Improved survival of heart transplant recipients increased the incidence of chronic renal failure after transplantation. Highly sensitive, early and effective monitoring of post transplant renal function is still on research. This study aimed to evaluate the prognostic value of Cystatin C for patients being in various stages after heart transplantation.

Results: At listing, no significant differences were noted between the 2 groups (HIV+ vs HIV−) for sex ratio, viral etiology, number of nodule(s) (1.6±0.9 vs 2.3±2.4, p = 0.8), maximal diameter of nodule(s) (27±8mm vs 25±12mm, p = 0.9), and AFP level. Rate of patients in each group that exceeded Milan criteria were similar (2/20 (10%) vs 11/61 (18%)). HIV+ patients were younger (49±5 years vs 56±5 years, p = 0.001). The rate of patients treated by chemoembolization (mean number of cure: 1.5±0.5 vs 1.4±1, p = 0.86) was similar but the rate of radiofrequency was higher in HIV+ patients (8/20 (40%) vs 11/61 (18%), p = 0.04). Drop-out (DO) of HIV+ patients were significantly higher (7/20 (35%) vs 6/61 (9%), p = 0.007). Tumoral progression (n = 5) and HIV evolution (n = 2) were responsible of DO in HIV+. With a similar waiting-time (7±8 months vs 4±5 months, p = 0.13), 13 HIV+ and 55 HIV− were transplanted with one post-operative death in each group. On the explanted liver, no significant differences were noted concerning the number of nodule(s) (2.3±1.6 vs 2.6±3.2, p = 0.70), with a maximal diameter of (27±13mm vs 28±14mm, p = 0.82), presence of satellite nodules (4/13 vs 21/49, p = 0.39), vascular invasion (6/13 vs 22/48, p = 0.98) but Edmonson grade was higher in HIV+ (3.1±1.1 vs 2.5±1.1, p = 0.04). After a mean follow-up of 16±18 months and 24±16 months for HIV+ and HIV− patients (p = 0.11), respectively, a tumoral recurrence was noted in 4/13 (30%) HIV+ patients at 2, 3, 11 and 37 months vs 2/49 (4%) in HIV− patients at 20 and 28 months after LT (p< 0.001). Conclusion: In our series, because of high drop-out (35%) and recurrence after LT (30%) in HIV+ patients, a better selection in this kind indication must be performed.

Einleitung: Das hepatocelluläre Carcinom (HCC) ist zum Zeitpunkt der Diagnosestellung häufig weit fortgeschritten und nur mehr palliativ (lokoregionär) therapierbar. Für die transarterielle Chemoembolisation (TACE) ist anhand der vorliegenden Daten ein Überlebensvorteil dokumentiert (1,2). Ziel unserer Studie war, das Überleben von Patienten mit HCC, die an der Medizinischen Universität Graz mittels TACE behandelt wurden, mit bisher publizierten Daten zu vergleichen.

Der MELD Score ist ein akzeptierter Prognoseparameter bei Patienten mit fortgeschrittener Leberdysfunktion und Grundlage für die Organ-Allokation bei Lebertransplantation. Die Messung der Indocyaningrün(ICG)-Clearance dient als quantitativer Leberfunktionstest, der vor allem die Leberdurchblutung und den hepatobiliären Anionentransport erfasst. Ziel der vorliegenden Studie war der Vergleich der prognostischen Aussagekraft von ICG-Clearance und MELD-Score bei Patienten mit Leberzirrhose.

Liver cell malignancy can be seen as one of the most common indications for hepatic transplantation, but the recurrence potential of the disease significantly limits its beneficial effects. Hepatic factors influencing the recurrence rate, such as nodule size and criteria wherein transplantations are expedited, are still investigated. Pretransplant intraarterial or percutaneous treatement seem to be predictive for recurrence-free patient survival. Early detection of malignancies via serum parameters as a prognostic factor seems promising. This article reports a special case, where despite an elevated, sensitive, serum marker profile, no HCC recurrence was detected over a 2-year follow-up.

