Few studies have examined causes of death in long-term survivors of orthotopic liver transplantation (OLT). We reviewed causes of death among 299 adult liver transplant recipients who survived more than 3 years after OLT at 2 centers. Thirty-eight of the 299 patients subsequently died. Nonhepatic causes accounted for 22 of 38 late deaths (58%). Death caused by malignancies occurred in 9 patients between 3.3 and 8.0 years after OLT. Eight patients died of cardiovascular complications. The 6 patients who died of myocardial infarction had risk factors for coronary artery disease. Hepatic failure caused by recurrent liver disease or chronic rejection accounted for 16 of 38 late deaths (42%). These 16 patients were younger than patients who died of nonhepatic complications (mean ages, 50.7 v 62.1 years; P ‫؍‬ .001). However, the mean interval between OLT and death was similar among patients who died of nonhepatic versus hepatic causes. Nine patients had recurrent liver disease leading to death, and 8 of 9 patients had recurrent chronic hepatitis C virus (HCV) infection. Chronic rejection resulting in graft failure and death occurred in 7 patients. In summary, de novo malignancies and cardiovascular complications accounted for more than half the late deaths. Patients who died of nonhepatic causes were significantly older than patients who died of hepatic causes. Chronic rejection and recurrent HCV infection accounted for the majority of hepatic causes of death. With longer followup, graft failure resulting from recurrent HCV infection will become the major cause of death in late survivors. (Liver Transpl 2001;7:811-815.)

Current protocols for prophylaxis against allograft reinfection after liver transplantation for chronic hepatitis B virus (HBV) infection include the administration of large doses of hepatitis B immune globulin (HBIG), with considerable associated economic costs. Monotherapeutic prophylaxis with lamivudine has been complicated by the development of resistant strains of HBV. We studied the effectiveness of a posttransplantation prophylaxis protocol using combination lamivudine and low-dose HBIG in 7 consecutive patients with chronic HBV infection, 4 of whom were serum HBV DNA positive before pretransplantation lamivudine therapy. All patients were serum HBV DNA negative at transplantation and received lamivudine, 100 mg/d, posttransplantation. HBIG, 2170 IU, was administered intramuscularly intraoperatively and daily for 14 days. Maintenance HBIG therapy consisted of 2170 IU intramuscularly twice weekly, tapered to every 2 to 4 weeks by 12 months posttransplantation.Target serum HBIG (HBV surface antibody) titers were less than 500 IU/L for 6 months, then greater than 300 IU/L until 12 months posttransplantation. Induction serum HBIG titers were determined daily in 5 patients, and both serum HBIG and hepatitis B surface antigen were determined every 4 weeks in all patients. One patient died 61 days posttransplantation; the surviving patients (n ‫؍‬ 6) were followed up for a mean of 532 days (range, 395 to 648 days). No patient has developed allograft reinfection. In the induction period, a target HBIG titer of greater than 500 IU/L was not achieved until a mean of 6.8 days (range, 5 to 10 days). In the maintenance period, all patients achieved the target HBIG titer. This suggests combination lamivudine and low-dose HBIG is effective in preventing allograft reinfection by HBV.

In the absence of prophylaxis, the reactivation of hepatitis B in oncology patients who are hepatitis B carriers is a well-known and often fatal complication of chemotherapy. The current recommendations in Canada and the USA are that patients who are positive for hepatitis B surface antigen (HBsAg) receive antiviral prophylaxis prior to chemotherapy. We report a 67-year-old man with B-cell lymphoma who developed hepatitis B reactivation following chemotherapy with cyclophosphamide, adriamycin, vincristine, prednisone and rituximab. Pre-chemotherapy, the patient was negative for HBsAg, positive for hepatitis B core antibody (anti-HBc) and weakly positive for hepatitis B surface antibody. Despite treatment with lamivudine, the patient died of fulminant hepatic failure. Our experience indicates that patients who are negative for HBsAg but positive for anti-HBc are still at risk for reactivation of latent hepatitis B during and after chemotherapy and may be considered for prophylaxis.

Many studies have reported improved health-related quality of life outcomes after orthotopic liver transplantation; however, specific research regarding sexual health in liver transplant recipients is limited. We surveyed liver transplant recipients to determine the prevalence of sexual dysfunction. Of the 320 adult liver transplant recipients surveyed by mailed questionnaire, 150 responded (42%). The median age was 54 years. A total of 62% of respondents were male, and 93% were at least 1 year after transplantation. Thirty-six respondents (24%) reported sexual dysfunction before transplantation; this persisted in 22 patients (15%) after transplantation. A total of 48 respondents (32%) reported de novo sexual dysfunction after transplantation. After transplantation, 23% of male and 26% of female respondents reported decreased libido, and 33% of men and 26% of women reported having difficulty reaching orgasm with intercourse. A total of 42% of respondents felt that immunosuppressive medication was the main contributing factor to their sexual problems: 33% and 35% of respondents receiving tacrolimus or cyclosporine monotherapy, respectively, experienced some degree of sexual problems after transplantation. Despite the reported sexual problems, 59% of respondents were "moderately" to "very satisfied" with their sexual relationships after transplantation. Nineteen percent of the respondents used sildenafil to improve their sexual function, and 65% of these reported benefit. In conclusion, sexual problem after orthotopic liver transplantation is a common but poorly studied problem. Although this single-center study has shed some light on the relationship between liver transplantation and sexual health, further prospective studies, involving larger study population and validated instruments, will be needed to better evaluate the influence of liver transplantation on recipients' sexual health. During the past 20 years, orthotopic liver transplantation has emerged as the treatment of choice for endstage liver diseases of various causes. Most transplant centers reported 1-year survival rates for adult transplant recipients of about 80-90% and 9-year survival rates of 55%. 1 As the clinical outcomes of orthotopic liver transplantation continue to improve, resulting in fewer postoperative complications and better immunosuppression, other outcomes, such as health-related quality of life, become important targets of evaluation. Although considerable research has been conducted on the morbidity and mortality of orthotopic liver transplantation, less is known about the influence of orthotopic liver transplantation on health-related quality of life of the transplant recipients. In particular, literature on sexual health for this population is limited.Sexual health encompasses not only sexual function, but also involves the full range of human experience. Sexuality allows communication of emotional feelings, provides a means of physical pleasure and gratification, enhances feelings of self-worth, and strengthens relationships. 2...

None of the DAAs are completely free of drug interactions. Awareness and management of drug interactions is critical to optimize outcomes and minimize adverse effects in these patient populations.