Liver transplantation is being performed with excellent 5-year survival. Significant comorbidities exist, however, which appear to be related to long-term immunosuppression.

Livers with even severe microvesicular steatosis can be reliably used for transplantation without the fear of high rates of primary nonfunction. There was a significant incidence of poor early graft function, but this did not affect outcome. Microsteatosis is usually associated with some underlying risk factor in the donor and is reversible, as demonstrated by follow-up biopsies after transplant.

Publications about liver transplantation (LTX) for autoimmune hepatitis (AIH) have started to emerge, but many issues remain unresolved. We reviewed data on 32 patients transplanted for AIH to determine how pretransplantation and posttransplantation characteristics correlate with recipient outcome, including disease recurrence. Recipients were 37؎ 14 years old; 30 of 32 were women. Most had chronic disease (8 ؎ 6 years); 25% had fulminant failure. The majority had ascites (91%), jaundice (88%), elevated prothrombin time (18 ؎ 3 seconds), and hypoalbuminemia (2.7 ؎ 0.6 g/dL). All had hypergammaglobulinemia (3.0 ؎ 1.0 g/dL) and autoantibodies (72% antinuclear, 74% smooth muscle). Only one was HLA A1-B8-DR3 positive. Other autoimmune disorders affected 25% of patients; half improved after transplantation. Actuarial survival was 81% at 1 and 2 years posttransplantation. There was a high frequency of rejection (75% of recipients had 1.7 ؎ 0.8 episodes), and 39% of rejections required OKT3. Among 24 recipients with long-term follow-up (27 ؎ 14 months), histologically proven recurrent AIH occurred in 25%, 15 ؎ 2 months posttransplantation; half (3 patients) required retransplantation 11 ؎ 3 months after diagnosis. After retransplantation 2 of 3 patients had re-recurrence within 3 months; 1 received a third LTx. Recurrence occurred in 6 of 18 patients transplanted for chronic disease vs. 0 of 6 transplanted as fulminants (P ‫؍‬ not significant [NS] Until a short time ago the literature on LTX for AIH was sparse, including one publication that addressed the role of LTX for AIH, 2 and some reports about recurrence of AIH after LTX. [4][5][6][7] Recently, several retrospective reviews on LTX for AIH have emerged from various transplantation programs [8][9][10][11][12] as well as a few publications about rejection and immunosuppression after LTX for AIH. [13][14][15] In general there is consensus about the demographics of AIH patients that come to LTX. However, there are unresolved issues regarding the posttransplantation course of these patients. For example, there is controversy about the prevalence, risk factors, and outcome of recurrent AIH, and about appropriate posttransplantation immunosuppression strategies that take into account the increased immunoreactivity of these patients.To address some of these issues, we reviewed our data on 32 patients who underwent LTX for a primary indication of AIH and we sought to determine whether specific pretransplantation characteristics or various aspects of the postoperative course could be used to predict posttransplantation outcome, including disease recurrence. PATIENTS AND METHODSWe retrospectively reviewed our data on patients in whom a clinical and pathologic diagnosis of AIH had been made on the basis of the diagnostic criteria of the International Autoimmune Hepatitis Group 16 and who underwent transplantation at The Mount Sinai Medical Center (New York, NY) between September 1988 and January 1995. Patients with coexisting causes of hepatitis, such as viral or alcohol-ind...