Die Echokardiographie ist neben vielen anderen Untersuchungen ein wesentlicher Bestandteil der Evaluierung eines potenziellen Herz-Organspenders. Die transthorakale Echokardiographie liefert nichtinvasiv wichtige Informationen über Morphologie und Funktion des Herzens. Ganz entscheidend ist die Beurteilung des linken Ventrikels hinsichtlich Hypertrophie und systolischer Funktion, weiters der Ausschluss angeborener Herzfehler sowie die Beurteilung der Herzklappen. Bei hirntoten Patienten findet sich häufig eine systolische Dysfunktion des linken Ventrikels, was zur Folge hat, dass diese Herzen häufig nicht als Spenderorgane verwendet werden. Die regionalen Wandbewegungsstörungen können keinem bestimmten Koronarversorgungsgebiet zugeordnet werden und sind häufig nur vorübergehend vorhanden. Sie können sich spontan oder durch ein entsprechendes Spendermanagement zurückbilden. Daher sollte die echokardiographische Evaluierung nicht nur einmal erfolgen, sondern bei initial eingeschränkter Funktion des linken Ventrikels nach Einleitung entsprechender Maßnahmen wiederholt werden. Dadurch könnte der Prozentsatz der transplantierbaren Herzen gesteigert werden, was angesichts des Mangels an Spenderorganen von großer Bedeutung wäre. Meistens wird man mit der transthorakalen Echokardiographie das Auslangen finden, bei stark eingeschränkter Untersuchungsqualität oder speziellen Fragestellungen kann jedoch auch eine transösophageale Echokardiographie oder eine Kontrast-Echokardiographie notwendig werden. Ob bei einem potenziellen Herz-Organspender eine Koronarangiographie indiziert ist, richtet sich nicht so sehr nach den Wandbewegungsstörungen als nach anderen Faktoren, wie Alter, Geschlecht und Risikoprofil des Spenders, aber auch nach der Verfügbarkeit der Untersuchung und der Dringlichkeit vonseiten des Empfängers.

BACKGROUND:Patients after orthotopic liver transplantation (OLT) have a high risk of developing incisional hernia (IH). In the literature incidences between 5% and 17% are reported.PATIENTS AND METHODS:In 90 patients, who underwent OLT between October 1998 and December 2005, a retrospective analysis on the occurrence of IH was performed. Surgical access for OLT was a transversal upper laparotomy. Age, gender, primary disease, ICU stay, immunosuppressive regimen and two different closure techniques (running suture or single sutures in layers) were evaluated.RESULTS:In 73 patients (76.7%, group 2) healing of the incision was without problems, in 17 patients (23.3%, group 1), IH occurred. Total survival was similar between the groups (86.3% vs. 94.1%, n.s.). No significant differences between the groups concerning age, gender, body mass index, platelet count and duration of ICU stay were found. Also, the technique of abdominal closure had no impact on the development of IH. No IH was found in patients with hepatocellular carcinoma (n = 15), whereas end-stage liver cirrhosis (n = 75) was associated with development of IH (p = 0.064). Multivariate analysis revealed end-stage liver cirrhosis, Sirolimus, and MMF to be independent significant risk factors for IH after OLT.CONCLUSION:IH following OLT has to be regarded a frequent complication. While technique of abdominal closure seems to have no impact, primary diagnosis and kind of immunosuppressive regimen exerted a significant influence on the formation of IH.

Introduction: Sirolimus improves post transplant maintenance therapy in LTX. Dermal side effects causing pain and discomfort can limit patients' compliance. The package insert mentions such skin disorders as acne and rash. One case of Sirolimus-induced leucocytoclastic vasculitis is reported in the literature.Methods: From July 1998 to October 2003, Sirolimus was implemented in the immunosuppressive protocol in 23 out of 60 liver recipients. Sirolimus target levels are between 3 and <10 ng/dl. Combination with a calcineurinblocker and/or MMF (mycophenolate mofetil) depending on liver function and creatinine is standard.Weekly patient monitoring in the first month after discharge included physical examination, blood samples, and immunosuppresant trough levels. Biopsies were taken from untypical efflorescences. Results: Three patients with non-specific effloresces were reported: one with leucocytoclastic vasculitis and one with exfoliate forearm dermatitis required change of medication while one perivascular lymphocytic eosinophilic dermatitis subsided after dose reduction.In three cases of mouth ulcer, trough levels exceeded 10 ng/dl and in six patients acne diminished after dose reduction. Eighteen out of 23 patients are still receiving sirolimus.Reasons for removal from the study were incompliance and incompatibility. Two patients died. Discussion: Immunosuppressants inevitably produce side effects in TX recipients. The positive management of troublesome side effects contributes importantly to compliance and patient survival. (C) 2004 Elsevier B.V. All rights reserved.

