Immunosuppressive regimens on conversion of cytomegalovirus infection to disease in liver transplant recipients

Background: Cytomegalovirus (CMV) disease is one of the most common infectious complications after liver transplantation. It is the cause of numerous morbidity and mortalities. Intensity of immunosuppression defined as overall immunosuppressive drug dosage seems to affect infectious complications. The main purpose of this study is to investigate the intensity of immunosuppression on conversion of CMV infection to disease in this population. Methods: In this cross-sectional study, we retrospectively evaluated and analyzed the data of all recipients who underwent orthotopic liver transplantation (OLT) between March 2014 and March 2016 and had positive serum PCR for CMV after transplantation in follow- up course. Of 134 recipients, only 66 adult liver transplant recipients were eligible to be studied.  Multiple variables such as MELD score, cold ischemic time, warm ischemic time, operative data, immunosuppressive drugs and regimen, plasma CMV viral load, donor and recipient CMV IgG serostatus were recorded and analyzed. Results: of the 66 patients, 50 (76) had CMV infection and 16 (24) had disease. There was significant association between donor CMV IgG serostatus, extra corticosteroid pulse therapy, acute cellular rejection, serum tacrolimus level and conversion of CMV infection to CMV disease (P=0.005, 0.001, 0.031, 0.031). Conclusion: It seems that the intensity of immunosuppression has influence on conversion rate of CMV infection to disease in liver recipients

Predictors of Death in the Liver Transplantation Adult Candidates: An Artificial Neural Networks and Support Vector Machine Hybrid-Based Cohort Study

Background: Model for end-stage liver disease (MELD) is currently used for liver transplantation (LT) allocation, however, it is not a sufficient criterion. Objective: This current study aims to perform a hybrid neural network analysis of different data, make a decision tree and finally design a decision support system for improving LT prioritization.Material and Methods: In this cohort follow-up-based study, baseline characteristics of 1947 adult patients, who were candidates for LT in Shiraz Organ Transplant Center, Iran, were assessed and followed for two years and those who died before LT due to the end-stage liver disease were considered as dead cases, while others considered as alive cases. A well-organized checklist was filled for each patient. Analysis of the data was performed using artificial neural networks (ANN) and support vector machines (SVM). Finally, a decision tree was illustrated and a user friendly decision support system was designed to assist physicians in LT prioritization. Results: Between all MELD types, MELD-Na was a stronger determinant of LT candidates’ survival. Both ANN and SVM showed that besides MELD-Na, age and ALP (alkaline phosphatase) are the most important factors, resulting in death in LT candidates. It was cleared that MELD-Na <23, age <53 and ALP <257 IU/L were the best predictors of survival in LT candidates. An applicable decision support system was designed in this study using the above three factors.  Conclusion: Therefore, Meld-Na, age and ALP should be used for LT allocation. The presented decision support system in this study will be helpful in LT prioritization by LT allocators

To the Readers

Transplantation medicine is one of the most complex and challenging fields in medical sciences. It is a relatively young discipline with an impressive rate of growth and geographic expansion. Few areas in medicine are so much intertwined with ethnicity, ethical, religious and jurisdictionalfactors as organ transplantation. We are confident that experiences gained in this part of the world will constitute a valuable cache in furthering this burgeoning field.It is our firm conviction that scientific exchange is the most influential factor in the growth of human knowledge. We therefore feel invoked to create our own forum for presentation of experienceas a means of contribution to human knowledge. The rapid pace of proliferation of transplantation in this part of the world warrants establishing of local journals to serve this purpose. The International Journal of Organ TransplantationMedicine aims at forming a means through which national and international scientists and clinicians to contribute to the developmentof the discipline.Chimerical figures in the mythology of these areas are witness to the interest of its people and have permeated in the traditional beliefs for millennia by the idea of mixing human body and powerful animals, the most famous of which is represented in the Sphinx of Egypt and the winged bull in Persepolis.With decades of productive experience at the centers of Shiraz University of Medical Sciences, and the major conglomerate of transplantation clinics of Avicenna, we are confident that we can render our due share in promoting this exciting branch of medicine

Prevalence and risk factors of renal dysfunction after liver transplant: A single-center experience

