Liver transplantation and surgery : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society最新文献

{"title":"Endoscopic surveillance and primary prophylaxis for upper gastrointestinal bleeding in liver transplant candidates.","authors":"A. Burroughs","doi":"10.1053/jlts.2002.0080308","DOIUrl":"https://doi.org/10.1053/jlts.2002.0080308","url":null,"abstract":"Objective: Screening for varices has been recommended in patients with cirrhosis to prevent variceal hemorrhage (primary prophylaxis). In addition, therapy is recommended after the initial episode of variceal bleeding to prevent recurrence (secondary prophylaxis). However, the degree of adherence to these recommendations remains unclear. The purpose of our study was to determine whether these recommendations are being followed in patients presenting for evaluation of orthotopic liver transplantation. Methods: One hundred twenty-five patients referred for liver transplantation were evaluated. Data regarding demographics, clinical information, relevant time intervals (diagnosis of cirrhosis to screening, screening to initial variceal bleeding, variceal bleeding to referral, diagnosis of cirrhosis to referral), screening strategies used, and implementation of primary or secondary prophylaxis was obtained. The differences among quantitative variables were analyzed with Student's t test. Quantitative variables were evaluated with the Mantel-Haenzel [Chi ]2 test or Fisher's exact test. Statistical significance was designated at p [lt ] 0.05. Results: Our study found that 46% of patients presenting for evaluation of liver transplantation had screening endoscopy or radiological studies to detect the presence of varices. On the contrary, secondary prophylaxis was performed in all patients with a prior history of variceal hemorrhage. Screening for varices displayed no regional differences. Conclusions: In our cohort, screening for varices is not being consistently performed, thus delaying the timely implementation of primary prophylaxis. Therefore, the adherence to currently available practice guidelines and the education of physicians to implement screening in this patient population is an important goal. (Am J Gastroenterol 2001;96:833-837.)","PeriodicalId":18112,"journal":{"name":"Liver transplantation and surgery : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2002-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80969246","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Toward tolerance: lessons learned from liver transplantation.","authors":"J J Fung","doi":"10.1053/JTLS005s00090","DOIUrl":"https://doi.org/10.1053/JTLS005s00090","url":null,"abstract":"<p><p>*Define the various concepts of transplantation tolerance: Immunologically: unresponsiveness to donor antigens Clinically: ability to discontinue nonspecific immunosuppression Outcome-based: ability to prevent long-term immunologically mediated graft loss (i.e., chronic rejection). *Understand the various possible mechanism(s) involved in developing transplantation tolerance: Central tolerance: clonal deletion Peripheral tolerance: Blocking antibodies Cytokine imbalance Clonal T-cell anergy Active regulation of T- and B-cell proliferation. *Methods to achieve transplantation tolerance: Macrochimerism: recipient cytoablation and donor reconstitution Microchimerism: bone marrow augmentation, growth factors Intrathymic inoculation: central tolerance? T-cell costimulatory blockade: induction of T-cell anergy. *Limitations of achieving transplantation tolerance: No markers to define tolerance Poor understanding of acute and chronic rejection mechanisms (e.g., direct v indirect antigen presentation, high- v low-affinity T cells for alloantigen) What cells are involved in the development of tolerance? How stable is clinical tolerance: are the dynamics influenced by nontransplant factors (e.g., antigenic stimulation by viral factors)? Need for a two-pronged approach: nonspecific phase followed by specific phase?</p>","PeriodicalId":18112,"journal":{"name":"Liver transplantation and surgery : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1999-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21296069","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Immunology of acute and chronic hepatic allograft rejection.","authors":"J M Vierling","doi":"10.1053/JTLS005s00001","DOIUrl":"https://doi.org/10.1053/JTLS005s00001","url":null,"abstract":"","PeriodicalId":18112,"journal":{"name":"Liver transplantation and surgery : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1999-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21296060","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Incidence, timing, and risk factors for acute and chronic rejection.","authors":"J Neuberger","doi":"10.1053/JTLS005s00030","DOIUrl":"https://doi.org/10.1053/JTLS005s00030","url":null,"abstract":"<p><p>Rejection of the liver allograft may be classified as massive hemorrhagic necrosis or acute and chronic rejection. Massive hemorrhagic necrosis is now rarely seen; it occurs within the first few days after transplantation and is associated with transplantation across the blood-type groups. Early acute rejection (within 28 days of transplantation) is usually of little clinical