Introduction: Calcineurin inhibitor (CI)-associated renal impairment and renal failure after liver transplantation has been recognized since the early days of its use. Various strategies have been used to prevent or slow down the progression of renal dysfunction in liver transplant recipients, but did not succeed. In this report, we describe the course of renal function of 58 stable liver transplant recipients and compared 2 groups with different immunosuppressive protocols.Methods: In the study group, 22 patients at various intervals from liver transplantation were included. The immunosuppressive therapy consisted of Sirolimus (SRL). Additional all patients except 2 received Mycophenolate Mofetil (MMF) and 14 of them also received Tacrolimus. Patients of the control group (36 patients) had an immunosuppressive therapy with calcineurin inhibitors. Patients were monitored for creatinine monthly and creatinine clearance (CCr) every sixth month. Risk factors for renal dysfunction were evaluated.Results: After introduction of SRL in patients with renal impairment and after a mean follow-up time of 12 (2-26) months, there was a decrease of 28.3% in mean creatinine and of 41.8% in mean urea. We observed an improvement of renal function in ail patients initially after introduction of SRL. In the control group, in comparison to preoperative levels. there was an increase of 27.5% in mean creatinine and of 13.3% in mean urea after a mean follow-up time of 3.6 years with CI therapy.Conclusion: The results of our retrospective study showed that with SRL renal impairment could be stopped and renal function could be improved. We suggest administering immunosuppressive therapy with SRL in combination with low dose Tacrolimus and/or MMF for patients with renal impairment. (C) 2004 Elsevier B.V. All rights reserved.

INTRODUCTION:Sirolimus (SRL) is an immunosuppressive agent of potential benefit in clinical liver transplantation (LTX). One of the major side effects of SRL is hyperlipidemia, which is reported in up to 44% of patients. In this report, we describe the lipid profiles of 20 stable liver transplant recipients who received SRL for immunosuppression.METHODS:The study group received SRL in combination with tacrolimus and/or mycophenolate mofetil (MMF). The control group was administered calcineurin inhibitor (CI) and MMF. Fasting serum cholesterol level, high-density lipoproteins (HDL) and low-density lipoproteins (LDL) were measured regularly. Furthermore, the total cholesterol/HDL ratio and the LDL/HDL ratio were evaluated. Diabetes and hypertension were monitored as well.RESULTS:In the SRL group, hypercholesterolemia was found in three patients (15%) and hypertriglyceridemia in two patients (10%). There was no marked difference from the control group, although a higher association of SRL with hyperlipidemia was described in the literature. Furthermore, HDL and LDL levels were similar in both groups, as well as total cholesterol/HDL ratio and LDL/HDL ratio. Diabetes and hypertension had a similar incidence in both the groups. Thus, there was no difference concerning the cardiovascular atherosclerosis risk between the immunosuppressive protocol with SRL or with CI.DISCUSSION:The results of our retrospective study demonstrated that the immunosuppressive regimen can potentially influence the incidence of hyperlipidemia in patients after LTX. SRL in combination with tacrolimus and/or MMF had no higher incidence of hyperlipidemia than CI and MMF. The combination of immunosuppressive therapy with low dose and low levels of each immunosuppressive agent could decrease the risk of atherosclerosis and its complications in long-term survivors after LTX.

