Liver transplant recipients are at high risk of developing acute and chronic renal failure. Moreover, introduction of the model for end-stage liver disease (MELD) score for primary allocation of liver grafts favors patients with pretransplant kidney dysfunction, which in turn have a higher risk of posttransplant renal failure. Calcineurin inhibitors (CNI) further increase the risk of renal failure and therefore sparing CNI with the use of mycophenolate mofetil (MMF) may improve renal function. MMF may either be used de novo in the immediate posttransplant period in combination with low-dose CNI (scenario 1) or patients that receive immunosuppression based on CNI may be converted to MMF in combination with minimization or elimination of CNI (scenario 2). Although many retrospective cohort studies and nonrandomized trials have implicated efficacy of this approach the evidence from randomized controlled studies has not been summarized. In the current review we report the results of a systematic review and meta-analysis of randomized controlled trials.

INTRODUCTIONThe localisation of focal liver lesions is usually performed according to the Couinaud classification system. The exact description of localisation and size of liver lesions is especially important for surgical procedures. The aim of this prospective study was the evaluation of differences and agreements in the localisation and size of hepatic lesions as found by ultrasound (US), computed tomography (CT) and according to the intraoperative status (OP).MATERIAL AND METHODS32 patients (21 male, 11 female) were enrolled in the study. The results obtained from sonography, computed tomography and surgery were classified into 5 categories for localisation and for size, respectively.RESULTSAccording to the agreement between sonography and computed tomography, 25 % of all hepatic lesions were classified into category 1 (exact agreement), whereas 40.6 % were ranked into category 2 (almost exact agreement). Correlating sonography and intraoperative results, 31.3 % of the lesions were classified into category 1 and 46.9 % into category 2. In the comparison of CT with OP, 34.4 % of the lesions were found to be in category 1 and 43.8 % in category 2. Concerning the size of the lesions, almost half of the tumours (46.9 %) were classified into category 1 on the basis of the correlation between US and CT and 21.9 % on the basis of the correlation between US and OP.DISCUSSIONThe localisation and description of the size of hepatic lesions is mainly similar or even identical on the basis of the different methods. Further improvements might be achieved by the introduction of a consistent nomenclature.

To the Editor: In his recent in-depth review of cholesterol crystal embolization syndrome (CCE), Meyrier has delineated the pathogenesis, differential diagnoses, and therapeutic aspects of CCE. In addition to therapeutic measures of paramount importance such as restriction of further intravascular interventions, stop of anticoagulation, and treatment of renal insufficiency with dialysis, we would like to add the possibility of performing renal transplantation in selected CCE cases with end-stage renal disease and stable clinical course after diagnosis of CCE. We have previously reported a patient with CCE successfully undergoing renal transplantation. According to the best of our knowledge, there are so far no other published cases of the renal transplantation after CCE-induced end-stage renal disease. Briefly, a 63-year-old patient with a high load of atherosclerotic risk factors (heavy smoker, hypertension 160/80–180/100 mm Hg, severe hyperlipidemia (triglycerides up to 500 mg/dl; low-density lipoprotein cholesterol up to 240 mg/dl)) suffered from end-stage renal disease owing to cholesterol emboli after coronary angiography because of symptomatic coronary artery disease in October 1997. Within 1 week, the patient developed renal failure necessitating hemodialysis since December 1997. Smoking cessation, effective control of blood pressure (o130/80 mm Hg), and serum lipids (low-density lipoprotein cholesterol o100 mg/ dl) was achieved and maintained until successful renal transplantation from a living related donor in 1998. Until his last follow-up in May 2006, kidney function has remained stable with a current serum creatinine level of 1.28 mg/dl, corresponding to a calculated creatinine clearance of 60 ml/ min. Serum lipids have remained normalized with diet and pravastatin therapy (40 mg/day) with total cholesterol levels of about 187 mg/dl and low-density lipoprotein cholesterol levels of about 120 mg/dl as well as normotensive blood pressure levels have been achieved with losartan, doxazosin, nitrendipin, and nebivolol combined antihypertensive therapy, and the patient refrained from smoking. In conclusion, secondary prevention of CCE, that is, rigid long-term control of the underlying atherosclerotic risk factors may enable a selected subgroup of patients with CCE to undergo successful renal transplantation with excellent long-term patient and graft survival. 1. Meyrier A. Cholesterol crystal embolism: diagnostic and treatment. Kidney Int 2006; 69: 1308–1312. 2. Kammerl MC, Fischereder M, Zuelke C et al. Renal transplantation in a patient with end stage renal disease due to cholesterol embolism. Transplantation 2001; 71: 149–151.

