Background: Early cholestasis is not uncommon after liver transplantation and usually signifies graft dysfunction. The aim of this study was to determine if serum synthetic and cholestatic parameters measured at various time points after transplantation can predict early patient outcome, and graft function.Methods: The charts of 92 patients who underwent 95 liver transplantations at Rabin Medical Center between 1991 and 2000 were reviewed. Findings on liver function tests and levels of serum bilirubin, alkaline phosphatase (ALP), and gamma glutamyl transpeptidase (GGT) on days 2, 10, 30, and 90 after transplantation were measured in order to predict early (6 months) patient outcome (mortality and sepsis) and initial poor functioning graft. Pearson correlation, chi(2) test, and Student's t-test were performed for univariate analysis, and logistic regression for multivariate analysis.Results: Univariate analysis. Serum bilirubin greater than or equal to10 mg/dL and international normalized ratio (INR) >1.6 on days 10, 30, and 90, and high serum ALP and low albumin levels on days 30 and 90 were risk factors for 6-month mortality; serum bilirubin greater than or equal to10 mg/dL on days 10, 30, and 90, high serum ALP, high GGT, and low serum albumin, on days 30 and 90, and INR greater than or equal to1.6 on day 10 were risk factors for sepsis; high serum alanine aminotransferase, INR >1.6, and bilirubin greater than or equal to10 mg/dL on days 2 and 10 were risk factors for poor graft function. The 6-month mortality rate was significantly higher in patients with serum bilirubin greater than or equal to10 mg/dL on day 10 than in patients with values of <10 mg/dL (29.4% vs. 4.0%, p = 0.004). Patients who had sepsis had high mean serum ALP levels on day 30 than patients who did not (364.5 +/- 229.9 U/L vs. 70.8 +/- 125.6 U/L, p = 0.005). Multivariate analysis. Significant predictors of 6-month mortality were serum bilirubin greater than or equal to10 mg/dL [odds ratio (OR) 9.05, 95% confidence intervals (CI) 1.6-49.6] and INR >1.6 (OR 9.11, CI 1.5-54.8) on day 10; significant predictors were high serum ALP level on day 30 (OR 1.005, 1.001-1.01) and high GGT level on day 90 (OR 1.005, CI 1.001-1.01). None of the variables were able to predict initial poor graft functioning.Conclusion: Several serum cholestasis markers may serve as predictors of early outcome of liver transplantation. The strongest correlation was found between serum bilirubin greater than or equal to10 mg/dL on day 10 and early death, sepsis, and poor graft function. Early intervention in patients found to be at high risk may ameliorate the high morbidity and mortality associated with early cholestasis.

De novo tumors (DNT) are a serious complication after orthotopic liver transplantation (OLT), showing a higher overall incidence ranging from 4.7% to 15.7% in non-selected series. Skin cancer (SC) is the most frequent malignancy observed, ranging from 6% to 70% of the tumors observed, followed by post-transplant lymphoproliferative disorders (PTLD) (4.3–30%). Different immunosuppressive protocols do not seem to influence DNT appearance. Colon and upper aerodigestive cancer after OLT seems to be more prone to develop when there are associated risk factors, such as primary sclerosing cholangitis (PSC) and alcoholic liver cirrhosis (ALC). Some risk factors, such as age, smoking, alcohol and others seem to play a role in higher risk for malignancy, but the presence of a long-term immunosuppressive state, more than the specific regimen used, is the basis for this higher incidence. Ethnic and demographic factors are also important variables influencing the heterogeneity of the results, especially influencing Kaposi's sarcoma and skin tumors.

Background. There is at present very little information about hepatitis B virus (HBV) infection in children after liver transplantation. This is the first study to assess the safety and efficacy of lamivudine in this patient population.Methods. We describe three children aged 5-14 years who underwent liver transplantation for fulminant hepatitis A, hyperoxaluria, and cystic fibrosis. Despite adequate immunoprophylaxis, two of the children who were serum hepatitis B surface antigen-positive before transplantation (HBV DNA-negative by hybridization) had a reactivation of the disease, and one had a de novo HBV infection, at 12-18 months after transplantation. Lamivudine 3 mg/kg was administered on a compassionate-use basis for 14-36 months.Results. After 1 month of therapy, HBV DNA disappeared from the serum in all patients by hybridization and in two patients by polymerase chain reaction. In all three children, alanine transaminase levels normalized. One child developed lamivudine resistance after 22 months with no evidence of hepatic decompensation. Repeated liver histological studies revealed progression of hepatic fibrosis in one child. All children remained serum hepatitis B surface antigen-and hepatitis B e antigen-positive. No adverse effects of the drug were noted.Conclusion. Lamivudine is beneficial and well tolerated in children with HBV infection after liver transplantation.

