Analysis of Health Behaviors in Patients After Liver Transplant.

Currently, transplantation is one of the most effective treatments for the failure of organs such as liver, kidneys, or heart. Keeping to specific recommendations by organ recipients is extremely important, as they are vital to the effectiveness of the transplant. Positive health behaviors (HBs) have significant impact on strengthening the recipient's health. AIM: The aim of this work is to indicate which HBs are exhibited by patients after liver transplants. MATERIALS AND METHODS: The study group consisted of 115 adult liver recipients, in various times after their transplants. The average age in the group was 53.83 years old. The major reason for transplant was post-inflammatory cirrhosis of liver originating from hepatitis B or C viral infection. A diagnostic survey was used in the study, as well as a tool in the form of an original questionnaire and Juczynski's standard Health Behavior Inventory (HBI) questionnaire. RESULTS: On the scale of general HBI index, patients achieved high results (M = 101), which shows that most recipients were disciplined in adhering to HBs. The worst results were achieved in the category of good eating habits, which proves that some respondents do not keep to the principles of healthy eating. The longer the time after the transplant, the lesser the extent in complying with HBs by recipients, in the first place in the scope of maintaining positive mental attitude. Specific behaviors were slightly worse, especially in residents of the countryside. CONCLUSIONS: Adherence to particular categories of health strengthening behaviors is conditioned by specified sociodemographic variables. Sex, level of education, and professional status significantly affect the implementation of pro-health activities. These are best implemented by women who had completed university and high school education who are on a pension or retired.

Results of Renal Transplant From Deceased Anti-hepatitis C Virus Donors, Poland 1998-2012.

Kidney transplant (KTx) is the best method of renal insufficiency treatment. In dialyzed patients, mortality rises with the time on dialysis. There is a continuing shortage of organs for transplantation, hence a propensity to expand the donor pool with expanded-criteria donors, anti-hepatitis C virus-positive included. In the above case a transmission of hepatitis C virus (HCV) genotype to recipient is present. It has been proven that contamination with more than 1 HCV genotype did not worsen KTx outcomes. There are 2.6% anti-HCV(+) donors in Poland. Use is only possible in cases of anti-HCV(+) and anti-HCV RNA(+) recipients. METHODS: Retrospective analysis covered 8675 deceased donors (1998-2012 Polish data from Poltransplant). The early (after 12 months) and late (after 60 months) graft and patient survival was assessed in KTx recipients, with documented recipient and donor data spanning at least 1 year after KTx. In comprehensive analysis, 7016 KTx recipients with known anti-HCV status were included according to anti-HCV profile of recipient and donor. The results are in absolute and percentage values and P < .05 assessed with χ2 test. RESULTS: Twelve-month survival: recipient (R) (95%), graft (G) (89%), total; R (95% vs 89%, P < .001), G (88 vs 79, P < .001) in HCV(-) to HCV(+/-) vs HCV(+) to HCV(+); R (95 vs 94, P = .2), G (88 vs 83, P < .001), HCV(-) to HCV(-) vs HCV(-) to HCV(+); R (93 vs 95, P = .004), G (82 vs 89, P < .001) in HCV(+/-) to HCV(+) vs HCV(-) to HCV(-); R (95 vs 89, P < .001), G (88 vs 79, P < .001) in HCV(-) to HCV(-) vs HCV(+) vs HCV (+). Sixty-month survival: R (86%), G (75%), total; R (84 vs 88, P = .01), G (63 vs 71, P = .001) in HCV(+/-) to HCV(+) vs HCV(-) to HCV(-); R (88 vs 80, P = .003) in HCV(-) to HCV(-) vs HCV(+) to HCV(+). CONCLUSIONS: The worst anti-HCV serological profile was HCV(+) to HCV(+), although transplanting HCV(+) to HCV(+) did not worsen outcomes in that group. Worse KTx outcomes of HCV(+) over HCV(-) donors can be attributed to HCV(+) status of the recipient.

