Characteristics and outcomes of neutropenia after orthotopic liver transplantation.

Neutropenia after orthotopic liver transplantation (LT) is relatively common, but the factors associated with its development remain elusive. We assessed possible predictors of neutropenia (absolute neutrophil count [ANC] ≤ 1000/mm(3) ) within the first year of LT in a cohort of 304 patients at a tertiary medical center between 1999 and 2009 using time-dependent survival analysis to identify risk factors for neutropenia. In addition, we analyzed neutropenia as a predictor of the clinical outcomes of death, bloodstream infection (BSI), invasive fungal infection, cytomegalovirus (CMV) disease, and graft rejection within the first year of LT. Of the 304 LT recipients, 73 (24%) developed neutropenia, 5 (7%) of whom had grade 4 neutropenia (ANC < 500/mm(3) ). The following were independent predictors for neutropenia: Child-Turcotte-Pugh score (hazard ratio [HR] 1.15; 95% confidence interval [CI], 1.03-1.30; P = 0.02), BSI (HR, 2.89; 95% CI, 1.63-5.11; P < 0.001), CMV disease (HR, 4.28; 95% CI, 1.55-11.81; P = 0.005), baseline tacrolimus trough level (HR, 1.02; 95% CI, 1.01-1.03; P = 0.007), and later era LT (2004-2009 versus 1999-2003; HR, 2.28; 95% CI, 1.43-3.65; P < 0.001). Moreover, neutropenia was found to be an independent predictor for mortality within the first year of LT (HR, 3.76; 95% CI, 1.84-7.68; P < 0.001). In conclusion, our data suggest that neutropenia within a year after LT is not unusual and is an important predictor of mortality.

Novel use of intravenous immunoglobulin G in complement factor H missense mutation: a case report.

A white girl presented at 8 months of age with thrombotic microangiopathy, followed by recurrent episodes of renal dysfunction, hemolysis, and thrombocytopenia, compatible with atypical hemolytic uremic syndrome. The episodes of the syndrome were treated by a combination of infusions of fresh frozen plasma, plasmapheresis, and continuous venovenous hemodialysis. Interval resolution occurred between episodes. At 2 years of age, prophylactic infusions of fresh frozen plasma were started between relapses, but this proved to be poorly protective; however, introduction of prophylactic intravenous gamma globulin at age 3.5 years resulted in prolonged remission (42 months). Serum levels of the third and fourth components of complement, total hemolytic complement, and complement factor H were normal. Results of the third component functional assay were low before and normalized after the start of immunoglobulin G prophylaxis. A missense mutation of complement factor H was identified. At 6 years of age, the patient underwent bilateral native nephrectomy and started long-term peritoneal dialysis, followed by a combined liver-kidney transplant at age 8 years. Four and a half years after transplant, she has excellent renal and liver graft function without recurrence of atypical hemolytic uremic syndrome.

Tacrolimus-associated eosinophilic gastroenterocolitis in pediatric liver transplant recipients: role of potential food allergies in pathogenesis.

Tacrolimus is a macrolide agent that is now the primary immunosuppressant used in prevention of graft rejection in transplant recipients. It has been found to be superior to cyclosporine (CSA) for rescue therapy as well as for earlier weaning of steroids. Both tacrolimus and CSA share similar toxicity profiles; however, their gastrointestinal side effects have received little attention. We report three cases of eosinophilic colitis in liver transplant recipients, maintained on tacrolimus as immunosuppressive medication post-liver transplantation. These patients also had high serum immunoglobulin (Ig)E levels, eosinophilia and IgE-positive radioallergosorbent test for milk proteins. The colitis appeared to be mediated by food allergies. Each patient had symptomatic improvement following reduced immunosuppression and an appropriately restricted diet. We conclude that tacrolimus may play a role in the initiation of food allergies, leading to eosinophilic colitis. More studies are needed in a controlled setting to identify the prevalence of similar findings among other pediatric liver transplant recipients.

Donor kidney exchanges.

Kidney transplantation from live donors achieves an excellent outcome regardless of human leukocyte antigen (HLA) mismatch. This development has expanded the opportunity of kidney transplantation from unrelated live donors. Nevertheless, the hazard of hyperacute rejection has usually precluded the transplantation of a kidney from a live donor to a potential recipient who is incompatible by ABO blood type or HLA antibody crossmatch reactivity. Region 1 of the United Network for Organ Sharing (UNOS) has devised an alternative system of kidney transplantation that would enable either a simultaneous exchange between live donors (a paired exchange), or a live donor/deceased donor exchange to incompatible recipients who are waiting on the list (a live donor/list exchange). This Regional system of exchange has derived the benefit of live donation, avoided the risk of ABO or crossmatch incompatibility, and yielded an additional donor source for patients awaiting a deceased donor kidney. Despite the initial disadvantage to the list of patients awaiting an O blood type kidney, as every paired exchange transplant removes a patient from the waiting list, it also avoids the incompatible recipient from eventually having to go on the list. Thus, this approach also increases access to deceased donor kidneys for the remaining candidates on the list.

Resource utilization among kidney transplant recipients.

BACKGROUND: Hospitalization consumes a significant portion of the end-stage renal disease (ESRD) program, which includes kidney transplant recipients. Identification of kidney transplant recipients at risk of increased resource utilization could lead to appropriate interventions to attenuate the complications related to kidney transplant, which may reduce resource utilization. METHODS: This retrospective cohort study of kidney transplant recipients was performed to identify risk factors for hospital utilization. The study population consisted of patients who received kidney transplant at our center between October 1990 and September 1999 and were followed in the outpatient clinic. RESULTS: Of the 220 patients, 171 (78%) were hospitalized during a median follow-up of 36 months. The number of hospitalizations, hospital days, and outpatient visits per patient-year at risk were 1.1, 6.3, and 21.6, respectively. Infection episodes were the leading cause of hospitalization. In a multivariate regression analysis, cytomegalovirus (CMV)-positive status of donor (RR 1.58; 95% CI 1.15, 2.18) and a higher number of hospital days during the transplant hospitalization (RR 1.10 per 7 days increase; 95% CI 1.03, 1.19) were associated with a higher risk of hospitalization, while higher serum albumin (RR 0.84 per 0.5 g/dL increase; 95% CI 0.73, 0.97), higher hematocrit (RR 0.95 per 1% increase; 95% CI 0.92, 0.98), higher glomerular filtration rate (GFR) (RR 0.91 per 10 mL/min/1.73 m2; 95% CI 0.85, 0.99), and an increased interval since transplant (RR 0.84 per 6 months increase; 95% CI 0.75, 0.93) were associated with a lower risk of hospitalization. CMV-positive status of the donor (RR 1.11; 95% CI 1.00, 1.21) and presence of cardiovascular disease (RR 1.12; 95% CI 1.00, 1.24) were associated with a higher risk of outpatient visits, while Caucasian race (RR 0.82; 95% CI 0.73, 0.94), higher serum albumin (RR 0.88 per 0.5 g/dL increase; 95% CI 0.84, 0.93), higher hematocrit (RR 0.96 per 1% increase; 95% CI 0.95, 0.97), and an increased interval since transplant (RR 0.79 per 6 months increase; 95% CI 0.76, 0.83) were associated with a lower risk of outpatient visits. CONCLUSION: Identification of risk factors associated with increase resource utilization among kidney transplant recipients could aid in the development of targeted interventions to improve clinical and economic outcomes.