Rapporter la nature, l’incidence, les outils diagnostiques et les moyens thérapeutiques des complications chirurgicales de la transplantation rénale.Une recherche bibliographique exhaustive à partir de Medline (http://www.ncbi.nlm.nih.gov/) et Embase (http://www.embase.com/) a été réalisée entre 1960 et 2016 en utilisant les mots clés suivants « complications chirurgicales ; fistule ; lymphocèle ; sténose ; thrombose » en combinaison avec le mot clef « transplantation rénale » dans le champ « Titre/Résumé ». Les articles obtenus ont ensuite été sélectionnés sur leur méthodologie. Ainsi 7618 articles ont été identifiés dont plus spécifiquement 981 pour les complications vasculaires, 1016 pour les complications urinaires et 239 pour les lymphocèles. Après élimination des doublons et sélection, 190 articles ont été revus et sélectionnés.L’incidence des complications chirurgicales de la transplantation rénale varie de 1 à 30 % selon les séries ; elles sont souvent rapportées de façon incomplète et leur prise en charge est rarement consensuelle. Les techniques d’angioplastie ont apporté une amélioration sensible du traitement des complications vasculaires du transplant à moyen et long terme. Les facteurs de risque de thromboses des vaisseaux du transplant sont le rein droit, la présence d’artères multiples du transplant, l’existence d’une artériopathie chez le donneur ou le receveur, les troubles hémodynamiques per-procédure, la présence d’une néphropathie diabétique ou un antécédent d’accident thromboembolique chez le receveur. Les complications urinaires et la lymphocèle, si elles ne mettent pas en jeu la survie du transplant, sont responsables d’une morbidité conséquente pour le receveur. L’anastomose pyélo-urétérale d’emblée ou de rattrapage fait partie des principales options thérapeutiques des sténoses et fistules urétérales.La prévention des complications chirurgicales de la transplantation nécessite une préparation minutieuse du transplant, et un respect rigoureux des bonnes pratiques chirurgicales. Les comorbidités de plus en plus importantes des receveurs sélectionnés, et des donneurs marginaux, n’ont pas permis de diminuer significativement la morbidité globale de la transplantation rénale.To report the nature, incidence, diagnosis and treatment options of surgical complications after renal transplantation.Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov/) and Embase (http://www.embase.com/) database from 1960 to 2016 using the following keywords “fistula; lymphocele; stricture; thrombosis”, in association with “renal transplantation” in Title/Abstract field. Articles were selected according to methods, language of publication and relevance. A total of 7618 articles were identified including specifically 981 for vascular complications, 1016 for urologic complications and 239 for lymphocele; after careful selection 190 publications were eligible for our review.Surgical complications occur in 1 to 30% of renal transplantations while being incompletely reported without consensual management. Angioplasty techniques led to a significant improvement of short- and long-term vascular complications outcome. Risk factors for transplant thrombosis are a right allotransplant, multiple renal arteries or vasculopathy in the donor, diabetes, arterial disease or thrombophilia in the recipient and hemodynamic changes during procedure. Urinary complications and lymphocele significantly impair overall outcome and recipients quality of life with no demonstrated impact on allotransplant survival. Immediate or salvage pelvi-ureterostomy is a main treatment option for ureteral strictures and fistula.Prevention of surgical complications following renal transplantation relies on careful allotransplant preparation and strict respect of surgical best practices. Increasing comorbidities in recipients as well as marginal donors are significant limits for the improvement of post-transplant surgical outcome.

Some dialyzed patients suffer from lower urinary tract (LUT) anatomic and functional disturbances. Complete LUT assessment should be performed to decide whether they can be included on the waiting list, because such disorders, if not diagnosed and properly treated before transplant, may lead to graft loss.Based on data in the medical records of 4170 dialysis patients, 535 were selected for further investigation: 265 patients after undergoing urethrocystography or urethrocystoscopy, were included on the waiting list for transplantation and 145 patients underwent nephroureterectomy owing to reflux, nephrolithiasis, polycystic renal disease, or hydronephrosis. Five patients with urethral or bladder neck stricture underwent urethral dilation or bladder neck incision. These patients were also ultimately listed for transplantation. Twenty-two patients, with serious LUT disease were qualified for kidney transplantation after extra-anatomic urine outflow. Ninety-eight patients underwent a urodynamic study (URD) to assess LUT disturbances.Of 535 studied patients, 460 (86%), including those who underwent surgical or pharmacologic treatment, were ultimately listed for kidney transplantation. Out of 98 patients who underwent a URD, 45 (46%) were included for kidney transplantation, and 47 for transplantation with atypical urinary outflow. Six patients were excluded from transplantation owing to refusal of investigations or serious contraindications.All potential kidney recipients should undergo proper evaluation of the LUT before being qualified for kidney transplantation. This study allows selection of patients who should undergo surgical and/or pharmacologic treatment before transplantation.

The last decade has witnessed an explosion in the development of new immunosuppressive agents targeted to distinct components of the immune response. This article reviews the basic mechanisms associated with allograft rejection, outlines contemporary immunosuppressive strategies, and discusses the mechanisms of action and roles of contemporary and potential future immunosuppressive agents.

Due to a shortage of suitable kidneys for transplantation there has been an increase in the use of kidneys taken from old and marginal donors, which has led to a high incidence of acute tubular necrosis. Several reports suggest that the administration of calcium channel blockers improves the initial function after renal transplantation. We conducted a randomized, double-blind placebo-controlled trial to study the effect of the calcium channel blocker gallopamil on the incidence and course of acute tubular necrosis following cadaveric renal transplantation. A trend developed showing a decrease in episodes of acute tubular necrosis in gallopamil versus placebo, and became statistically significant when the outcome of kidneys from donors older than 50 years was analyzed separately [gallopamil 6/14 (42%) vs. placebo 10/11 (91%), P < 0.01 corrected chi(2)]. We conclude that pre-transplantation renal graft perfusion and post-transplantation recipient treatment with gallopamil reduces the incidence of post-transplantation acute tubular necrosis, particularly in kidney taken from older donors.