significance and responds well to additional immunosuppression, whereas later rejection is associated with a greater risk for progression to graft loss. The incidence of early, acute rejection is dependent on the immunosuppressive regimen used and will vary between 20% and 70%. Patients who undergo transplantation for hepatitis B viral infection and alcohol-related liver disease have a lower incidence of rejection compared with those who undergo transplantation for cholestatic diseases, such as primary sclerosing cholangitis and primary biliary cirrhosis. Other factors that influence the incidence of acute rejection include age, race of recipient, and preservation injury. The incidence of chronic rejection is declining; most centers report current rates of 4% to 8%, whereas in earlier series, rates of 15% to 20% were observed. The reasons for this decline are unknown, but may relate to better immunosuppression. Chronic rejection usually presents within the first year posttransplantation. The greatest risk factor for chronic rejection is transplantation for chronic rejection; other factors include indication (especially primary sclerosing cholangitis, primary biliary cirrhosis, and autoimmune hepatitis); cytomegalovirus infection, and low levels of immune suppression.</p>","PeriodicalId":18112,"journal":{"name":"Liver transplantation and surgery : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1999-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21296062","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Use of antilymphocyte induction therapy in liver transplantation.","authors":"W J Wall","doi":"10.1053/JTLS005s00064","DOIUrl":"https://doi.org/10.1053/JTLS005s00064","url":null,"abstract":"<p><p>Polyclonal and monoclonal antilymphocyte agents (antilymphocyte globulin, antithymocyte globulin, OKT3, anti-interleukin-2 receptor antibody) are potent immunosuppressive agents that differ fundamentally in their mechanisms of action from cyclosporine- and tacrolimus-based induction therapy. Clinical trials and retrospective studies show low rates of acute rejection can be obtained when biological antilymphocyte agents are used for induction immunosuppression in liver transplant recipients. Infectious complications are similar to those of conventional induction regimens, and the incidence of posttransplant lymphoproliferative disease is acceptably low when excessive doses are not used. Published series of liver transplant recipients have so far not shown the clear superiority of antilymphocyte induction therapy, in terms of patient and graft survival, compared with standard therapy (cyclosporine or tacrolimus plus steroids and azathioprine). At present, there is no ideal induction regimen recommended for all patients.</p>","PeriodicalId":18112,"journal":{"name":"Liver transplantation and surgery : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1999-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21296066","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of immunosuppression and acute rejection on recurrence of hepatitis C: results of the National Institute of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database.","authors":"M Charlton,&nbsp;E Seaberg","doi":"10.1053/JTLS005s00107","DOIUrl":"https://doi.org/10.1053/JTLS005s00107","url":null,"abstract":"<p><p>Whereas the impact of early (first 6 postoperative weeks) acute cellular rejection on patient survival among liver transplant recipients as a whole has been reported to be favorable, we hypothesized treatment for acute cellular rejection may have differing impacts on patient and graft survival in hepatitis C virus (HCV)-infected and HCV-negative transplant recipients. We studied the impact of immunosuppression and rejection on patient and graft survival among the 166 HCV-infected and 602 HCV-negative transplant recipients enrolled onto the National Institute of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database. All data were collected prospectively. The association of early acute cellular rejection with mortality was determined using a Cox proportional hazards model with a time-dependent covariate. Median follow-up was 5.0 years for HCV-infected and 5.2 years for HCV-negative transplant recipients. HCV-infected transplant recipients experienced similar frequencies of acute cellular and steroid-resistant rejection as patients undergoing liver transplantation for most other indications. The mortality risk was significantly increased (relative risk = 2.4; P =.03) for HCV-infected transplant recipients who developed early acute cellular rejection compared with HCV-negative transplant recipients. None of the HCV-infected transplant recipients developed allograft failure secondary to chronic rejection. The choice of calcineurin inhibitor did not affect posttransplantation outcomes. Early acute cellular rejection occurs at similar frequencies in HCV-infected and HCV-negative transplant recipients. Although an episode of early acute cellular rejection is associated with a lower cumulative mortality among HCV-negative transplant recipients, the opposite is true for HCV-infected transplant recipients, who experience an increased risk for mortality after an episode of early acute cellular rejection. The adverse impact of early acute cellular rejection on patient survival should be considered in developing primary immunosuppression and acute cellular rejection treatment protocols for HCV-infected transplant recipients.