Due to the late onset of symptoms, retroperitoneal liposarcoma are often diagnosed in advanced stages when adjacent organs have been infiltrated and the tumours have reached extensive sizes. Surgery remains the first choice of therapy. We report on the primary resection of a 45-kg liposarcoma that was removed en-bloc including the left kidney and descending colon with -tumour-free margins. Nine months later, the follow-up revealed a right-sided recurrence of the tumour, which was surgically removed including the right ureter. Since then, the patient has been without any signs of tumour recurrence or metastases. This report demonstrates that even extreme-ly large tumours can be removed safely and that the size is not a contraindication for primary surgical treatment. Local recurrence is common as seen in our case, and occurs even after R0 resection up to 10 years after the first operation. Recurrences should be surgically removed as this is the only treatment which has been shown to increase survival in even R1 and R2 situations.

BACKGROUND:Portal vein thrombosis (PVT) is a surgical challenge in liver transplantation (LTx). In contrast to LTx in decompensated liver disease, which are associated with a higher morbidity and mortality, PVT influence on outcome is still under debate. To evaluate this influence at different stages of liver decompensation, we compared the outcome of patients suffering from PVT to patients with patent portal vein within different score ranges. METHODS:We included 193 LTx (24 with PVT) in our study, transplanted between 2004 and 2007 at our institution. Patients were divided into four Model of End-Stage Liver Disease (MELD) score groups, and outcome was compared between PVT- and non-PVT patients. RESULTS:In non-decompensated liver disease (MELD <15), we found a significantly decreased survival in patients suffering from PVT (one-yr survival 57% vs. 89%). By contrast, MELD score >15 (decompensated liver disease) leads to an equal or even better survival in PVT-patients compared with patients without PVT (one-yr survival 91% vs.75%), with an only slightly increased morbidity. CONCLUSION:Outcome in patients with PVT seems to be dependent on pre-operative disease severity. In contrast to compensated liver disease, no influence of PVT on outcome could be found in decompensated liver disease, and should therefore not be considered as a contraindication in LTx.

BACKGROUND:At present, inflammation is considered to be one of the key players in the development and maintenance of atherosclerosis, with ample impact on renal transplant outcomes. Interleukin-6 (IL-6) levels and the underlying genetically determined "high-producer" status impact cardiovascular morbidity and mortality. In end-stage renal disease (ESRD) patients, the role of genetically determined IL-6 differences in cardiovascular and renal outcomes of kidney transplantation is controversial. In this study, we sought to clarify the influence of IL-6 haplotypes on cardiovascular and renal outcomes among kidney transplant recipients.METHODS:Three hundred fifty-two first kidney transplant patients were genotyped for the two "clade" IL-6 polymorphisms ((-174)G/C and (1888)G/T) and two missense polymorphisms (Pro32Ser, Asp162Val), which are known to influence IL-6 levels and outcome.RESULTS:We observed four IL-6 haplotypes among our population: CCAG: 57.0%, CCAT: 2.8%, GCAT: 39.2%, GCTT: 1.0%. After stratifying the haplotypes into diplotypes in three different models, we failed to observe associations with early or late graft outcomes, or with all-cause or cardiovascular mortality. These findings were also confirmed when we separately analyzed each polymorphism.CONCLUSION:Despite evidence of associations in other transplant and ESRD cohorts, we could not confirm any association between IL-6 haplotypes/diplotypes and cardiovascular or graft-related outcomes among our population at high risk for inflammatory diseases.