BACKGROUND: Poor initial graft function secondary to reperfusion remains a major problem in liver transplantation. A new technique of reperfusion was introduced in our center and evaluated in a retrospective study covering the last 6 years. METHODS: Seventy-nine liver transplantations were performed by piggyback technique with retrograde reperfusion via the caval vein and antegrade reperfusion via the portal vein. RESULTS: Sixty-eight out of 74 patients (91.9%) were alive and well at day 8 after LTX. On day 1 after liver transplantation, mean aspartate aminotransferase was 526 U/L and on day 8 it was 48 U/L. Except in the 3 patients presenting with hepatic artery thrombosis, primary nonfunction or poor early graft function did not occur. A postreperfusion syndrome was observed in 3.6%. CONCLUSIONS: After retrograde reperfusion, low postoperative liver enzyme values and good initial liver function can be observed. Furthermore, hemodynamic disturbances were uncommon.

Background. Organ shortage is a major problem in transplantation. Many potential donors are still lost due to a lack of information and communication. Many transplantation centers report a major donor increase after introducing new donor policies. The aim of this study was to evaluate in retrospective fashion a new donor policy in our region.Methods. For the past 10 years all reported donors from intensive care units (ICUs) in our region were evaluated. Our new policy had 2 main steps: accepting more marginal grafts and using a transplantation representative. The goal was the improved communication with ICUs to support physicans involved in donor care. A public information program was also implemented.Results. In the first year, numbers of donors obviously improved (+60.5%) an remained stable the following year. The mean donor age increased to 41.56 years. The donor pool showed mainly an improved kidney-donation rate (+53%) with also an increase in multiorgan donation (+37%). One year posttransplantation survival was not negatively influenzed by this donor pool. As expected, transplantation activities increased notably, particularly liver transplantation (+31.11%) but also kidney transplantation (+26.73%).Discussion. Many donors are lost because physicans in charge of brain dead patients are. not fully informed about modified donation criteria. The reason for this is a lack of information and communication by transplantation units. Improved surgical techniques and better preoperative, intraoperative, and postoperative treatment have yielded better results with marginal grafts. Immediate graft function in recipients of suboptimal grafts may be delayed, but without a significantly negative impact on patient and graft survival. Because the age of organ recipients is steadily increasing with fewer contraindications for transplants, more organs will be needed.

P483 Aims: The reperfusion phase during orthotopic liver transplantation is a critical event with sometimes profound hemodynamic and cardiac changes that may be responsible for intraoperative death. The postreperfusion syndrome, as first described by Aggarwal, was defined as a 30% decrease in mean arterial pressure lasting at least 1 minute within the first 5 minutes after beginning of reperfusion. We present the influence of a retrograde reperfusion technique in liver transplantation on the postreperfusion syndrome. Methods: Fifty-six liver transplantations in 53 patients were performed in piggy-back technique with retrograde reperfusion. After completing piggy-back anastomosis, the caval vein was declamped immediately and retrograde low pressure reperfusion of the graft with low oxygenated venous blood was established. To provide optimal retrograde liver reperfusion, the portal vein of the donor liver was not clamped when the portal anastomosis was performed. After completing portal anastomosis, the recipient portal vein was declamped immediately. During arterial anastomosis, the transplanted liver was antegradely perfused via the portal vein. When hepatic artery anastomosis was completed, the hepatic artery was declamped and arterial perfusion started. In order to evaluate postreperfusion syndrome, the course of mean blood pressure before and after reperfusion was examined in the patients. Results: We observed a postreperfusion syndrome in 2 patients (3.6%), 4 patients (7.1%) had a decrease in mean arterial pressure of 20-29%, 18 patients (32.2%) of 10-19%, 27 patients (48.2%) of 1-9% and 5 patients (8.9%) had a small increase in mean arterial pressure. Fifty out of 53 patients (94.34%) were alive and well on day 8 after liver transplantation. The one-year-survival rate was 85%. Conclusions: In our experience, retrograde reperfusion is highly effective for evacuating the perfusion fluid from the transplanted liver. We hypothesize that low pressure perfusion with low oxygenated blood reduces the production of free oxygen radicals. As sudden influx of cold, acidic and hyperkalemic blood and release of vasoactive substances and toxic agents from the grafted liver have been described as being responsible for postreperfusion syndrome, we suppose that retrograde reperfusion could diminish these effects. Our retrospective study showed that retrograde reperfusion seems to maintain stability during the reperfusion phase. Hemodynamic disturbances during liver transplantation were uncommon, leading us to suppose that the incidence of postreperfusion syndrome could be diminished with retrograde reperfusion technique.

