Early Postoperative Pain and its Predictors in the Adult to Adult Living Donor Liver Transplantation Cohort Study.

BACKGROUND: Little is known about how well postoperative pain is managed in living liver donors, despite pain severity being the strongest predictor of persistent pain with long-lasting disability. METHODS: We conducted a prospective multicenter study of 172 living liver donors. Self-reported outcomes for pain severity, activity interference, affective (emotional) reactions, adverse effects to treatment, and perceptions of care were collected using the American Pain Society Patient Outcomes Questionnaire-Revised. Mixed-effects linear regression was used to identify demographic and psychosocial predictors of subscale scores. RESULTS: Donors were young (36.8 ± 10.6) and healthy. Of 12 expert society analgesic recommendations for postoperative pain management, 49% received care conforming to 3 guidelines, and only 9% to 4 or 5. More than half reported adverse effects to analgesic treatment for moderate to severe pain that interfered with functional activity; however, emotional distress to pain was unexpectedly minimal. Female donors had higher affective (ß = 0.88, P = 0.005) and adverse effects scores (ß = 1.33, P < 0.001). Donors with 2 or more medical concerns before surgery averaged 1 unit higher pain severity, functional interference, adverse effects, and affective reaction subscale scores (ß range 1.06-1.55, all P < 0.05). Receiving information about pain treatment options increased perception of care subscale scores (ß = 1.24, P = 0.001), whereas depressive symptoms before donation were associated with lower scores (ß = -1.58, P = 0.01). CONCLUSIONS: Donors have a distinct profile of pain reporting that is highly influenced by psychological characteristics. Interventions to improve pain control should consider modifying donor behavioral characteristics in addition to optimizing pain care protocols.

Low risk of hepatitis B virus recurrence after withdrawal of long-term hepatitis B immunoglobulin in patients receiving maintenance nucleos(t)ide analogue therapy.

Hepatitis B virus (HBV) recurrence rates of 0-16% had been reported in patients maintained on nucleoside analogues (NA) after hepatitis B immunoglobulin (HBIG) discontinuation after orthotopic liver transplantation (OLT). However, follow-up in most studies was short. We aimed to determine the long-term risk of HBV recurrence using this strategy. All HBV patients who received > or =7 doses of intravenous HBIG after OLT, with no HBV recurrence while receiving HBIG, and who eventually discontinued HBIG and were maintained on NA, were included. HBV recurrence was defined as HBsAg-positive or HBV DNA > or =5 log copies/mL on 2 consecutive occasions. Twenty-one patients met the inclusion criteria. Immediate post-OLT prophylaxis was combination HBIG and NA in 15 patients, whereas 6 patients received HBIG monotherapy for 62-109 months before NA was added. HBIG was discontinued a median of 26 (range, 0.2-121) months after OLT. Median follow-up post-HBIG discontinuation was 40 (range, 5-51) months. Only 1 patient, who had 12 months of HBIG and was noncompliant to NA therapy, had HBV recurrence, 34 months after HBIG discontinuation. One patient had HBV DNA of 3.3 log copies/mL 47 and 48 months after HBIG discontinuation but remained HBsAg-negative. Lamivudine-resistant mutations were detected in both patients. Probability of HBV recurrence was 0% and 9% at 2 and 4 years after HBIG discontinuation. Three patients had 1-2 episodes of transiently detectable HBV DNA. All were HBV DNA and HBsAg negative on repeated tests over a period of 2-36 months. Maintenance therapy with NA after discontinuation of long-term HBIG therapy is associated with a low risk of HBV recurrence after OLT in compliant HBV patients.