Epstein-Barr virus PCR correlated with viral histology and serology in pediatric liver transplant patients.

Epstein-Barr virus (EBV)-associated illnesses in posttransplant patients are difficult to diagnose. Attempts to aid in the diagnosis of such illnesses using the polymerase chain reaction (PCR) analysis for EBV have met with variable success due to the potential exquisite sensitivity of the assay. We have designed a relatively insensitive EBV PCR assay and compared the results with objective evidence of EBV activity including serologic response and in situ hybridization for the EBV genome. Eighty-five specimens from 65 patients were analyzed by the EBV PCR using DNA from whole blood. EBV serologic evaluation was done on 53 of the samples and in situ hybridization for EBV (EBER-1 mRNA) on 46 paired liver biopsies. Of 85 samples, 25 (29%) were positive for EBV using the PCR assay. Intensity of amplification was graded 0.5-1+ (weak) to 3+ (strong). Using these criteria, 19 EBV PCR-positive samples were graded 0.5-1+, 5 were graded 2+, and 1 was graded 3+. Of the moderate to strongly positive samples (2+ or 3+), five of six had two or more EBER-1-positive cells in the liver biopsies. Of the remaining 40 liver biopsies with either negative or weak positive PCR results, 3 had only single cells positive for EBER-1; the remainder were negative. In addition, PCR-positive results correlated with increasing EBV anti-early antigen antibody (P = .005) and viral capsid antigen IgG immunoglobulin G VCA (P = .05) EBV-positive results using the PCR assay correlated with objective evidence for increased EBV burden in children after liver transplantation. These preliminary data suggest that this PCR test may be useful to help guide immunosuppressive therapy in the posttransplant patient. Further evaluation using larger numbers of patients will be necessary to confirm this.

Percutaneous transhepatic endoscopic electrohydraulic lithotripsy of biliary tract calculi after orthotopic liver transplantation.

The development of biliary tract calculi after orthotopic liver transplantation presents a unique clinical problem. Previously described techniques for removing biliary stones by shock wave lithotripsy, litholytic therapy with oral bile acids, and endoscopic mechanical extraction may be ineffective or contraindicated in liver transplant patients. For this reason, percutaneous transhepatic electrohydraulic lithotripsy (EHL) was performed using an 11 French flexible ureteroscope in two pediatric patients who developed biliary tract calculi following orthotopic liver transplant. There were no complications and postoperative follow-up over 4 years has been uneventful. To our knowledge, these represent the first reported cases of percutaneous transhepatic endoscopic EHL to fragment biliary tract stones in a transplanted liver, which for us has been a safe and effective therapeutic option.

Epstein-Barr virus-associated leiomyosarcomas in liver transplantation recipients. Origin from either donor or recipient tissue.

BACKGROUND: Leiomyosarcoma, a mesenchymal malignancy with smooth muscle differentiation, is extremely rare in children. Immunosuppression, due to either antirejection medication in organ transplantation recipients or human immunodeficiency virus infection (HIV), appears to constitute a predisposition. METHODS: Two cases of leiomyosarcoma in pediatric liver transplantation recipients were investigated and compared clinically with respect to site of origin and course of the disease and pathologically by routine histology and electron microscopy, by forensic DNA methodology for origin from donor or recipient tissue, and by EBER-1 in situ hybridization for evidence of latent Epstein-Barr virus (EBV) infection. RESULTS: A 9-year-old male developed a high grade, poorly differentiated leiomyosarcoma in his allografted liver 2 years after transplantation, and despite antineoplastic chemotherapy, he died of metastatic disease. The genotype of his tumor indicated an origin from allografted tissue. A 12-year-old female had a low grade retroperitoneal leiomyosarcoma involving the superior mesenteric vein. After resection, she remained disease free without chemotherapy. The genotype of her tumor indicated an origin from native tissue. In both tumors, latent EBV infection was documented. CONCLUSIONS: Neoplastic smooth muscle proliferation in immunosuppressed liver transplantation recipients is analogous to the more common posttransplantation lymphoproliferative disorder in involving transformation of either engrafted donor tissue or recipient tissue elsewhere in the body, in displaying a wide spectrum of histologic differentiation, grade and clinical behavior, and in exhibiting evidence of latent EBV infection.