Objectives: Renal dysfunction is one of the most significant complications after liver transplant. It is attributed mainly to nephrotoxicity caused by calcineurin inhibitors. We evaluated the renal functioning in liver transplant recipients alive for at least 6 months after liver transplant. Materials and Methods: One hundred seventy patients (108 male [63.5%], 62 female [36.5%]; mean age, 31.4 +/- 13.3 years; age range, 13-61 years) were included in this study. Patients who had undergone a liver transplant between 1994 and 2006 at the Organ Transplantation Center of the Shiraz University of Medical Sciences in Shiraz, Iran, and had been alive for at least 6 months after surgery were included. Data were collected regarding age, sex, body mass index, underlying liver disease, graft type, immunosuppressive medications, serum creatinine levels, and glomerular filtration rate before, 1, and 6 months after liver transplant. Renal dysfunction was defined as a serum creatinine level above 132.6 mu mol/L or a glomerular filtration rate less than 60 mL/min/1.73 m(2), based on our reference range. Glomerular filtration rate was calculated using the Schwartz formula (glomerular filtration rate mL/min/1.73 m(2) = K X Ht (cm) / Cr mg/dL). Data were analyzed with SPSS software. Results: The mean follow-up was 25.9 +/- 23.5 months (range, 6-156 months). The main indications for liver transplant were cryptogenic cirrhosis (n=42), hepatitis B infection (n=34), autoimmune cirrhosis (n=30), Wilson's disease (n=21), and primary sclerosing cholangitis (n=18). The mean pretransplant glomerular filtration rate was 93.7 +/- 35.6 mL/min/1.73 m(2). The mean glomerular filtration rates in the first and sixth months after liver transplant were 81.6 +/- 29.3 mL/min/1.73 m(2) and 83.6 +/- 32.9 mL/min/1.73 m(2). Sex, body mass index, type of immunosuppressive medication, and underlying liver disease were not predictors of renal dysfunction (P > .05). Posttransplant renal dysfunction was significantly more common in older patients (ie, those aged 38.8 years and older) (P = .0001) and those with a family history of renal disease (P < .05). Conclusions: Renal dysfunction may be a significant problem for patients after liver transplant, and early detection of renal dysfunction in patients after liver transplant is important. Of all the risk factors studied here, only older age and family history of renal disease were correlated with development of renal dysfunction after liver transplant

Using inverted autogenous veins to substitute arteries in a canine model

Aims : Rapid harvesting of autogenous graft over a wire is an optional way in trauma surgery and it places the inverted conduit so that its adventitial layer is within the lumen of the graft. Our aim of this study was to compare the patency of inverted autogenous graft vs noninverted graft in dogs. Settings and Design : Experimental animal models. Materials and Methods : In this experimental study, 12 dogs were anesthetized and 10 cm of the external jugular vein was excised. The vein was equally divided into two 5-cm sections. One section was inverted and the other was left intact. Afterward, 5 cm of both the femoral arteries were removed and the right (inverted) and the left (not inverted) arteries were grafted, respectively. The patency of the arteries was evaluated by Color Doppler ultrasonography immediately postoperation and up to 6 months thereafter. Statistical Analysis : Data were analyzed with Fisher&#x2032;s exact test using SPSS version 15. P value below 0.05 was significant. Results: None of the 12 inverted vein grafts were patent at 3 rd to 14 th days follow-up with Doppler ultrasonography. All of them were completely obstructed by thrombosis. However, 11 (92&#x0025;) of the noninverted vein grafts were patent both at 3 and 6 months follow-up. One of the noninverted grafts was almost completely obstructed with thrombosis (90&#x0025;) and the other 2 were incompletely obstructed with intimal thickening. Conclusions : Despite many favorable results in the previous studies with regard to excellent patency of inverted vein graft, our results were disappointing and we recommend using the graft in the right direction and taking care to preserve the intima intact

