This report documenting the transmission of rabies virus from an organ donor to multiple recipients underscores the challenges of preventing and detecting transmission of unusual pathogens through transplantation.

The incidence of acute kidney injury (AKI) has been reported to vary between 17% and 95% post-orthotopic liver transplantation. This variability may be related to the absence of a uniform definition of AKI in this setting. The purpose of this study was to identify the degree of AKI that is associated with long-term adverse outcome. Furthermore, to determine the best definition (for use in future studies) of AKI not requiring dialysis in post-liver transplant patients, we retrospectively reviewed the effect of 3 definitions of AKI post-orthotopic liver transplantation on renal and patient outcome between 1997 and 2005. We compared patients with AKI to a control group without AKI by each definition. AKI was defined in 3 groups as an acute rise in serum creatinine, from the pretransplant baseline, of Ͼ0.5 mg/dL, Ͼ1.0 mg/dL, or Ͼ50% above baseline to a value above 2 mg/dL. In all groups, the glomerular filtration rate was significantly lower at both 1 and 2 years post-transplant. Patient survival was worse in all groups. Graft survival was worse in all groups. The incidence of AKI was highest in the group with a rise in creatinine of Ͼ0.5 mg/dL (78%) and lowest in patients with a rise in creatinine of Ͼ50% above 2.0 mg/dL (14%). Even mild AKI, defined as a rise in serum creatinine of Ͼ0.5 mg/dL, was associated with reduced patient and graft survival. However, in comparison with the other definitions, the definition of AKI with the greatest impact on patient's outcome post-liver transplant was a rise in serum creatinine of Ͼ50% above baseline to Ͼ2 mg/dL. See Editorial on Page 455Acute kidney injury (AKI) is a frequent complication post-liver transplantation. The incidence has been reported to range between 17% and 95% in different studies. [1][2][3][4] The etiology of AKI post-liver transplantation is usually multifactorial. These factors include surgeryrelated events, blood loss, hypotension, sepsis, calcineurin inhibitor (CNI)-induced vasoconstriction, and volume depletion. 4 At our institution, we tend to target a lower central venous pressure to protect the liver transplant against passive congestion with subsequent worsening of preservation injury in the immediate posttransplant period. Furthermore, renal dysfunction may be present prior to transplantation because of hepatorenal syndrome or other factors such as infections or intravascular volume depletion. [5][6][7] Therefore, a rise in serum creatinine is common post-liver transplantation. A high burden of chronic kidney disease (CKD) and end-stage renal disease (ESRD) has been reported postliver transplantation, most frequently due to CNI-induced nephrotoxicity.8 However, other factors may contribute to the development of this complication. 8,9 A report from our institution has shown that the incidence of ESRD is 9.5% after 13 years of follow-up postliver transplantation.10 AKI has been proposed to be an important risk factor for the long-term development of CKD and ESRD.9 However, most of the studies have been limited to AKI requiring renal replacement the...

Tumor recurrence after liver transplantation for hepatocellular carcinoma is associated with a poor prognosis. Because immunosuppression is a well-known risk factor for tumor growth, it is surprising that its possible role in the outcome of liver transplantation has been poorly evaluated. We performed a case-control review of prospectively collected data and compared 2 groups of patients according to the type of immunosuppression after liver transplantation for hepatocellular carcinoma at a single center. One hundred six patients received tacrolimus and mycophenolate mofetil, and 121 received sirolimus. Patients in the sirolimus group had significantly higher recurrence-free survival rates than patients in the tacrolimus group (P ϭ 0.0003). The sirolimus group also had significantly higher patient survival rates than the tacrolimus group at 1 year (94% versus 79%), 3 years (85% versus 66%), and 5 years (80% versus 59%; P ϭ 0.001). Sirolimus was well tolerated, and the patients in this study did not have the increase in surgical complications noted by other investigators. Leukopenia was the most common side effect, but it typically resolved with dose reduction. Dyslipidemia and mouth ulcers were common but were easily controlled. In summary, the data suggest a beneficial effect of sirolimus immunosuppression on recurrence-free survival, which translates into patient survival benefits.

