A Rare Complication of Peritoneal Dialysis (PD) Catheter: Perforation of Sigmoid Colon by Migrating Tip of Peritoneal Dialysis Catheter.

BACKGROUND Peritoneal dialysis (PD) has benefits over hemodialysis (HD), including the ability of daily performance at home without interfering with important activities such as school attendance in children. However, there are risks and complications associated with it. This is the third pediatric case report of a dormant PD catheter tip perforating the colon and protruding through the anus, but without peritonitis, as would be highly expected. CASE REPORT A 12-year-old male with ESRD secondary to obstructive uropathy received a pre-emptive deceased donor kidney transplant that failed within a few days due to thrombosis secondary to factor V Leiden deficiency. Transplant nephrectomy was performed and several months later he was started on PD. Subsequently, due to multiple episodes of catheter drain failure, the modality was switched to HD with a plan to remove the PD catheter later. Two months after discontinuing PD, he presented to the Emergency Department with the catheter tip protruding through the anus and he was asymptomatic. Abdominal X-ray (AXR) and CT scans were performed. The PD catheter was removed and the colon was repaired by proctosigmoidoscopy and laparotomy. Five years later, he continues to be on HD by preference, with arteriovenous fistula (AVF), without any complications of perforation. CONCLUSIONS There are 2 cases previously reported in children with colonic perforation by the tip of a PD catheter without signs and symptoms of peritonitis, but those patients were on immunosuppression after kidney transplant. Our patient is unique because he was not on immunosuppression.

Socioeconomic Factors Associated with Readmission after Deceased Donor Renal Transplantation.

Early hospital readmissions after kidney transplantation pose a significant financial burden and hardship for patients and health-care institutions alike. We sought to identify the risk factors associated with increased likelihood of readmission after transplantation, and examined to determine whether patient socioeconomic demographics impacted the likelihood of perioperative readmissions. We evaluated all deceased donor renal transplants performed at our institution between August 2011 and December 2015. In a cohort of 325 transplant operations that met our inclusion criteria, 117 (36%) were readmitted to the hospital within 90 days of discharge. In univariable analyses, length of stay and pretransplant disabled status were associated with increased likelihood of readmission within 90 days of transplant. When placed into multivariable models, there was a suggestion association with length of stay and disability status. Kidney donor profile index, estimated posttransplant survival, employment, race, age, and payor status were not associated with readmission. In conclusion, the factors associated with posttransplant readmission are not necessarily influenced by socioeconomic factors in our study population. The data collected in this single center study indicate that the factors associated with increased rates of readmission are likely clinical in nature.

Hepatitis E in post-liver transplantation: is it time to routinely consider it?

Hepatitis E, although commonly recognized in the Eastern Hemisphere, is less well recognized in the West. Particularly owing to this disease's grave impact on outcomes after liver transplantation, greater consideration of hepatitis E is necessary in the context of abnormal liver tests. Here, we review the most recent data on detecting and managing hepatitis E, both pre- and post-liver transplantation, discuss major detection assay limitations, consider future directions, and propose an algorithm for the diagnosis and management of pre-and post-transplantation hepatitis E.

Hepatocyte autophagy is linked to C/EBP-homologous protein, Bcl2-interacting mediator of cell death, and BH3-interacting domain death agonist gene expression.

