Immunosuppression and Liver Transplantation

A 13-Year Nationwide Analysis of Nocardia and Actinomyces Infection Outcomes in Liver Transplant Recipients

Liver transplant (LT) recipients have a profound susceptibility to infections. Although Nocardia and Actinomyces (NAs) are well-known bacteria that typically affect immunosuppressed patients, a scarcity of research exists on the effects of LT with NA infections. Our study aims to evaluate the outcomes associated with NA infections in patients with LT. Patients were selected from the National Inpatient Sample (NIS) from 2008 through 2020. International Classification of Disease revision 9 (ICD-9) and ICD revision 10 (ICD-10) codes. Patients admitted with a history of LT were subdivided into those who were and were not diagnosed with an NA infection. Records were weighted using the NIS algorithm. Primary outcomes were all-cause hospital mortality, acute kidney injury (AKI), acute myocardial infarction (AMI), shock, and a composite of these. Secondary outcomes were length of stay, total charges, cytomegalovirus (CMV), and transplant rejection. Demographics and comorbidities were compared between the groups with a weighted chi-square test. Outcomes were compared between the two groups, and adjusted odds ratios (ORs) and regression coefficients were calculated using weighted logistic or linear regression as appropriate. ORs were adjusted for age, gender, race, hospital characteristics, Charlson Comorbidity Index (CCI), median income based on zip code, weekend admission, and insurance. There were 469,141 patients with LT who were included in this study, 310 of them had NA infection (0.07%). Patients in each group were of similar age, race, and overall medical complexity (P > .05). Patients with NA infection were less likely to have a history of coronary artery disease (CAD; 4.84% vs 16.20%, P < .05), hypertension (14.53% vs 25.82%, P < .05), and obesity (1.61% vs 9.0%, P < .05) than the healthy controls. Patients with LT with NA infection were found to have higher odds of mortality (OR = 5.50, P < .001), AKI (OR = 1.9, P < .05), composite outcome (OR = 2.19, P < 0.01), and more likely to have CMV infection (OR = 6.38, P < .01). Patients with LT with NA infection stayed 13.11 days longer in the hospital (P < .01) with charges of $60,399 more (P < .01) than the healthy controls. Patients with LT who acquired an NA infection were at nearly six-fold higher odds of death and other negative outcomes. Based on previous research that has demonstrated organ transplant patients to be at high risk of infections, more vigilant care should be taken to protect patients with LT from such opportunistic infections.

Lesson learnt from 60 years of liver transplantation: Advancements, challenges, and future directions

Over the past six decades, liver transplantation (LT) has evolved from an experimental procedure into a standardized and life-saving intervention, reshaping the landscape of organ transplantation. Driven by pioneering breakthroughs, technological advancements, and a deepened understanding of immunology, LT has seen remarkable progress. Some of the most notable breakthroughs in the field include advances in immunosuppression, a revised model for end-stage liver disease, and artificial intelligence (AI)-integrated imaging modalities serving diagnostic and therapeutic roles in LT, paired with ever-evolving technological advances. Additionally, the refinement of transplantation procedures, resulting in the introduction of alternative transplantation methods, such as living donor LT, split LT, and the use of marginal grafts, has addressed the challenge of organ shortage. Moreover, precision medicine, guiding personalized immunosuppressive strategies, has significantly improved patient and graft survival rates while addressing emergent issues, such as short-term complications and early allograft dysfunction, leading to a more refined strategy and enhanced post-operative recovery. Looking ahead, ongoing research explores regenerative medicine, diagnostic tools, and AI to optimize organ allocation and post-transplantation car. In summary, the past six decades have marked a transformative journey in LT with a commitment to advancing science, medicine, and patient-centered care, offering hope and extending life to individuals worldwide.