Liver Donation and Transplantation in Poland: Numbers, Indicators, and Trends.

We aim to provide a panorama of liver donation and transplantation in Poland, where each year around 300 liver transplantations from deceased donors and 20 liver fragment transplantations from living donors are performed. This means about 9 transplantations per population of 1 million. Each year, the number of deceased donors reaches more than 500. In more than 50% of cases, livers are used. The law allows liver procurement from living donors. Until the end of 2013, liver fragments were recovered from 236 living donors and transplanted mainly to pediatric recipients (n = 232). A living-donor registry was created to monitor and assess the health condition of donors. The range of the national waiting list and allocation is nationwide. It is managed with the use of the Web tool www.rejestry.net. There are 2 modes of recipient referral: "urgent" and "elective." Allocation is either patient oriented and center oriented. Disease groups, which comprise the most frequent indications for transplantation in adults, include the cirrhosis group (48%), in which the highest number of procedures was performed for patients with hepatitis C virus (24%); alcohol-induced cirrhosis (14%); alcohol-induced hepatitis (8%), and hepatitis B virus cirrhosis (7%). Among pediatric recipients, the most frequent indications were congenital cholestatic diseases, which made up 38% of all transplantation indications. The results of liver transplantations are collected in the national transplant register. The 1-year graft and recipient survival with deceased donor transplantation are 81% and 84% and with living donor transplantation 86% and 89%. The 5-year graft and recipient survival in deceased donor transplantation are 69% and 73%, and in living donor transplantation are 80% and 83%.

Liver Transplant Registry in Poland: Web-Netted Quality Tool in Liver Transplantation From Deceased and Living Donors.

BACKGROUND: Poltransplant managed a national transplant registry with the use of the Web tool www.rejestry.net. It collects information about all organ transplantations in the country along with outcomes. This article presents a formal analysis of data collected in the registry for the years 1998 to 2014. MATERIALS AND METHODS: Results presented are actual, not extrapolated, numbers; these were calculated only for the events for which the observation was complete, meaning that a given term of follow-up had passed and the information on recipient's and graft survivals were available. RESULTS: All liver transplant procedures were registered from the years 1998 to 2014, with follow-up data completeness of 89% to 99%. Detailed statistical descriptions of liver transplant results were significantly better for transplants from living donors, in comparison to deceased donors, for pediatric recipients. Results for pediatric and adult recipients did not vary if the organ was from a deceased donor. Elective and primary transplantations have significantly better results in comparison to urgent and re-transplanted cases. Results depend on indications for transplantation. Significantly better results were obtained in the case of cholestatic diseases and cirrhosis other than hepatitis C virus. Significantly worse results were obtained in acute liver failure, independently of etiology. Results in the case of hepatitis C virus cirrhosis, metabolic diseases, and neoplasms do not vary significantly. CONCLUSIONS: The strength of these findings are based on the registry's reliability and completeness. The registry fulfills its aims related to collecting records and monitoring graft function, and recipient survival. The data are an important source of information, to be used by transplantation institutions and referred to in the literature.

Delayed, Uncommon Recurrence of Hepatocellular Carcinoma After Liver Transplantation: A Case Report.

We report a case of a 27-year-old man diagnosed with the infection of HBV delta in the 8th month of life. The treatment complied with evidence-based medical guidelines, comprising neoadiuvant chemotherapy and surgery. Liver transplantation from a deceased donor followed by chemotherapy was performed when the patient was 16 years 9 months of age because of recurrent HCC tumor. The patient qualified for immunosuppressive treatment (rapamycin, tacrolimus), lamivudine, anti-HBs globulin intravascular infusion, and anti-HBV vaccination as a prophylaxis against reinfection with HBV. In conclusion, this case demonstrates the importance of a postoperative follow-up of patients with HCC, even years after liver transplantation.

Pregnancy and delivery in women with esophageal varices due to hepatic vein thrombosis.