SINGLE DOSE OF G-CSF IN LEUKOPENIA AFTER POST LIVER TRANSPLANT

Immunosuppressive therapies are the main treatment modalities after transplantation to prevent rejection. One of the major side effects of potent immunosuppressant is Leukopenia. Granulocyte colony stimulating factor (G-CSF) is a cytokine agent which is increasing life span and functional activity of mature neutrophils. G-CSF is a well-established treatment of chemotherapy induced Leukopenia, during hematopoietic stem cell transplantation and HIV infection neutropenia. There were several studies in animal models of liver diseases which showed hematopoietic stem cell mobilization into the injured liver and their differentiation to hepatocytes. There were a few clinical trials in human after development of neutropenia in post Liver transplantation (LTx) periods. This study was designed as a pilot study to evaluate the safety of G-CSF on Leukopenia in early post LTx periods. Seventeen Leukopenic patients in 4 weeks after LTx entered to the study and randomized in one to one manner in this open label study. Treatment group received 0.3 mg of GCSF (PD- G-CSF) at the time of Leukopenia (≤3000/mm3) and Short term patient's and graft survival were determined. Data are reported as mean and all date were analyzed using chi square and Student t-test. (SPSS of ware, version 14) P values&lt; 0.05 were considered significant. Nine patients in control group and 8 patients recruited in the treatment group. There were no significant differences in days of hospital admission (P: 0.244), microbiologic active Cultures (P: 0.30), Oropharyngial candidiasis (P: 0.30), acute cellular rejection (ACR) (P: 0.437) and day of desirable Mycofenolate Mofetile (MMF) dosage achievement (P: 0.691) and episodes of ACR treatments (P: 0.08). Our open labeled pilot study showsthat single dose of G-CSF in leukopenic post liver transplant patients is safe. Although there was no statistically significant beneficial effect on hospital stay, opportunistic and surgical site infections but there was a trend toward less ACR episodes in the treatment group. Whether single dosage has a beneficial effect on liver function, survival, rejection and hospital stay needs further research in another clinical trial.Keywords:G-CSF, Leukopenia, Post Liver Transplan

The use of micro pulse oximetery as a new detector of tissue perfusion in solid organ transplantation

Vascular complications are a frequent cause of transplant failure; angiography, duplex sonography, computerized tomography (CT) scan, CT-angiography and microdialysis are the methods that were suggested for the detection of arterial obstruction after transplantation. In this study, we suggest a new method. Eight healthy adult dogs were included in the trial. All cases were operated by the same surgeon and the liver, pancreas, spleen, kidney and bowel tissue were exposed. The probes of the device, which were designed for this study, were inserted on the organ parenchyma. The device, a neonatal pulse oximeter, has two probes that were fixed by a holder in front of each other; the distance between the probes was changeable via a spring. The pulse and the oxygen saturation of the tissue were measured initially. Following this, by inducing ischemia with vessel clamping, the pulse and the oxygen saturation were measured again. The collected data were analyzed under the supervision of a statistician. In the liver and spleen, we could not detect a clear pulse wave and oxygenation. On the other hand, in the pancreas, kidney and bowel, we detected a clear curve of oxygenation and pulse in all cases. Obstruction caused significant changes: the pulse was not detected and the oxygenation decreased significantly. Our study suggests that with early diagnosis, the surgeons can detect arterial occlusion immediately and early intervention may decrease parenchymal damage. This study is the first experience in this field, and these findings need to be validated with further studies

Pure Uterine Lipoma and Focal Nodular Hyperplasia of the Liver: Concurrence of a Rare Tumor and Another Incidental Finding

Background. Fatty uterine tumors, especially pure uterine lipoma, are very rare, but clinically and radiologically, they can mimic other primary benign and malignant uterine neoplasms. Case Report. A multipara 61-year-old postmenopausal woman presented with abnormal vaginal bleeding for 3 months. Assessment by ultrasound and magnetic resonance imaging (MRI) revealed a hyperechoic mass in the uterine corpus. Furthermore, during radiologic investigation, there was an incidental isoechoic mass in the left lobe of the liver. Pure uterine lipoma and hepatic focal nodular hyperplasia were diagnosed. Conclusion. Pure lipoma of the uterus, even though rare, has to be kept in the differential diagnosis of uterine neoplasms, especially in postmenopausal women. Till now, just a few concurrent tumors have been reported with pure uterine lipoma, and among them, FNH is the first extragenital tumor