Bibliometric and LDA analysis of acute rejection in liver transplantation: Emerging trends, immunotherapy challenges, and the role of artificial intelligence

With the rising demand for liver transplantation (LT), research on acute rejection (AR) has become increasingly diverse, yet no consensus has been reached. This study presents a bibliometric and latent Dirichlet allocation (LDA) topic modeling analysis of AR research in LT, encompassing 1399 articles. The United States, Zhejiang University, and the University of California, San Francisco emerged as leading contributors, while Levitsky J and Uemoto SJ were key researchers. The most influential journals included the American Journal of Transplantation, Journal of Hepatology, and Transplantation. The analysis reveals a transition from traditional histological assessments to molecular diagnostics, genetic and epigenetic profiling, and noninvasive biomarkers such as donor-derived cell-free DNA (dd-cfDNA) and microRNAs. Advances in immune checkpoint inhibitors (ICIs), cell-based therapies (Tregs, mesenchymal stem cells (MSCs)), AI-guided immunosuppression, and nanoparticle-mediated drug delivery systems reflect a growing emphasis on precision medicine. In addition, recent exploration of microbiome-based therapies and regenerative medicine, including MSCs and their extracellular vesicles, offers promising new avenues for reducing long-term immunosuppressive drug dependency and enhancing graft survival. These developments not only improve early AR detection and personalized treatment but also reduce toxicity, foster immune tolerance, and expand the scope of individualized therapeutic options. Global collaboration, supported by cutting-edge research and AI-driven decision-making, remains essential for refining AR strategies, improving graft survival, and achieving better long-term patient outcomes.

Advancing immunosuppression in liver transplantation: A narrative review

Immunosuppression is essential to ensure recipient and graft survivals after liver transplantation (LT). However, our understanding and management of the immune system remain suboptimal. Current immunosuppressive therapy cannot selectively inhibit the graft-specific immune response and entails a significant risk of serious side effects, i.e., among others, de novo cancers, infections, cardiovascular events, renal failure, metabolic syndrome, and late graft fibrosis, with progressive loss of graft function. Pharmacological research, aimed to develop alternative immunosuppressive agents in LT, is behind other solid-organ transplantation subspecialties, and, therefore, the development of new compounds and strategies should get priority in LT. The research trajectories cover mechanisms to induce T-cell exhaustion, to inhibit co-stimulation, to mitigate non-antigen-specific inflammatory response, and, lastly, to minimize the development and action of donor-specific antibodies. Moreover, while cellular modulation techniques are complex, active research is underway to foster the action of T-regulatory cells, to induce tolerogenic dendritic cells, and to promote the function of B-regulatory cells. We herein discuss current lines of research in clinical immunosuppression, particularly focusing on possible applications in the LT setting.

Recurrent rejections after liver transplantation for hepatocellular carcinoma with stem cell features in an adult patient

Patients with hepatoblastoma featuring carcinoma characteristics have better outcomes after liver transplantation, than after chemotherapy and resection. Possibly this should be extrapolated to aggressive subtypes of hepatocellular carcinomas in non-cirrhotic livers, where early liver transplantation might also be indicated. However, the risks associated with liver transplantation and immunosuppressive treatment after liver transplantation are once again demonstrated by this case of a 32-year-old women with a negative personal and familial history of liver diseases. She underwent transplantation (DBD) for a hepatocellular carcinoma with stem cell features (HCC-HS; an aggressive 'hepatoblast subtype' of hepatocellular carcinoma) after chemotherapeutical downstaging techniques failed to sufficiently downstage the tumor. Despite being on conventional immunosuppressive regimens (tacrolimus and mycophenolate mofetil with initial corticosteroids tapered), this patient still developed two severe rejection episodes, one of which necessitated retransplantation (DCD). Both episodes were preceded by alterations in tacrolimus trough levels, either intentionally, when tacrolimus was reduced within a nephroprotective regimen, or unintentionally, when rifampicin, a CYP3A4 inducer, significantly lowered the trough levels. Together, these episodes stress the importance of therapeutic drug monitoring of tacrolimus. Furthermore, the patient experienced an everolimus-linked drug-induced thrombotic microangiopathy, underwent multiple ERCPs for an anastomotic stricture and only one and a half year after the first liver transplantation she already suffers from long-term immunosuppressive-related side effects such as impaired glucose tolerance, hypertension and a potential cardiomyopathy. At present, she is still alive and experienced no recurrence of her primary tumor. Her case underscores the significant challenges in post-liver transplantation care.