Use of distal splenorenal shunt in children referred for liver transplant evaluation.

Variceal bleeding remains a common cause of morbidity for children with both intrahepatic and extrahepatic portal hypertension. Occasionally, patients referred for liver transplant evaluation have significant variceal bleeding, despite adequate synthetic liver function. During a 7-year period, 322 children were referred for liver transplant evaluation. Six underwent distal splenorenal shunt surgery after evaluation. There were four boys and two girls. The average age was 11 +/- 4 years, and the average weight was 39 +/- 15 kg. The etiology of variceal bleeding was intrahepatic portal hypertension in five (1 biliary atresia, 2 chronic hepatitis, 2 congenital hepatic fibrosis) and extrahepatic portal vein thrombosis in one. Two patients had no previous attempts at sclerotherapy (one because of an abnormality in platelet function, the other because of extensive gastric varices), and four had multiple previous sclerotherapy treatments. No patient had preoperative encephalopathy. Three cases were Child's class A, and three were Child's class B. Preoperative evaluation of the portasystemic system was performed with magnetic resonance (MR) imaging or splenoportography. All patients underwent a distal splenorenal shunt procedure, four of whom also had splenopancreatic disconnection. One patient required 100 mL of blood replacement, and five required no blood. The average length of hospital stay was 9.8 +/- 2.2 days. Postoperative complications were minimal. All patients are alive, without recurrent gastrointestinal bleeding or encephalopathy, and they have patent shunts, which was confirmed by MR or Doppler ultrasound at a mean of 25 +/- 20 months after shunt surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

University of Wisconsin preservation solution compared with Euro Collins preservation solution in pediatric liver transplantation.

Orthotopic liver transplantation has become the accepted treatment for end-stage liver disease in children. To evaluate the efficacy of the University of Wisconsin (UW) preservation solution in pediatric liver transplantation, a group of 34 livers preserved with UW solution was compared in a nonrandomized fashion with a historical control group of 34 livers preserved with Euro Collins (EC) solution. Primary graft nonfunction did not occur in either group. Both groups were similar with respect to age, sex, weight, diagnosis, severity of the recipient's condition, donor condition at harvest, donor/recipient blood type match, and immunosuppressive management. The UW group had a significantly higher bilirubin, AST, ALT, and GGT during the first week after transplantation when compared with the EC group but no significant differences were noted after the ninth post-transplant day. No differences were noted when the groups were compared as to surgery time (9.1 v 8.4 hours), blood volumes replaced (1.8 v 2.0), number of ICU days (5.0 v 6.5), total number of infections per graft (1.0 v 0.8), total hospital days (31 v 30), and hospital cost ($134,000 v $126,000). The total preservation time was improved from 7 hours (range, 3.2 to 9.9) in the EC group to 13.9 hours (range, 6.9 to 22.3) in the UW group (P < .001). UW solution allows a significant increase in cold ischemic time in liver transplantation when compared with EC. This increase in preservation time resulted in no detrimental effect when compared with EC and potentially led to milder episodes of rejection in the postoperative period.

Cognitive patterns in school-age children with end-stage liver disease.