The Model for End-Stage Liver Disease (MELD) score is now the criteria for allocation in liver transplantation for patients with chronic disease. Although the score has been effective in the prediction of mortality in patients awaiting liver transplantation, its abilities to predict posttransplantation outcome need study. The aim of this study is to compare outcome in the first 2 years after liver transplantation according to the pretransplantation MELD score. The study includes 669 consecutive patients who underwent primary liver transplantation between December 1993 and October 1999 in a single transplant center. Patients who died of malignancy were excluded from the series. Pretransplantation MELD score was calculated using the United Network for Organ Sharing formula. Patients were stratified according to MELD score less than 15, 15 to 24, and 25 and higher. Posttransplantation survival at 3, 6, 12, 18, and 24 months was significantly lower in the groups with a higher MELD score. The difference was significant for hepatitis C and noncholestatic liver diseases, but not cholestatic diseases. In patients with a MELD score between 15 and 24, survival was significantly greater with cholestatic diseases and lower in patients with hepatitis C. In our study, pretransplantation MELD score correlates with survival in the first 2 years after transplantation. There is a survival advantage for patients with cholestatic diseases compared with those with hepatitis C. These findings suggest the need to readjust MELD scorebased allocation decisions to consider patient outcome. (Liver Transpl 2003;9:117-123.)

The aims of this analysis are to characterize the incidence and types of malignancies and tumor-specific mortality in our institution. Retransplantation, rejection episodes, and OKT3 use were evaluated. Our single-institution prospective database of 1,570 liver transplantations in 1,421 patients was analyzed. Data were statistically analyzed regarding sex, age at transplantation, time from transplantation to diagnosis of tumor, tumor type, and follow-up time. One hundred twenty-five patients (8.8%) developed de novo tumors; 69 patients were men, 56 patients were women. Seventeen patients received more than one allograft. De novo tumors were as follows: skin, 41; lymphomas, 35; lung, 11; colon, 6; anal, 2; rectal, 1; breast, 7; thyroid, 3; oropharyngeal squamous cell, D e novo malignancy after liver transplantation is an unfortunate complication of a successful operation. The development of such malignancies can be caused by a multifactorial combination of individual and regional predispositions to malignancy, pretransplantation disease states, recipient viral status, and the use and intensity of various immunosuppressive regimens to maintain allografts. Incidence rates are reported to range between 3% and 15%, which is at least two times the incidence observed in the general population. [1][2][3][4] In addition, the risk for development increases with time from transplantation.Previous results in liver transplantations were with cyclosporine-based immunosuppression regimens. In this current period, immunosuppression continues to develop, and various immunosuppression regimens are used. Tacrolimus-based immunosuppression with two or more additional agents is now routine. Our institution previously used a cyclosporine-based regimen and changed to a tacrolimus-based regimen in the 1990s. In addition, use of monoclonal antibody agents now is common for steroid-resistant rejection.Objectives of this retrospective review are to characterize the incidence and types of malignancies and tumor-specific mortality in our large single-institution experience. Possible risk factors, such as retransplantation, absence or presence of rejection episodes, and use of OKT3, also are evaluated. MethodsSingle-institution prospective database information for our liver transplantations was reviewed from January 1985 to October 1999. Patients who underwent transplantation for primary liver tumors that developed recurrent tumors posttransplantation were excluded from this review. In some transplant recipients with de novo tumors, metachronous lesions developed; the initial lesion was counted as a single incidence. The time to develop de novo tumors was calculated from the date of first liver transplantation (some individuals received more than one transplant) to the time of our notification of the patient's first malignancy in months. Tumor types and their anatomic locations were recorded. Tumorrelated mortality and tumor-specific survival were evaluated statistically. The impact of maintenance immunosuppression with cyclosporine or tacro...