Improving Patient Safety in Medication Management by Medication Reconciliation and Pharmaceutical Care Process in Post-Liver Transplant Clinic

INTRODUCTION

Liver transplant recipients receive many medications for anti-rejection, infection prophylaxis, and treatment of comorbidities. Most of them also receive medications from multiple sources. Therefore, these patients are prone to drug-related problems (DRPs) and medication errors. This study aimed to study the effect of medication reconciliation (MR) and pharmaceutical care processes by transplant pharmacists in the post-liver transplant clinic.

METHODS

This study was a retrospective study in Siriraj Liver Transplant Center, Mahidol University, Thailand. Patients who received pharmaceutical care from transplant pharmacists were compared before and after the implementation of MR (October 2020-September 2021 vs October 2021-September 2022) to assess the prevalence of medication errors and identify DRPs between the 2 groups.

RESULTS

Before implementation of MR, in a total of 797 visits, 69 medication errors (8.7%) were found. The most errors were medication omissions (44.9%, n = 31). After the implementation of MR, in a total of 879 visits, 44 medication errors (5.0%) were found. Most were medication omission and incorrect strength (31.8%, n = 14). Medication errors significantly decreased by 36.2% (P < .001) after the implementation of MR. Regarding DRPs, transplant pharmacists could significantly detect more DRPs after implementation of MR, 66 DRPs before implementation of MR vs 111 DRPs after implementation of MR (P < .001). The most DRPs were non-adherence (34 vs 41).

CONCLUSIONS

MR can reduce medication errors and assist transplant pharmacists in identifying DRPs that will lead to active intervention by attending physicians and/or patients to improve medication management and patient safety in post-liver transplant care.

Immunology demystified: A guide for transplant hepatologists

Liver transplantation has become standard practice for treating end-stage liver disease. The success of the procedure relies on effective immunosuppressive medications to control the host's immune response. Despite the liver's inherent capacity to foster tolerance, the early post-transplant period is marked by significant immune reactivity. To ensure favorable outcomes, it is imperative to identify and manage various rejection types, encompassing T-cell-mediated, antibody-mediated, and chronic rejection. However, the approach to prescribing immunosuppressants relies heavily on clinical judgment rather than evidence-based criteria. Given that the majority of patients will require lifelong immuno suppression as the mechanisms underlying operational tolerance are still being investigated, healthcare providers must possess an understanding of immune responses, rejection mechanisms, and the pathways targeted by immunosuppressive drugs. This knowledge enables customization of treatments and improved patient care, even though a consensus on an optimal immunosuppressive regimen remains elusive.

Enhancing Kidney Transplant Care through the Integration of Chatbot

Kidney transplantation is a critical treatment option for end-stage kidney disease patients, offering improved quality of life and increased survival rates. However, the complexities of kidney transplant care necessitate continuous advancements in decision making, patient communication, and operational efficiency. This article explores the potential integration of a sophisticated chatbot, an AI-powered conversational agent, to enhance kidney transplant practice and potentially improve patient outcomes. Chatbots and generative AI have shown promising applications in various domains, including healthcare, by simulating human-like interactions and generating contextually appropriate responses. Noteworthy AI models like ChatGPT by OpenAI, BingChat by Microsoft, and Bard AI by Google exhibit significant potential in supporting evidence-based research and healthcare decision making. The integration of chatbots in kidney transplant care may offer transformative possibilities. As a clinical decision support tool, it could provide healthcare professionals with real-time access to medical literature and guidelines, potentially enabling informed decision making and improved knowledge dissemination. Additionally, the chatbot has the potential to facilitate patient education by offering personalized and understandable information, addressing queries, and providing guidance on post-transplant care. Furthermore, under clinician or transplant pharmacist supervision, it has the potential to support post-transplant care and medication management by analyzing patient data, which may lead to tailored recommendations on dosages, monitoring schedules, and potential drug interactions. However, to fully ascertain its effectiveness and safety in these roles, further studies and validation are required. Its integration with existing clinical decision support systems may enhance risk stratification and treatment planning, contributing to more informed and efficient decision making in kidney transplant care. Given the importance of ethical considerations and bias mitigation in AI integration, future studies may evaluate long-term patient outcomes, cost-effectiveness, user experience, and the generalizability of chatbot recommendations. By addressing these factors and potentially leveraging AI capabilities, the integration of chatbots in kidney transplant care holds promise for potentially improving patient outcomes, enhancing decision making, and fostering the equitable and responsible use of AI in healthcare.