P556 Aims: With improved survival of liver transplant recipients, chronic renal failure has become an important cause of morbidity and is associated with a high mortality. Five years after transplantation 78% had at least mild to moderate chronic renal failure and 2.8% developed severe chronic renal failure. The incidence of severe renal dysfunction after more than 10 years after liver transplantation was described with 9.5 %. One of the challenges of renal studies is the accurate measurement of renal function. In order to evaluate and compare parameter for renal dysfunction, we studied a cohort of patients after liver transplantation. Methods: Forty-three patients at various intervals from liver transplantation were included to the study. Routineously patients were monitored for creatinine monthly and creatinine clearance every sixth month. For the present study, we investigated serum creatinine, urea, renal creatinine clearance and cystatin C as marker for renal function. Furthermore urinary sediment was examined by urinary test, automated urinary sediment analyser and urine microscopy. Results: The results of our study showed that 44.2% had normal creatinine levels, 46.5% had creatinine levels between 1.4 and 2.0 mg/dl and 9.3% were higher than 2.0 mg/dl. Sixteen of the patients (37.2%) had urea levels under 44 mg/dl, 62.8% had elevated urea levels. Creatinine clearance was between 95 and 160 ml/min in 21.1% and was decreased in all the other patients. Mild renal insufficiency was found in 13.2%, moderate in 47.3% and severe in 18.4%. Cystatin C was normal in 5%, between 1 and 2 mg/l in 67.5% and more than 2 mg/l in 27.5%. Urinary sediment was without pathological findings in 55.8% of the urinary test, in 51.1% of the automated sediment analyser and in 37.2% of the microscopic examination. Renal hematuria occurred in 27.9% of the urinary test, in 32.5% of the automated sediment analyser and in 44.2% of urine microscopy. Furthermore urine microscopy offered the possibility to differentiate between the etiology of renal dysfunction and chronic or acute renal failure. Cystitis and pyelonephritis occurred in 2.3% and 6.9%. In 4.6% an acute tubular damage was diagnosed and 6.9% showed a chronic tubular damage. Conclusions: The investigation of cystatin C in patients after liver transplantation has not been described before. The results of our study confirmed cystatin C as early prognostic marker of patients with renal dysfunction rather than serum creatinine and renal creatinine clearance. Concerning damages of the kidney urine microscopy offers the best possibility to identify the etiology. Different causes for renal impairment can be detected and an adequate therapy can be initiated in time. Infection can be diagnosed early, even when there is no clinical appearance and the urinary test is negative. In reference to our study we suggest that cystatin C and urine microscopy should be investigated regularily in patients after liver transplantation in order to recognize renal dysfunction in time and to prevent progressive renal failure.

Background: Poor initial graft function secondary to reperfusion remains a major problem in liver transplantation. Retrograde reperfusion, a new method of reperfusion during liver transplantation was introduced in our center. We evaluated this technique in a retrospective study and compared the results concerning primary graft function with a historical control group. Methods: In the study group 56 liver transplantations were performed in piggy-back technique with retrograde reperfusion. In the historical control group 21 patients underwent liver transplantation in standard technique with standard reperfusion. Results: Fifty (twenty) out of 53 (21) patients were alive and well on day 8 after liver transplantation. On day 1 after liver transplantation, mean aspartate aminotransferase was 221 U/L in the study group and except of 3 patients (6,6%) with hepatic artery thrombosis no primary nonfunction appeared. In the control group on day 1 after liver transplantation mean aspartate aminotransferase was 327 U/L and three patients (14,2%) had primary nonfunction. Conclusions: Our retrospective study demonstrates that retrograde reperfusion via the caval vein and antegrade reperfusion via the portal vein is feasible; it lowered postoperative liver enzyme values and improved initial liver function after LTX. Further careful evaluation will be necessary to verify these findings.