Clinical recurrence of hepatitis C after liver transplantation can lead to cirrhosis, liver failure, and death. In patients undergoing liver transplantation for hepatitis C, we assessed the efficacy of interferon alfa-2b (IFN) in preventing recurrent hepatitis. We randomized 86 patients to either an IFN group (3 MU three times a week starting within 2 weeks after transplantation and continued for 1 year) or a control (no IFN) group. Recurrence, the primary end point, was diagnosed on biopsy performed at 1 year or for abnormal biochemistries. HCV RNA levels were measured by branched-chain DNA (bcDNA) assay and arbitrarily defined as low, moderate, or high (F10 ؋ 10 5 , 10-100 ؋ 10 5 , or G100 ؋ 10 5 Eq/mL, respectively). Data on 30 IFN patients and 41 no-IFN patients who survived H3 months were reviewed. Mean follow-up was 669 ؎ 228 days for IFN patients and 594 ؎ 254 days for no-IFN patients. IFN patients were less likely to develop recurrent hepatitis (8 IFN vs. 22 no-IFN patients, P ‫؍‬ .017, log rank analysis). IFN and 1-month HCV RNA level were independent predictors of recurrence. IFN reduced the risk of recurrence by a factor of 0.4 (P ‫؍‬ .04, Cox proportional hazards model); HCV RNA level Ͼ100 ؋ 10 5 Eq/mL at 1 month after transplantation increased the risk by a factor of 3.1 (P ‫؍‬ .01). Low, moderate, and high viral levels at 1 and 3 months were associated with significantly different rates of recurrence in IFN patients (P ‫؍‬ .05 at 1 month and P ‫؍‬ .003 at 3 months) but not in untreated patients (P ‫؍‬ .28 at 1 month and P ‫؍‬ .25 at 3 months). In patients with two or more rejections, the risk of recurrence was increased by a factor of 2.17 (P ‫؍‬ .05). On 47 1-year biopsies (24 IFN; 23 no IFN), piecemeal necrosis was more common in untreated patients (P F .02). One-and 2-year patient survival, respectively, was 96% and 96% with IFN and 91.2% and 87.2% without (P ‫؍‬ NS). Prophylactic IFN reduced the incidence of recurrent hepatitis after transplant. Although IFN was most effective in patients with low HCV RNA levels, we also noted an effect in patients with moderate levels. IFN did not prevent viremia, suggesting that it may work through alternative mechanisms.(HEPATOLOGY 1998;28: 831-838.)Hepatitis C is becoming the most common indication for orthotopic liver transplantation. 1 After transplantation for this indication, however, hepatitis C viral RNA (HCV RNA) is detectable in serum in approximately 95% of patients. 2 Because the virus remains present, the new graft is at risk for recurrent disease. Clinical recurrence of hepatitis C has been reported in up to 62% of patients after orthotopic liver transplantation 2-4 and can lead to progressive liver failure, cirrhosis, and death. 5 Studies using quantitative assays for viral RNA have revealed a possible association between high serum HCV RNA levels and active hepatitis after transplantation. 6 The observation that quantitative HCV RNA levels are higher after liver and kidney transplantation than before suggests that immunosuppression may enhance...

Between March 1991 and August 1995, 36 livers from donors >/=70 years old were transplanted. In donors, we recorded the following risk factors: alanine aminotransferase > 120 and rising, dopamine dose > 15 microg/kg/min, hypotension (systolic blood pressure <80) >1 hr, stay in the intensive care unit >5 days and body mass index >/=27. In 35 recipients, we recorded pretransplant United Network for Organ Sharing (UNOS) status, cold/warm ischemia time, intraoperative blood loss, and occurrence of poor early graft function or primary nonfunction. Mean recipient age was 55 years (range, 25-75 years). Four recipients were UNOS status 1, 19 were UNOS 2, and 12 were UNOS 3. Two livers were used as second grafts for primary graft nonfunction. Mean donor age was 73 years (range, 70-84 years). Intracranial bleeding was the cause of death in the majority of donors. The 36 donors had 40 risk factors; 10 donors had >1 risk factor. Mean cold and warm ischemia times were 9:08 +/- 2:57 hr and 51 +/- 9 min. Mean total operative time was 7.5 hr. Posttransplant mean peak alanine aminotransferase and aspartate aminotransferase levels were 937.3 +/- 703.1 IU/L and 923.3 +/- 708.5 IU/L, respectively. Mean prothrombin time on postoperative day 2 was 14.9 +/- 1.6 sec. Average total bilirubin on postoperative day 5 was 4.9 mg/dl. Median length of stay in the intensive care unit was 4 days. One recipient had poor early graft function; two recipients had primary nonfunction. Mean follow-up was 503 days (range, 110-1714 days). Three-month actual graft and patient survival rates were 85% and 91%, respectively. One-year actuarial graft and patient survival rates were also 85% and 91%, respectively. We conclude that older livers can be used safely. Advanced donor age should not be a contraindication to liver procurement.