Although children with end-stage liver disease (ESLD) have been found to have cognitive delays, the relationship between patterns of cognitive function and diagnostic category, age of onset, duration and severity of disease has not been assessed before transplantation. Verbal and performance IQ (VIQ, PIQ) scores and scores on Bannatyne's cognitive factors for 43 children with ESLD were compared with those of 15 control children with cystic fibrosis (CF) and with existing normative data. Children with biliary atresia had deficits in PIQ, spatial and sequential scores. Children with alpha-1 antitrypsin deficiency did not differ significantly from CF controls but did show deficits compared with normative data. Children with onset of disease in the first year of life had deficits on all cognitive measures compared with both control groups. In contrast, children with later onset differed from the normative population only on VIQ and the acquired knowledge factor. In multiple regression analyses, duration of disease and indexes of liver dysfunction combine to predict cognitive scores. These preliminary findings suggest that children with early onset of liver disease are at high risk for cognitive impairment.

Neuropsychological function in young children who have undergone liver transplantation.

Presented neuropsychological data from 20 patients between the ages of 4 and 9 years, who had undergone liver transplantation at least 12 months prior to study participation, and compared them to a control group of 20 children with cystic fibrosis. The liver transplant group showed deficits in VIQ, PIQ, visual-spatial and abstraction/reasoning skills, but not in alertness/concentration, motor, or sensory-perceptual functions. On motor and sensory-perceptual tests, no differences were found in direction of lateralization of deficits. Visual-spatial deficits found in this study sample are similar to those found in adults with end-stage liver disease and in a previous report of an overall older group of children following liver transplantation. However younger children have greater evidence of generalized impairment and VIQ deficits which have not been found in older groups. Findings are discussed in relation to possible etiology, location of brain damage, and clinical implications.

Neuropsychological outcome of pediatric liver transplantation.

Children with end-stage liver disease who undergo liver transplantation may have unrecognized neuropsychological and academic deficits, for which remediation programs may be available. Intellectual, academic, and neuropsychological measures of 28 pediatric patients who had received successful liver transplantation at least 1 year previously were compared with those of 18 patients with cystic fibrosis (to control for effects of growth retardation and chronic illness) matched for age, age at diagnosis, physical growth, and parents' socioeconomic status. Liver transplant patients had significantly lower scores on nonverbal intelligence tests (mean +/- SD for liver transplant vs cystic fibrosis patients: 89.1 +/- 19.1 vs 105.8 +/- 17.6), lower academic achievement, and lower zeta scores for age in the areas of learning and memory (-0.68 +/- 1.09 vs 0.19 +/- 1.24), abstraction and concept formation (-1.73 +/- 1.58 vs -0.79 +/- 1.37), visual-spatial function (-0.66 +/- 1.09 vs 0.10 +/- 0.69), and motor function (-0.13 +/- 0.85 vs 0.36 +/- 0.57). No differences were found on tests of verbal intelligence, or in alertness and concentration, perceptual-motor, and sensory-perceptual areas. Cyclosporine levels were found to correlate positively with motor speed (r = .41, P less than .05). Thorough psycho-educational and neuropsychological evaluations should be considered for pediatric patients who receive liver transplantation to allow these children to maximize their potential.

Selective use of splenectomy after liver transplantation in children.

In a series of 106 pediatric liver transplantations, five patients were identified with recurrent rejection who could not tolerate the addition of azathioprine (Aza) to their immunosuppressive therapy because of leukopenia. Splenectomy was performed posttransplantation to allow the use of Aza. The number and severity of rejection episodes were compared before and after splenectomy in these patients. In addition, presplenectomy and postsplenectomy rejection frequencies were compared with rejection frequencies in 35 patients who did not require splenectomy and had at least 1 1/2 years of follow-up. Mild, moderate, and severe rejection episodes were defined by the treatment (mild, steroid bolus only; moderate, steroid recycle; and severe, monoclonal antibodies or Minnesota antilymphocyte globulin) required to produce complete resolution. There was a mean of 342 +/- 111 days from transplantation to splenectomy and a mean of 674 +/- 109 days of follow-up after splenectomy. Follow-up in the control group was 934 +/- 44 days. After splenectomy, the average platelet count increased from 78 +/- 15 to 514 +/- 113 (P = .020) and white blood cell count increased from 3.2 +/- 0.6 to 16.7 +/- 2.7 (P = .010). Splenectomy permitted the implementation of Aza therapy in one patient who previously was not a candidate because of hypersplenism and allowed uncomplicated Aza therapy in four patients who became severely leukopenic during previous Aza trials. All five patients who underwent splenectomy demonstrated a statistically significant (P less than .05) decrease in the total number of rejection episodes. Rejection frequency after splenectomy was no different from the rejection frequency in patients who did not require splenectomy (P = .682).(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric liver transplantation: a 3-year experience.