BACKGROUND:Transplant renal artery stenosis (TRAS) is a frequent complication after renal transplantation, however long-term follow-up data after interventional treatment are rare.PATIENTS:In our transplant center 11 of 264 consecutive renal transplant recipients (4.17%) were diagnosed with TRAS. In addition, TRAS occurred in 2 renal transplant recipients that had been transplanted at other centers but who had their follow-up examinations in our center. Either a rise of the serum creatinine level and/or worsened systemic hypertension or routine examination with color Doppler sonography were indications for further diagnostic workup.METHODS:Direct angiography of the transplant renal artery was performed followed by percutaneous transluminal angioplasty (PTA) after the diagnosis of TRAS was confirmed in all of these patients.RESULTS:The immediate success rate for PTA was 92.3% (12/13). Only 1 patient with a severe kinking of the transplant renal artery had to undergo surgery to restore renal function. No complications occurred after the interventions. Thereafter the patients were monitored for a mean observation period of 33.15 months. Serum creatinine levels were significantly lower after the intervention, and estimated glomerular filtration rate (eGFR) increased accordingly. With regard to blood pressure there was only a trend for lower blood pressure levels and less antihypertensive use, whereas the dose of the prescribed drugs decreased significantly with time after interventional treatment of TRAS. In addition, a long-lasting rise of the hemoglobin levels could also be demonstrated.CONCLUSION:In summary, the beneficial effect of PTA of TRAS on renal function is long-lasting. Therefore, PTA, usually combined with stent placement, should be first-line treatment in TRAS in all patients. Surgical revascularization is only warranted, if PTA fails.

Loss, M1; Mantouvalou, K1; Rochon, J2; Tsui, T Y.1; Obed, A1; Schlitt, H J.1 Author Information

Ischemia/reperfusion (I/R) injury is an unavoidable barrier that significantly affects outcome of solid organ transplantation. Here, we establish a protein transduction system to extend graft preservation time and to prevent I/R injury in heart transplantation. We generated a recombinant heme oxygenase-1 (HO-1) protein containing a modified protein transduction domain (PTD). PTD could cross cover cell membrane and carry target molecule to parenchymal cells of cold-preserved heart grafts. The newly generated PTD-HO-1 protein localized mainly in subcellular membrane organelle and nucleus after delivery that significantly prolonged cold preservation of heart grafts. This effect was associated with significantly less endothelial cell activation, less neutrophil and macrophage infiltration in PTD-HO-1-transduced heart grafts after reperfusion as compared with controls. In addition, transduction of PTD-HO-1 protein to heart graft significantly suppressed the I/R injury-associated myocardiocyte apoptosis. The infarct areas of heart graft after I/R injury were significantly reduced after PTD-HO-1 protein treatment. We show here for the first time that PTD can maintain its biological activities during cold preservation. Transduction of cell penetrating HO-1 protein significantly prolongs the cold preservation time and protects the graft from the I/R injury. This approach represents a novel method for the improvement of the overall outcome of organ transplantation.

Benign liver tumors are being detected more frequently due to the widespread use of ultrasound and complementary methods and due to improvements in diagnostic accuracy. In the case of a reliable diagnosis of asymptomatic hemangioma or focal nodular hyperplasia surgery is not indicated. Hepatic adenoma of considerable size should be resected primarily based on the risk of rupture. Improvements in diagnostic imaging as well as the optimization of surgical procedures with extremely low complication rates permit an individualized management strategy founded on evidence-based algorithms. In the case of an equivocal diagnosis, we advocate low-risk tumor resection instead of tumor biopsy due to the inherent complication rates of hemorrhage or tumor-cell dissemination and possible misleading histology.

Transplantation: July 27, 2008 - Volume 86 - Issue 2S - p 414-415 doi: 10.1097/01.tp.0000331510.13266.b4

Tsui, T Y.; Scherer, M N.; Loss, M; Doenecke, A; Schlitt, H J.; Obed, A Author Information

A 51-year-old renal transplant recipient presented with marked renal function deterioration 13 months after renal transplantation. After exclusion of ureteral obstruction, transplant artery stenosis and acute rejection, the diagnosis of a severe renal vein stenosis was made by an MR scan. After angiographic confirmation of the stenosis, treatment was attempted with percutaneous stent angioplasty. The long-term clinical course was favorable, with marked improvement in renal function. Transplant renal vein stenosis is a rare, but potentially curable, cause of renal allograft functional deterioration.

