Transplantation in autoimmune liver diseases

Liver transplantation remains an effective treatment for those with end-stage disease and with intractable liver-related symptoms.The shortage of organs for transplantation has resulted in the need for rationing.A variety of approaches to selection and allocation have been developed and vary from country to country.The shortage of donors has meant that new approaches have to be adopted to make maximal use of the available organs;these include splitting grafts,use of extended criteria livers,livers from non-heart-beating donors and from living donors.Post transplantation,most patients will need life-long immunosuppression,although a small proportion can have immunosuppression successfully withdrawn.Newer immunosuppressive drugs and different strategies may allow a more targeted approach with a reduction in side-effects and so improve the patient and graft survival.For autoimmune diseases,transplantation is associated with significant improvement in the quality and length of life.Disease may recur after transplantation and may affect patient and graft survival.

Donor transmitted and de novo cancer after liver transplantation

Cancers in solid organ recipients may be classified as donor transmitted,donor derived,de novo or recurrent.The risk of donor-transmitted cancer is very low and can be reduced by careful screening of the donor but cannot be abolished and,in the United Kingdom series is less than 0.03%.For donors with a known history of cancer,the risks will depend on the nature of the cancer,the interventions given and the interval between diagnosis and organ donation.The risks of cancer transmission must be balanced against the risks of death awaiting a new graft and strict adherence to current guidelines may result increased patient death.Organs from selected patients,even with high-grade central nervous system(CNS)malignancy and after a shunt,can,in some circumstances,be considered.Of potential donors with non-CNS cancers,whether organs may be safely used again depends on the nature of the cancer,the treatment and interval.Data are scarce about the most appropriate treatment when donor transmitted cancer is diagnosed:sometimes substitution of agents and reduction of the immunosuppressive load may be adequate and the impact of graft removal should be considered but not always indicated.Liver al-lograft recipients are at increased risk of some de novo cancers,especially those grafted for alcohol-related liver disease and hepatitis C virus infection.The risk of lymphoproliferative disease and cancers of the skin,upper airway and bowel are increased but not breast.Recipients should be advised to avoid risk behavior and monitored appropriately.

How regenerative medicine and tissue engineering may complement the available armamentarium in gastroenterology?

The increasing shortage of donors and the adverse effects of immunosuppression have restricted the impact of solid organ transplantation.Despite the initial promising developments in xenotransplantation,roadblocks still need to be overcome and this form of organ support remains a long way from clinical practice.While hepatocyte transplantation may be effectively correct metabolic defects,it is far less effective in restoring liver function than liver transplantation.Tissue engineering,using extracellular matrix scaffolds with an intact but decellularized vascular network that is repopulated with autologous or allogeneic stem cells and/or adult cells,holds great promise for the treatment of failure of organs within gastrointestinal tract,such as endstage liver disease,pancreatic insufficiency,bowel failure and type 1 diabetes.Particularly in the liver field,where there is a significant mortality of patients awaiting transplant,human bioengineering may offer a source of readily available organs for transplantation.The use of autologous cells will mitigate the need for long term immunosuppression thus removing a major hurdle in transplantation.

Late post liver transplant protein losing enteropathy: Rare complication of incisional hernia

Development of oedema and hypoproteinaemia in a liver transplant recipient may be the first signs of graft dysfunction and should prompt a full assessment. We report the novel case of a patient who, years after liver transplantation developed a functional blind loop in an incisional hernia, which manifested as oedema and hypoproteinaemia secondary to protein losing enteropathy. After numerous investigations, the diagnosis was made by flurodeoxyglucose positron emmision tomography (FDG-PET) imaging. Surgical repair of the incisional hernia was followed several months later by resolution of the protein loss, and confirmed at a post operative FDG-PET scan at one year.

Is There a Crisis in Heart Transplantation? Reflection over 10 Years

Heart transplantation is without doubt a very effective treatment for patients’ whose lives and well-being are threatened by their failing heart. We previously categorized our concerns into four areas or Ds: Donor availability, Disorganization, Disillusionment (of clinicians) and Disaffection (of tomorrow’s clinicians). After a decade, this is a timely reflection on this crisis of cardiac transplantation. It is also appropriate to set this in the context of a fifth D, the Demand for heart transplantation. In this reflective analysis, we use the 5 Ds to explore the current climate in heart transplantation, with particular reference to the situation in the UK.