Chronic rejection after liver transplantation:Opening the Pandora’s box

Chronic rejection(CR)of liver allografts causes damage to intrahepatic vessels and bile ducts and may lead to graft failure after liver transplantation.Although its prevalence has declined steadily with the introduction of potent immunosuppressive therapy,CR still represents an important cause of graft injury,which might be irreversible,leading to graft loss requiring re-transplantation.To date,we still do not fully appreciate the mechanisms underlying this process.In addition to T cell-mediated CR,which was initially the only recognized type of CR,recently a new form of liver allograft CR,antibody-mediated CR,has been identified.This has indeed opened an era of thriving research and renewed interest in the field.Liver biopsy is needed for a definitive diagnosis of CR,but current research is aiming to identify new non-invasive tools for predicting patients at risk for CR after liver transplantation.Moreover,the minimization or withdrawal of immunosuppressive therapy might influence the establishment of subclinical CR-related injury,which should not be disregarded.Therapies for CR may only be effective in the“early”phases,and a tailored management of the immunosuppression regimen is essential for preventing irreversible liver damage.Herein,we provide an overview of the current knowledge and research on CR,focusing on early detection,identification of non-invasive biomarkers,immunosuppressive management,re-transplantation and future perspectives of CR.

De novo malignancies after liver transplantation: The effect of immunosuppression-personal data and review of literature

BACKGROUND Immunosuppression has undoubtedly raised the overall positive outcomes in the post-operative management of solid organ transplantation. However, long-term exposure to immunosuppression is associated with critical systemic morbidities. De novo malignancies following orthotopic liver transplants (OLTs) are a serious threat in pediatric and adult transplant individuals. Data from different experiences were reported and compared to assess the connection between immunosuppression and de novo malignancies in liver transplant patients. AIM To study the role of immunosuppression on the incidence of de novo malignancies in liver transplant recipients. METHODS A systematic literature examination about de novo malignancies and immunosuppression weaning in adult and pediatric OLT recipients was described in the present review. Worldwide data were collected from highly qualified institutions performing OLTs. Patient follow-up, immunosuppression discontinuation and incidence of de novo malignancies were reported. Likewise, the review assesses the differences in adult and pediatric recipients by describing the adopted immunosuppression regimens and the different type of diagnosed solid and blood malignancy.RESULTS Emerging evidence suggests that the liver is an immunologically privileged organ able to support immunosuppression discontinuation in carefully selected recipients. Malignancies are often detected in liver transplant patients undergoing daily immunosuppression regimens. Post-transplant lymphoproliferative diseases and skin tumors are the most detected de novo malignancies in the pediatric and adult OLT population, respectively. To date, immunosuppression withdrawal has been achieved in up to 40% and 60% of well-selected adult and pediatric recipients, respectively. In both populations, a clear benefit of immunosuppression weaning protocols on de novo malignancies is difficult to ascertain because data have not been specified in most of the clinical experiences. CONCLUSION The selected populations of tolerant pediatric and adult liver transplant recipients greatly benefit from immunosuppression weaning. There is still no strong clinical evidence on the usefulness of immunosuppression withdrawal in OLT recipients on malignancies. An interesting focus is represented by the complete reconstitution of the immunological pathways that could help in decreasing the incidence of de novo malignancies and may also help in treating liver transplant patients suffering from cancer.

COVID-19 in a pregnant kidney transplant recipient-what we need to know:A case report

BACKGROUND In the era of the coronavirus disease 2019(COVID-19)pandemic,kidney transplant recipients are more susceptible to severe acute respiratory syndrome coronavirus(SARS-CoV-2)infection,developing severe morbidity and graft impairment.Pregnant women are also more likely to develop severe COVID-19 disease,causing pregnancy complications such as preterm births and acute kidney injury.CASE SUMMARY Herein,we report the case of a pregnant woman with a third kidney transplantation who developed COVID-19 disease.The reduction of immunosuppressive drugs and strict monitoring of trough blood levels were needed to avoid severe SARS-CoV-2-related complications,and permitted to continue a healthy pregnancy and maintain good graft function.In such a complex scenario,the concomitance of COVID-19-related morbidity,the risk of acute rejection in the hyperimmune recipient,graft dysfunction and pregnancy complications make the management of immunosuppression a very difficult task and clinicians must be aware.CONCLUSION Tailoring the immunosuppressive regimen is a key factor affecting both the graft outcome and pregnancy safety.

Hemoperitoneum secondary to rupture of cystic artery pseudoaneurysm

BACKGROUND:Spontaneous hemoperitoneum of hepato- biliary origin is commonly due to hemorrhage from a liver tumor.It is rarely caused by spontaneous rupture of aneurysm in visceral arteries. METHODS:We report an unusual case of hemoperitoneum caused by rupture of cystic artery pseudoaneurysm,and also outline the approach to its management through surgical and radiological methods. RESULTS:In our patient,the pseudoanurysm was initially treated with percutaneous thrombin injection.However this method of treatment failed after initial success.The pseudoanurysm was finally obliterated successfully using microcoil embolization. CONCLUSIONS:The mainstay of treatment of cystic artery pseudoaneurysm is cholecystectomy and ligation of the aneurysm.Recent publications showed success in using microcoil embolisation.In this case we also outline the use of percutaneous thrombin injection as a definitive treatment method and discuss its success or failure as a new method of treatment.

Prophylactic drains in totally laparoscopic distal gastrectomy:are they always necessary?

Prophylactic drains have always been a useful tool to detect early complications and prevent postoperative fluid collections,particularly in gastrointestinal surgery.Recently,the utilization of such drains has been debated,due to mounting evidence that they could be harmful rather than beneficial.Based on recent published articles,Liu et al reported that the routine use of prophylactic drains in total laparoscopic distal gastrectomy might not be necessary for all patients.Herein,we express our opinion regarding this interesting publication.