BACKGROUND: Endoplasmic reticulum (ER) stress and autophagy each play important roles in hepatocyte cell injury. We hypothesized that gene expression of C/EBP-homologous protein (CHOP) and the BH3 proteins Bcl2-interacting mediator of cell death (BIM) and BH3-interacting domain death agonist (BID) are involved in a complex interplay that regulates ER stress-induced autophagy and cell death. MATERIALS AND METHODS: Hepatocytes were cultured from lean Zucker rats. Confluent hepatocytes were incubated with single or combined small interfering RNA for CHOP, BIM, and/or BID for 24 h providing gene inhibition. Incubation with tunicamycin (TM) for another 24 h stimulated ER stress. Quantitative real-time polymerase chain reaction determined the expression levels of CHOP, BIM, and BID. Immunostaining with microtubule-associated protein 1 light chain 3 measured autophagy activity. Trypan blue exclusion determined the cell viability. RESULTS: TM treatment increased the messenger RNA levels of CHOP and BIM but decreased the messenger RNA levels of BID. TM increased autophagy and decreased cell viability. Individual inhibition of CHOP, BIM, or BID protected against autophagy and cell death. However, simultaneous treatment with any combination of CHOP, BIM, and BID small interfering RNAs reduced autophagy activity but increased cell death independent of ER stress induction. CONCLUSIONS: Autophagy in hepatocytes results from acute ER stress and involves interplay, at the gene expression level, of CHOP, BIM, and BID. Inhibition of any one of these individual genes during acute ER stress is protective against cell death. Conversely, inhibition of any two of the three genes results in increased nonautophagic cell death independent of ER stress induction. This study suggests interplay between CHOP, BIM, and BID expression that can be leveraged for protection against ER stress-related cell death. However, disruption of the CHOP/BH3 gene expression homeostasis is detrimental to cell survival independent of other cellular stress.

Hepatocellular carcinoma: resection versus transplantation.

Hepatic resection and transplantation remain the standard curative therapies for hepatocellular carcinoma. These treatments are limited to either patients with early-stage tumors in the case of transplantation or patients with preserved liver function in the case of resection. Currently, patients with early-stage tumors and advanced liver disease are best served by transplant evaluation; however, the best treatment strategy for patients with well-preserved liver function, absence of portal hypertension, and early-stage HCC is debated. Numerous retrospective studies have documented better disease-free survival with transplantation, although the benefit on overall survival is less clear. This effect is likely due to the availability of effective liver-directed therapies for recurrence postresection and the effect of immunosuppression on tumor progression following posttransplant recurrence. Survival studies based on intention-to-treat principle incorporating patients listed for transplantation, but did not undergo the procedure due to waitlist dropoff have also suggested that overall survival rates may not be different despite high recurrence rates following resection. Transplantation has been shown to offer a survival advantage beyond 5-years; however, improvements in adjuvant therapies may narrow this gap. Determining optimal therapy for an individual patient requires consideration of numerous factors including tumor stage, severity of liver disease, and comorbidities as well as geographic and logistical factors that may affect transplant availability.

Small bowel obstruction after pediatric liver transplantation: the unusual is the usual.

BACKGROUND: Intestinal obstruction is a rare but serious complication after liver transplantation. Adhesions are the most common cause of obstruction in the nontransplantation setting; however, after pediatric liver transplantation unusual causes must be considered. STUDY DESIGN: A prospectively maintained institutional database was analyzed for all reoperations for intestinal obstruction on pediatric liver allograft recipients from 1990 to 2009. RESULTS: During the study period, 181 pediatric patients underwent liver transplantation at the study center. The most common indication for transplantation was biliary atresia. Seven patients required reoperation for intestinal obstruction. All 7 patients had abdominal operations before transplantation and 5 of 7 received reduced-size grafts. No patients had adhesive small bowel obstruction. The cause was right-sided diaphragmatic hernia in 4 and post-transplantation lymphoproliferative disorder (PTLD) in 3. Diaphragmatic hernia was demonstrated by chest radiograph in 3 of 4 patients. The fourth was taken to surgery with a presumptive diagnosis of intestinal obstruction and a diaphragmatic hernia was found at exploration. In patients with PTLD causing obstruction, 2 presented with an obstructing mass and the third presented with intussusception. Mean time to reoperation was 29 months after liver transplantation. Patients with diaphragmatic hernia presented earlier post-transplantation than those with PTLD (4.2 ± 2.4 months versus 59.3 ± 54.6 months, respectively; p = 0.0003, Fisher's exact test). Six patients are alive at a median follow-up of 5.8 years. One patient succumbed to recurrent B-cell lymphoma. CONCLUSIONS: Intestinal obstruction after pediatric liver transplantation is commonly related to what would conventionally be considered unusual causes. A high index of suspicion must be maintained and early operative therapy considered as obstruction because causes such as diaphragmatic hernia and PTLD are unlikely to resolve with conservative measures.