AIM: Retrospective analysis of the course of pregnancy, labor and mode of anesthesia in women with portal hypertension and esophageal varices induced by portal vein thrombosis. MATERIAL: From 2000 to 2012 seven pregnant were admitted. None had liver transplantation (Ltx), the varicose have been in the 1st stage. Each of them has been consulted by the obstetrician, transplant surgeon and anesthetist. The patient condition during pregnancy, labor and postpartum period was analyzed. RESULTS: Pregnancy in five cases proceeded physiologically. In one threatening miscarriage was diagnosed and treated with gestagens, two patients had tocolytic. One required variceal banding twice. In three thrombocytopenia worsened, with platelet count <70 g/L (up to 59 g/L). They received platelet transfusion before delivery. In one case, significant hipoproteinemia (4.7 g/L) occurred. In a case, GDM G1 and oligohydramnios were found. All women delivered at term (37-40 Hbd). In all general anesthesia with the use of remifentanil was done. There were no fluctuations in MAP and HR. Incision to delivery time was 2.5 min. Time from opioid administration to birth was <4 min. All children were born in good condition, weight 10-90 percentile. Regional anesthesia is contraindicated in patients with thrombocytopenia. In patients with esophageal varices sudden increase in heart rate and blood pressure can cause hemorrhage. CONCLUSION: Patients with portal hypertension can deliver at term. It is a high-risk pregnancy. In this group it is desirable to shorten the second stage of labor or complete it by c-section under general anesthesia with remifentanyl which allows getting desired analgesia without complications in the newborn. Surveillance of pregnant with portal hypertension must include monitoring of liver function and coagulation disorders.

Risk factors in cadaveric donors of livers procured for elective and urgent recipients.

Use of livers from cadaveric nonstandard donors has become justified, especially for recipients awaiting urgent transplantations. However, it is known that results are superior when organs are obtained from ideal rather than expanded-criteria donors. We designed a study to compare the characteristics of 582 liver donors whose organs were used for elective versus urgent transplantations in 2006-2008 and the recipients' outcomes. Donors and recipients were classified into 2 groups: 1) elective (n = 387); and 2) urgent transplantations (n = 195). We evaluated 12 donor risk factors: age >55 years, alcohol ingestion, intensive care unit stay >4 days, hypotensive episodes (<70 mm Hg >10 min), noradrenaline dose >0.1 µg/kg/min, anti-hepatitis B of core (+), Na level >155 mmol/L, international normalized ratio >1.5, aspartate transaminase >140 U/L, alanine transaminase >170 U/L, bilirubin >2.0 mg/dL, and changes in liver sonography. There were no significant differences in the frequency of incidence of 11 donor risk factors in both groups. Only sodium level >155 mEq/L significantly (P = .04) differed. Donors for elective recipients showed this factor more frequently than the urgent cohort. The mean number of risk factors per donor among the elective cases was 2.28 and for the urgent cases 2.3, a difference that was not significant. In almost all cases of liver transplantations (94%), donor-related risk factors were acceptable. The criteria for cadaveric liver donors were not different for elective versus urgent recipients; biologic characteristics of the transplanted organs were similar in both groups. A tendency was not observed to expand donor criteria for urgent recipients.

Viral hepatitis B and C markers in the population of deceased donors in Poland.

In the years 2001 to 2005 in Poland, 3146 potential deceased donors were referred with 2583 (82%) organs procured and 57 (2%) donors not used due to positive viral markers. According to Polish rules, in every case of possible organ harvest from a deceased donor we test viral markers of anti-HIV I/II, HBsAg, and anti-HCV. Organs from HBsAg-positive donors (the rule accepted in Poland a few years ago) are not transplanted; kidneys from anti-HCV(+) donors are transplanted into matched recipients. According to donor hospital capabilities, other viral tests are performed: anti-HBs, anti-HBc, HBeAg, and anti-HBe. We calculate the frequency of positive serological tests for viral markers among the population of deceased donors, for HBsAg it was 1.1% (from these donors 10 kidneys and 1 liver were transplanted); and for anti-HCV it was 2.6% (from these donors 78 kidneys were used). Anti-HBc-positive deceased donors, particularly liver donors (due to the high risk of viral transmission and de novo infection), are a major problem in transplantation, which reduced the number of used organs. Only 17 of 86 (20%) of the HBc-positive donors became liver donors compared with 257 of 524 (49%) donors from the HBc-negative group. But anti-HBc was checked only in 24% of potential donors (positive in 16.6% of cases), which means that 506 of 780 transplanted livers (65%) were obtained from donors of unknown anti-HBc status, 257 (33%) from anti-HBc-negative subjects and 17 (2%) from anti-HBc-positive subjects.