New Developments and Challenges in Liver Transplantation

Liver disease is increasing in incidence and is the third most common cause of premature death in the United Kingdom and fourth in the United States. Liver disease accounts for 2 million deaths globally each year. Three-quarters of patients with liver disease are diagnosed at a late stage, with liver transplantation as the only definitive treatment. Thomas E. Starzl performed the first human liver transplant 60 years ago. It has since become an established treatment for end-stage liver disease, both acute and chronic, including metabolic diseases and primary and, at present piloting, secondary liver cancer. Advances in surgical and anaesthetic techniques, refined indications and contra-indications to transplantation, improved donor selection, immunosuppression and prognostic scoring have allowed the outcomes of liver transplantation to improve year on year. However, there are many limitations to liver transplantation. This review describes the milestones that have occurred in the development of liver transplantation, the current limitations and the ongoing research aimed at overcoming these challenges.

T-cell specific antibody induction versus corticosteroid induction immunosuppression for liver transplant recipients: a meta-analysis

Corticosteroids remain the mainstay of immunosuppression for liver transplant recipients despite several serious complications including infection, hepatitis C virus (HCV) recurrence, diabetes mellitus (DM), and hypertension. We attempted to compare the safety and efficacy of T-cell specific antibody induction with complete corticosteroid avoidance. We searched MEDLINE, EMBASE, and Cochrane central library. Randomized controlled trials comparing T-cell specific antibody induction with corticosteroid induction immunosuppression were included. Our primary outcome was the incidence of biopsy-proven acute rejection. Eleven trials involving 1683 patients were included. The incidence of acute rejection was not significantly different between the antibody and steroid induction groups (risk ratio [RR] 0.85, 95% confidence interval [CI] 0.72, 1.01, P = 0.06, I2 = 0%). However, T-cell specific antibody induction significantly reduced the risk of cytomegalovirus infection (RR 0.48, 95% CI 0.33, 0.70, P = 0.0002, I2 = 3%), HCV recurrence (RR 0.89, 95% CI 0.80, 0.99, P = 0.03, I2 = 0%), DM (RR 0.41, 95% CI 0.32, 0.54, P < 0.0001, I2 = 0%) and hypertension (RR 0.71, 95% CI 0.55, 0.90, P = 0.005, I2 = 35%). Trial sequential analysis for acute rejection showed that the cumulative z-curve did not cross the Trial sequential boundary and the required information size was not reached. T-cell specific antibody induction compared to corticosteroid induction seems to significantly reduce opportunistic infections including cytomegalovirus infection and HCV recurrence and metabolic complications including DM and hypertension. However, given the insufficient study power, low quality of evidence, and heterogeneous immunosuppressive regimens, our results should be cautiously appreciated.

Prenatal Exposition to Different Immunosuppressive Protocols Results in Vacuolar Degeneration of Hepatocytes

Immunosuppressive drugs are essential for transplant recipients, since they prolong proper function of graft; however, they affect the morphology and function of organs, including liver. One commonly observed alteration in hepatocytes is vacuolar degeneration. Numerous medications are contraindicated in pregnancy and breastfeeding, mostly due to a lack of data concerning their advert effects. The aim of the current study was to compare the effects of prenatal exposition to different protocols of immunosuppressants on vacuolar degeneration in the hepatocytes of livers of rats. Thirty-two livers of rats with usage of digital analysis of the images were examined. Area, perimeter, axis length, eccentricity and circularity regarding vacuolar degeneration were analysed. The most prominent vacuolar degeneration in hepatocytes in the aspects of presence, area and perimeter was observed in rats exposed to tacrolimus, mycophenolate mofetil and glucocorticoids, and cyclosporine A, everolimus with glucocorticoids.This is the first study that demonstrates the results of the influence of multidrug immnunosuppression distributed in utero on the hepatic tissue of offspring.