From September 1, 1984 to March 1, 1988, 201 patients were evaluated for liver transplantation. Ninety-one orthotopic liver transplants were performed on 80 children ranging in age from 3 months to 15 years. The average waiting time for a transplant was 5 months, with children less than 10 kg in weight waiting a disproportionately long time. The average operative time was 10.6 hours and the average blood product replacement was 2.7 blood volumes. There was a steady improvement in both operative time and blood loss from 1985 to 1987. The overall hepatic arterial thrombosis rate was 9%; complex reconstructions having a thrombosis rate of 39%, and end-to-end anastomoses having a thrombosis rate of 1.4%. The average hospital stay was 37 days, and the major causes of postoperative morbidity and mortality were rejection (75%), infection (50%), and diarrhea (76%). The 1- and 3-year survival rates were 75% and 73%, respectively. Children with a successful transplant returned to home and school. After transplantation, 60% of the children exhibited catch-up growth and 88% have normal liver function. Pediatric liver transplantation is an effective modality in the treatment of children with terminal liver disease. Increased pediatric organ donation and the investigation of new operative techniques and types of preservation are necessary to meet the needs of an expanding recipient pool.

Studies on inflammation and wound healing: angiogenesis and collagen synthesis stimulated in vivo by resident and activated wound macrophages.

Wound inflammatory cells were harvested by aspiration of fluid from the "dead space" of subcutaneous rabbit wounds and transplanted into the cornea where, compared with suitable controls, they stimulated healing (i.e., angiogenesis, fibroplasia, and new collagen synthesis, which led to formation of visible, vascularized scar tissue). Analysis of the data and the literature supports the conclusions that: (1) inflammatory cells control the continuation of the repair process after the immediate effects of injury subside; (2) macrophages, as opposed to granulocytes, appear to be the major contributors; (3) activated by their presence in the wound, macrophages release substances that stimulate fibroplasia, collagen synthesis, and angiogenesis in vivo; and (4) tissue injury is not a maximum stimulus to repair, since endotoxin-treated macrophages have increased capacity to stimulate collagen synthesis and angiogenesis. A hypothesis is offered to explain the notorious clinical discrepancy between the extent of injury and the extent of repair.

Fat soluble vitamin deficiency in biliary atresia.

Between January 1973 and January 1980, 29 patients with biliary atresia treated by Kasai hepatic portoenterostomy were evaluated for deficiencies of vitamin A, D, and E. The mean vitamin A level in 11 patients with successful operations was 25.5 +/- 3.8 (SE) micrograms/100 ml whereas the level was 16.0 +/- 8.8 (SE) micrograms/100 ml in three patients with failed operations (normal: greater than 30 micrograms/100 ml). Vitamin E levels in 6 children (5 with sustained bile drainage) were 2.9 +/- 1.7 (SD) micrograms/ml (normal: greater than 4 micrograms/ml). Vitamin D deficiency was evaluated in 22 patients by serial radiographs of knees and wrists. Four children (18%) had pure osteomalacia and 13 children (59%) had combined osteoporosis and osteomalacia. The four oldest survivors (age 5-5.5 yr) resolved their bone disease without specific treatment. Serologic deficiencies of vitamins A and E and radiographic evidence of vitamin D deficiency exist in patients with biliary atresia despite operative establishment of bile flow. These deficiencies are present in both the younger and the older children. In the case of vitamin D, resolution may occur without specific treatment.