Long-term results of kidney transplantation from HCV-positive donors.

BACKGROUND: Due to the shortage of organs for transplantation, procurement of kidneys from marginal donors is inevitable. Not infrequently, these donors are infected with hepatitis C virus (HCV). AIM: We sought to determine the effect of transplanting kidneys from anti-HCV-positive donors to anti-HCV-positive recipients. PATIENTS AND METHODS: Among 765 procedures between 1994 and 2006, 259 kidney recipients were anti-HCV-positive, including 60 who received kidneys from anti-HCV-positive donors (HCV(+)/HCV(+) group) and the others, from seronegative donors (HCV(-)/HCV(+) group). The control group of 506 seronegative recipients received kidneys from seronegative donors (HCV(-)/HCV(-) group). All kidneys from anti-HCV-positive donors were preserved with machine perfusion. We investigated recipient liver function tests (LFTs; alanine aminotrasferase, aspartate aminotransferase; alkaline phosphatase, and bilirubin), graft survival, and patient survival. RESULTS: No significant difference was observed between the groups among the biochemistry results (LFTs, creatinine at 5 years). No significant differences, were observed in patient survival, graft survival, or number of patients returning to dialysis. CONCLUSION: Transplantation of kidneys from HCV-positive donors to HCV-positive recipients did not influence long-term liver function, or long-term renal allograft function. This strategy enhances the availability of transplantation as means of end-stage renal disease treatment.

Surgical site infections in liver recipients in the early posttransplantation period: etiological agents and susceptibility profiles.

OBJECTIVE: This study evaluated the frequency of microbial isolates and their susceptibility profiles from cultures at the surgical site of 83 liver recipients in the early posttransplantation period. PATIENTS AND METHODS: We prospectively collected microbiologic culture data on 83 adult patients undergoing orthotopic liver transplantation (OLT) using standard procedures and commercially available tests. Susceptibility of the strains to antibacterial agents was performed by the Clinical and Laboratory Standards Institute (CLSI) guidelines. RESULTS: All patients were followed prospectively for the first 4 weeks after surgery. Among 284 microbial isolates from clinical surgical site samples in 80 liver recipients, cultures were positive in 110 samples. The most commonly isolated species were: Gram-positive cocci (n = 222 isolates, 78%) with dominance of methicillin-resistant coagulase-negative staphylococci (MRCNS; 42%) and high-level aminoglycoside-resistant enterococci (HLAR strains; 24.3%). Gram-negative bacteria were identified in 21.5% of positive cultures, including 30 strains (24%) from the Enterobacteriaceae family, with 13.3% of extended spectrum beta-lactamase producers [ESBL(+)]. Significant differences (P = .0012) were observed during the analysis of changes in the occurrence of Gram-positive bacteria isolated from the surgical site in the first week versus the second to the end of the fourth week. CONCLUSION: Gram-positive bacteria predominated as 78% of isolates.

Bacteria isolated from bile samples of liver recipients in the early period after transplantation: epidemiology and susceptibility of the bacterial strains.