Farkas, S; Doenecke, A; Schnitzbauer, A; Scherer, M; Loss, M; Kirchner, G; Banas, B; Obed, A; Schlitt, H-J Author Information

Einleitung: Die sekundär sklerosierende Cholangitis (SSC) ist eine destruierende Erkrankung der Gallenwege, welche an Häufigkeit zunimmt und Patienten (Pat.) mit komplexen Langzeitintensivaufenthalten mit ARDS und Sepsis betrifft. Die SSC führt rasch zu einer Leberzirrhose. Bisher gibt es nur Einzelfallberichte bei SSC-Pat. nach Lebertransplantation (LTx). Pat./Meth.: In unserem Tx-Zentrum wurden 2004–2007 insgesamt 8 Pat. (40+8J.; 7m; MELD-Score: 24+5) wegen einer SSC lebertransplantiert (eine Re-LTx). Vier Pat. hatten schwere Polytraumata mit multiplen Knochenfrakturen, Sepsis und ARDS. Weitere 4 Pat. hatten die SSC im Rahmen von Langzeitintensivaufenthalten nach Sepsis mit ARDS bei internistischen Grunderkrankungen erworben. Die SSC wurde mittels ERCP (Galle: Mikrobiologie) gesichert und im Leberexplantat bestätigt. Primäre Immunsuppression: Basiliximab®, Ciclosporin und Prednisolon. Ergebnisse: Die SSC wurde innerhalb von 2+3 Mon. nach Polytrauma diagnostiziert. Die 3häufigsten Keime in der Galle waren: Enterokokken (n=4), Candida alb. (n=3), multiresist. E. coli (ESBL) (n=2). Die mittlere Nachbeobachtungszeit betrug 13+10 Mon.. Sieben von 8 Pat. überlebten den post-operativen Verlauf. Eine Pat. (Z.n. HELPP mit Sepsis) wurde trotz bestehender Infektsituation transplantiert. Sie verstarb 26 Tage post-LTx an einer Sepsis. Zwei (kein Polytrauma) von diesen 7 Pat. verstarben (Sepsis) innerhalb von 4 bzw. 8 Mon. post-LTx. 5 von 8 Pat. leben noch und haben eine gute Lebensqualität. Schlussfolgerungen: Pat., die wegen einer SSC bei internistischen Grunderkrankungen eine Lebertransplantation erhielten, hatten eine höhere Letalität (Sepsis) innerhalb des ersten Jahres nach LTx als SSC-Patienten mit Z.n. Polytrauma.

BACKGROUND/AIMS:The critical issue before major hepatic resection is to evaluate and detect patients with a potentially increased risk of hepatic failure. In this study the prognostic value of the monoethylglycinexylidide (MEGX)- liver function test was evaluated with regards to clinical course and survival after partial liver resection.METHODOLOGY:Between 1995 and 2000 a total of 55 patients (29 male, 26 female) underwent a partial liver resection at the Georg-August University of Göttingen. Forty-two patients were treated for malignant, and 13 for benign, disease. MEGX-testing was performed 15 and 30 minutes after a single-dose of 1mg/kg BW Lidocaine i.v. was applied.RESULTS:MEGX-test results after 30 minutes had significant influence on hospital mortality. Patients who died during the hospital stay showed median MEGX-30 minutes results of 32 microg/L in (4-107 microg/L) in comparison to the surviving patients with a median 68 microg/L (16-176 microg/L) (p = 0.026). Furthermore, patients with MEGX scaled categories of 3 and 4 had a significantly lower surivial at 150 days (p = 0.008) and overall (p = 0.0002). There was an indirect impact of MEGX on hospital stay, costs and mortality reflecting high fluid loss: patients with lower loss of fluid over drainages had a significantly lower mortality at 150 days (p = 0.00046) and overall (p = 0.00008), than did patients with higher fluid loss. Low MEGX-values significantly influenced long hospital stay (p = 0.00001) and high costs (p = 0.00001). Pathologic MEGX in combination with increased age, increased BMI and extensive surgical procedures including resection of over 50% volume of the liver had a significant influence on complications (p = 0.015).CONCLUSION:The preoperative MEGX-test, especially the 30 minutes value, is a useful medium to estimate the liver reserve in non-cirrhotic patients prior to liver resection. In combination with the resection volume it may be very useful to identify patients with a high risk of developing a postoperative liver failure.