Liver Graft Failure and Hyperbilirubinemia in Liver Transplantation Recipients After Clostridium difficile Infection

Epidemiology and Management of Infections in Liver Transplant Recipients

Background: Improvements in liver transplant (LT) outcomes are attributed to advances in surgical techniques, use of potent immunosuppressants, and rigorous pre-LT testing. Despite these improvements, post-LT infections remain the most common complication in this population. Bacteria constitute the most common infectious agents, while fungal and viral infections are also frequently encountered. Multi-drug-resistant bacterial infections develop because of polymicrobial overuse and prolonged hospital stays. Immediate post-LT infections are commonly caused by viruses. Conclusions: Appropriate vaccination, screening of both donor and recipients before LT and antiviral prophylaxis in high-risk individuals are recommended. Antimicrobial drug resistance is common in high-risk LT and associated with poor outcomes; epidemiology and management of these cases is discussed. Additionally, we also discuss the effect of coronavirus disease 2019 (COVID-19) infection and monkeypox in the LT population.

The outcomes of Clostridioides difficile infection in inpatient liver transplant population

BACKGROUND

Chronic immunosuppression is a known cause of Clostridioides difficile, which presents with colon infection. It is associated with increased mortality and morbidity. Our aim is to determine the inpatient outcomes of liver transplant patients with Clostridioides difficile infection (CDI) and trends in the last few years.

METHODS

We utilized the national re-admission data (2010-2017) to study the outcomes of CDI in liver transplant patients. Association of C. difficile with re-admission was computed in a multivariable model adjusted for age, sex, gastrointestinal bleeding, hypertension, diabetes, hyperlipidemia, congestive heart failure, cerebrovascular disease, obesity, cancer, insurance, chronic kidney disease, chronic obstructive pulmonary disease, dementia, peripheral vascular disease, smoking, hospital location, and teaching status.

RESULTS

During 2010-2017, there were 310 222 liver transplant patients hospitalized. Out of these, 9826 had CDI. CDI infection in liver transplant patients was associated with higher 30-day re-admission (14.3% vs. 11.21%, hazard ratio [HR]: 1.14, 95% confidence interval [CI]: 1.01-1.28, p = .02) and in-hospital mortality (odds ratio [OR]: 1.36, 95% CI: 1.14-1.61, p < .001). The most common causes of re-admission in the CDI group were recurrent CDI (41.1%), liver transplant complications (16.5%), and sepsis (11.6%). The median cost for liver transplant patients with C. difficile was significantly higher, $53 064 (IQR $24 970-$134 830) compared to patients that did not have C. difficile, $35 703 ($18 793-$73 871) (p < .001). The median length of stay was also longer for patients with CDI, 6 days (4-14) vs. 4 days (2-7) (p < .001).

CONCLUSION

CDI in post-liver transplant patients was associated with higher mortality, re-admission, health care cost, and longer length of stay. The most common cause of re-admission was recurrent CDI, which raises the question of the efficacy of standard first-line therapy.

Epidemiology and risk factors for infection after living donor liver transplantation

The epidemiology of infections after living donor liver transplantation (LDLT) is limited. We aimed to study the epidemiology and risk factors of infections after LDLT. The medical records of 223 adult patients who underwent LDLT from January 1, 2000 to August 31, 2015 were reviewed for all infections occurring up to 1 year. We estimated the cumulative incidence of infection using the Kaplan-Meier product limit method. Risk factors were analyzed with time-dependent Cox regression modeling. The majority of patients were Caucasian (94.6%) and male (64.6%), and the median age at transplantation was 55 years. The most common indication for transplantation was primary sclerosing cholangitis (37.7%). A total of 122 patients developed an infection during the follow-up period (1-year cumulative event rate of 56%), with the majority (66%) of these occurring within 30 days after transplantation. Enterococcus sp. was the most frequent pathogen identified. Multivariate analysis showed that increased Model for End-Stage Liver Disease (MELD) score (per 10-point change: hazard ratio [HR], 1.59), history of recurrent infections prior to transplant (HR, 2.01), Roux-en-Y anastomosis (HR, 2.37), increased log-number of packed red blood cell transfusions (HR, 1.39), and biliary complications (HR, 4.26) were independently associated with a higher risk of infection. Infections occur commonly after LDLT, with most infections occurring early and being related to the hepatobiliary system. Higher MELD scores, the type of biliary anastomosis, presence of biliary complications, and prior pretransplant infections are independently associated with a higher risk for infections. Liver Transplantation 23 465-477 2017 AASLD.

Diarrhea in solid-organ transplant recipients: a review of the evidence

OBJECTIVE

To provide a comprehensive review of the literature as it relates to diarrhea in solid organ transplant (SOT) recipients. In this article, we review the epidemiology, pathogenesis, clinical manifestations, diagnosis and management of diarrhea in SOT recipients and discuss recent advances and challenges.

METHODS

Two investigators conducted independent literature searches using PubMed, Web of Science, and Scopus until January 1st, 2013. All databases were searched using a combination of the terms diarrhea, solid organ transplant, SOT, transplant associated diarrhea, and transplant recipients. Articles that discussed diarrhea in SOT recipients were reviewed and relevant cross-references also read and evaluated for inclusion. Selection bias could be a possible limitation of the approach used in selecting or finding articles for this article.

FINDINGS

Post-transplant diarrhea is a common and distressing occurrence in patients, which can have significant deleterious effects on the clinical course and well-being of the organ recipient. A majority of cases are due to infectious and drug-related etiologies. However, various other etiologies including inflammatory bowel disease must be considered in the differential diagnosis. A step-wise, informed approach to post-transplant diarrhea will help the clinician achieve the best diagnostic yield. The use of diagnostic endoscopy should be preceded by exclusion of an infectious or drug-related cause of diarrhea. Empiric management with antidiarrheal agents, probiotics, and lactose-free diets may have a role in managing patients for whom no cause can be determined even after an extensive investigation.

CONCLUSIONS

Physicians should be familiar with the common etiologies that result in post-transplant diarrhea. A directed approach to diagnosis and treatment will not only help to resolve the diarrhea but also prevent potentially life-threatening consequences including loss of the graft as well. Prospective studies are required to determine the etiology of post-transplant diarrhea in different clinical and geographic settings.