OBJECTIVE: We estimated the frequency and susceptibility to antibacterial agents of bacterial isolates from bile samples obtained from 83 liver recipients in the early period after transplantation. PATIENTS AND METHODS: We prospectively collected data on 83 adult patients undergoing orthotopic liver transplantation (OLT), including bile samples taken during the first 30 days after OLT from adult liver recipients suspected to have bile infections. The isolation/identification of cultured bacteria was performed according to standard microbiological procedures and commercially available tests. Susceptibility of the strains to antibacterial agents was determined according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. RESULTS: Among 210 bile samples obtained from 79 liver recipients, bacterial cultures were positive in 110 samples from 59 (75%) recipients yielding 156 bacterial strains. The most commonly isolated species were as follows: gram-positive cocci (109 isolates) with dominance of coagulase-negative staphylococci (52%) and enterococci (36%); and gram-negative bacteria, 21 strains from the Enterobacteriaceae family and 14 of non-fermenting rods. We identified some multidrug-resistant (MDR) bacterial strains. In the first week after OLT, we investigated samples from 59 patients, yielding 36 bacterial strains. From the second to the end of the fourth week after OLT, 120 bacterial strains were isolated from 65 recipients. CONCLUSION: Gram-positive bacteria comprised 68.5%. The dominance of MDR gram-positive bacteria may be related to selection by perioperative antibiotic prophylaxis.

Detection of Clostridium difficile in stool samples from patients in the early period after liver transplantation.

OBJECTIVE: We examined the frequency of detection of Clostridium difficile (CD) toxins compared with the recovery of C. difficile in stool specimen cultures among orthotopic liver transplant (OLT) patients with nosocomial diarrhea in the early period. MATERIALS AND METHODS: The study included stool samples obtained during the first 30 days after OLT in adults who were suspected of CD-associated diseases. The identification of cultured CD strains was performed by standard microbiological methods. The presence of CD toxins was assayed using a commercial immunoassay. RESULTS: All patients were followed prospectively for CD infections from the date of OLT for the first 4 weeks after surgery. Among 54 samples, 16.7% were culture-positive for CD. CD toxins were tested on 54 samples, yielding 63% toxin-positive samples and 30% toxin- and culture-negative results. In the first week after OLT, samples from 19 patients were subjected to CD investigation. Among 19 samples positive for toxin, 52.6% of all samples were culture-negative. We analyzed 35 samples from the second to the fourth week after OLT in 31 recipients. Among 35 samples, 68.6% and 25.7% were positive for CD toxin and for culture, while 20% of samples were negative for toxin and culture. CONCLUSION: In our study, 63% of samples were toxin-positive with 16.7% yielding growth of CD and 30% being negative for toxins and cultures.

Etiological agents of bacteremia in the early period after liver transplantation.

Bacteremia is one of the major infections in orthotopic liver transplantation (OLT). The study of 83 adults who underwent OLT from 2001 to 2004, included patients followed prospectively from the day of transplantation to 4 weeks after the procedure by bacteriological cultures. The microorganisms were investigated according to standard National Committee for Clinical Laboratory Standards (NCCLS) procedures. Blood samples were examined in 59 recipients (71.1%) before and in 76 patients (91.6%) during the month after transplantation. Among 249 investigated samples, 96 were positive, as cultured from 19 recipients before OLT and 48 patients afterward. The most common were Gram-positive cocci (n = 71) and coagulase-negative staphylococci (n = 52), including methicillin-resistant coagulase-negative staphylococci (MRCNS). Enterococcus spp. occurred in 9 isolates (high-level aminoglycoside-resistant enterococci [HLAR] strains were cultured). We cultured the Enterobacteriaceae family (n = 16 isolates) and (n = 15 isolates), Gram-negative nonfermenting rods some of which were extended spectrum beta-lactamase producing [ESBL(+)] strains. The predominance of Gram-positive cocci was caused by CNS, and the use of prophylaxis to reduce Gram-negative bacteria. The increased rate of isolation of bacteria with multidrug resistance (MDR) to antimicrobial agents may be due to their frequent use for prophylaxis of bacterial infections in OLT. These MDR bacterial strains caused severe BSI after OLT.

Surgical complications of simultaneous pancreas-kidney transplantation: a 16-year-experience at one center.