</p>","PeriodicalId":18112,"journal":{"name":"Liver transplantation and surgery : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1999-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21295972","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Neoral/cyclosporine-based immunosuppression.","authors":"G A Levy","doi":"10.1053/JTLS005s00037","DOIUrl":"https://doi.org/10.1053/JTLS005s00037","url":null,"abstract":"<p><p>The introduction of cyclosporine (CsA) has been a major advance. Its use paved the way for successful programs in heart, lung, liver, kidney, and kidney-pancreas transplantation. The recent introduction of Neoral has overcome many of the problems associated with the use of Sandimmune (Novartis, Basel, Switzerland), including poor bioavailability, dependence on bile for absorption, and need for intravenous CsA early in the postoperative period. The use of Neoral has resulted in (1) a marked reduction in the incidence of acute cellular rejection, (2) ability to discontinue steroid therapy in the early posttransplantation period, and (3) low toxicity profiles. In direct comparison with tacrolimus, Neoral was equally efficacious and less toxic. This is even more impressive when one now realizes the monitoring of Neoral has been inadequate, and with more sensitive monitoring tools, including peak CsA level; a surrogate marker for C(max), CsA blood concentrations 2 hours after drug intake; or area under the CsA time-concentration curve, rejection rates may be improved, with improvement in toxicity profiles.</p>","PeriodicalId":18112,"journal":{"name":"Liver transplantation and surgery : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1999-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21296063","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Early steroid withdrawal in liver transplantation is safe and beneficial.","authors":"G T Everson,&nbsp;T Trouillot,&nbsp;M Wachs,&nbsp;T Bak,&nbsp;T Steinberg,&nbsp;I Kam,&nbsp;R Shrestha,&nbsp;M Stegall","doi":"10.1053/JTLS005s00048","DOIUrl":"https://doi.org/10.1053/JTLS005s00048","url":null,"abstract":"<p><p>This report reviews the literature and discusses steroid withdrawal after hepatic transplantation. Our experience with steroid withdrawal is highlighted. The hypothesis is that steroid withdrawal from liver transplant recipients is safe and beneficial. A review of the English literature yielded 16 reports with a total of 901 patients (749 adults and 152 children). Most reports were nonrandomized and uncontrolled. Only two reports were randomized, controlled trials; three reports featured early steroid withdrawal (</= 3 months); and one report featured very early steroid withdrawal (14 days). Steroid withdrawal was achieved in approximately 85% of the patients. Acute rejection was not significantly increased by steroid withdrawal; rates were 5% to 14% in uncontrolled trials and 7% versus 7% (late steroid withdrawal v control; P = not significant [NS]) and 4% versus 8% (early steroid withdrawal v control; P = NS) in controlled trials. Acute rejection rates after very early steroid withdrawal (14 days posttransplantation) were 42% to 46%, similar to or less than the 40% to 70% reported for steroid-containing regimens. Chronic rejection was not increased by steroid withdrawal; the rate was 3.9% in one uncontrolled trial and 0% versus 3% (early steroid withdrawal v control; P = NS) in one controlled trial. Patient and graft survival were not adversely affected. Steroid withdrawal was associated with reduced rates and better control of hypertension, reduced total cholesterol levels, reduced rate of posttransplantation diabetes mellitus, improved control of diabetes, and reduced rate of obesity. The aggregate experience with steroid withdrawal suggests it is safe, associated with improvement in several posttransplantation complications, and deserves broader clinical application.</p>","PeriodicalId":18112,"journal":{"name":"Liver transplantation and surgery : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1999-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21296064","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Mycophenolate mofetil as induction therapy after liver transplantation.","authors":"S V McDiarmid","doi":"10.1053/JTLS005s00085","DOIUrl":"https://doi.org/10.1053/JTLS005s00085","url":null,"abstract":"","PeriodicalId":18112,"journal":{"name":"Liver transplantation and surgery : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1999-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21296068","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Treatment of liver allograft rejection.","authors":"J M Millis","doi":"10.1053/JTLS005s00098","DOIUrl":"https://doi.org/10.1053/JTLS005s00098","url":null,"abstract":"","PeriodicalId":18112,"journal":{"name":"Liver transplantation and surgery : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1999-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21295971","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}