrophysiologic abnormalities. METHODS: We retrospectively examined patient characteristics, comorbidities, preoperative echocardiogram results, sudden cardiac death risk prediction model score, and 1-year postoperative mortality of patients with HCM who underwent liver transplantation at our institution from January 1, 2000, through January 1, 2015. RESULTS: Of the 2,812 liver transplantations performed during the study period, we identified 15 patients with a preoperative diagnosis of HCM. When comparing the patients who did vs did not survive the first year after orthotopic liver transplantation, we identified significant differences in maximal left ventricular wall thickness (P = .004) and resting left ventricular outflow tract gradient (P = .004). Preoperative left atrium size (measured by echocardiography; P = .66) and the sudden cardiac death risk prediction model score (P = .32) were not significantly associated with 1-year survival. CONCLUSIONS: Preoperative left ventricular outflow tract gradient exceeding 60 mm Hg was strongly associated with death during the first year after transplant. These results suggest that the severity of HCM influences patient outcomes.

Thromboelastography as a Predictor of Outcomes Following Liver Transplantation.

BACKGROUND: Thromboelastography (TEG) has been used perioperatively during liver transplantation (LT) to provide a real-time global hemostasis assessment for targeted blood product replacement. We aimed to analyze the relationship between post-LT TEG results and outcomes. METHODS: We retrospectively analyzed patients undergoing LT from November 2008 to December 2014 at Mayo Clinic Florida. All 441 single-organ 1st-time LT patients aged ≥18 years requiring post-LT intensive care unit management were included. TEG parameters including r time, k time, α angle, and maximum amplitude were measured regularly during the first 24 hours after LT. Outcomes included return to the operating room secondary to bleeding, length of hospitalization, survival, and early allograft dysfunction. RESULTS: A prolonged and/or lengthening r time, k time, and r+k time were all independently associated with increased length of hospitalization after LT. Increased maximum amplitude on the first post-LT TEG was associated with early allograft dysfunction. No notable associations of TEG parameters with survival or return to operating room were observed. CONCLUSIONS: The association of absolute and temporal TEG value changes with increased length of hospitalization and early allograft dysfunction suggests that TEG may have a role in identifying patients at high risk for these outcomes.

An explanation fro chloracne -- an industrial hazard.

Patients with chloracne were investigated and the results compared with data matched for age and site from patients with acne vulgaris. The ultrastructural appearances of pilo-sebaceous ducts in both groups were similar. The industrial group had significantly fewer C. acnes than the patients with ordinary acne. They also showed a significant increase in the surface lipid percentage composition of squalene, wax ester and cholesterol and this was associated with a significant decrease in the triglyceride free fatty acids and total triglyceride pool. We suggest that the acnegenic agent has produced its effect by modifying the metabolism of the pilo-sebaceous fluid.