Fifty-one simultaneous pancreas-kidney transplants (SPKT) were performed between 1988 and 2004 in patients of mean age 34 years and 23 years duration of diabetes treatment. All kidney and pancreas recipients were on maintenance hemodialysis therapy prior to SPKT. The pancreas with duodenal segment and the kidneys were harvested from cadaveric heart-beating donors. Cold ischemia time in UW solution varied from 4 to 14 hours (mean, 9 hours 35 minutes). Twenty patients had the duodenal segment sutured to the urinary bladder, and the remaining 31 grafts were drained to an isolated ileal loop. Quadruple immunosuppression was administered as well as an anticoagulant and antibiotic prophylaxis. Forty-nine patients (49/51, 96%) regained insulin independence in the immediate postoperative period; 44 (86%) displayed immediate graft function. The remaining patients experienced postoperative ATN, the longest duration was 18 days. Of 51 patients, 38 (14.5%) are alive (follow-up, 6 to 180 months), 26 (68.5%) have good pancreatic function, and 34 (89%), good kidney function. Nineteen (50%) patients regard their quality of life as improved compared to their pretransplant status, which is mainly attributed to being dialysis and insulin free. Of 19 patients, 14 (74%) reported measuring glycemia regularly due to fear of losing the pancreas graft. Of 19 persons, seven (37%) returned to work after transplantation. Four (8.3%) lost their kidney graft secondary to vascular complications (n = 2) or rejection (n = 2). Four pancreas grafts with bladder drainage required conversion to enteric drainage owing to persistent urinary infections or urinary fistulae. Fifteen (29%) patients lost their pancreatic grafts within 1 year of transplantation due to the following: vascular complications (n = 12), septic complications (n = 1), or rejection (n = 2). Thirteen patients died within 1 year after transplantation, 5 of septic complications, 5 of neuroinfection, 1 of pulmonary embolism, and 2 of myocardial infarction. In conclusion, SPKT is a successful treatment for diabetic nephropathy, burdened by the possibility of serious complications.

Quality of life after simultaneous pancreas-kidney transplantation.

Even recipients with satisfactory function of transplanted pancreas and kidney may show physical and/or social disability due to diabetic complications. Our aims were to evaluate diabetic complications influencing recipient quality of life and to assess patients' psychosociological status. Nineteen patients with functioning grafts who consented to take part in the study, underwent clinical evaluation and answered questions regarding their quality of life. Results showed excellent endocrine pancreatic function in 17 patients. In most recipients, insulin activity and C-peptide levels were elevated owing to systemic venous drainage. Opthalmological examination revealed blindness in 7 patients (in 4 cases with onset following SPKTx) and retinopathy in 13 patients (in 5 cases it appeared after SPKTx). Assessment of the cardiovascular system revealed satisfactory cardiac function in 16 of 19 patients; 4 patients underwent amputation of a lower limb following SPKTx. All 19 recipients admitted to a great benefit of transplantation; most patients declared ability to organize their life activity and social functions and 4 had regular employment. Conversely, most patients were afraid of graft loss, and half were often sad and even depressed.

Do all well-differentiated thyroid cancers constitute a definite contraindication to obtaining organs for transplantation? A case report.

In this case a thyroid gland tumor was diagnosed with fine needle aspiration (FNA) in a 34-year-old female donor of a liver fragment for living related liver transplantation. This diagnosis disqualified her as a donor. The increased incidence of thyroid cancer in Poland presents the possibility of their occurrence in potential donors. Well-differentiated thyroid papillary carcinomas larger than 1 cm in diameter, as well as follicular and medullary carcinomas (regardless their size and or clinical staging), present absolute contraindication to donation. Papillary microcarcinoma restricted to the thyroid gland (with no metastases in local lymph nodes) because of its specific behavior and almost always benign course, requires an individualized approach. It seemed that when a recipient is in a life-threatening condition, we should consider taking organs from a donor suffering of papillary microcarcinoma restricted to the thyroid gland.

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.