Barbara Coco,
Coordinator
Daniela Dalla Gasperina
Andrea Gori
Manuela Merli
Massimo Siciliano
Marcello Tavio
Despite advances in liver transplantation management,
infection complications remain a major source of morbidity
and mortality in recipients.
Before liver transplantation diagnosis and treatment of
active infections and assessment of the risk for infections
is mandatory
in order to optimize the management of
infectious diseases in the post-transplant setting.
PRE-OLT infectious work up
A four approaches strategy should be adopted to prevent infections:
a)
Screening
recipients and potential liver donors
b)
Prophylatic
antimicrobial therapy
c)
Vaccinations
In order to investigate
common clinical practice
in Italy a
questionnaire
was
submitted
to
the
Italian
Liver
Transplantation Centres and to the Liver Units involved in
liver transplant patient’s management
ITALIAN SURVEY ON PRE-OLT INFECTIOUS
WORK UP
Centres and Investigators who accept to
partecipate the survey:
•Torino (Salizzoni - Marzano)
•Milano Policlinico (Rossi – Caccamo)
•Milano Ist Tumori (Mazzaferro- Guarnieri)
•Bergamo (Colledan - Fagiuoli)
•Padova ( Cillo - Burra)
•Udine (Bresadola - Toniutto)
•Bologna (Pinna – Morelli)
•Modena (Gerunda – Codeluppi)
•Pisa (Filipponi – Balzano)
•Roma Gemelli (Agnes - Siciliano)
•Roma Policlinico Umberto I (Rossi- Ferretti)
•Napoli (Calise - Di Costanzo)
•Napoli (Cuomo - Di Costanzo)
•Ancona (Risaliti -Svegliati Baroni)
Screening for TB and Latent TB
Screening for HBV infection
Screening for CMV infection
Virological screening
(except HBV and CMV)
Screening for “foci”
Screening for other bacteria, parasites and
fungal infections
Data from 15 out of the 22 Italian Liver Transplant Centres
Data
from 15 out of the 22 Italian Liver Transplant Centres
Prophylaxis for Latent TB
:
PRE-OLT Prophylaxis of infections
Data from 15 out of the 22 Italian Liver Transplant Centres
40%
13%
13%
6%
13%
INH 6-9
m
INH for
3 m
INH
for 12
m
L-flox
for 9 m
Not
specify
Prophylaxis of Tubercolosis Infection
PRE-OLT Prophylaxis of infections
A systematic review of 7 studies estimated that, compared with the
general population, liver transplant recipients have
a 18-fold
increase in the prevalence of active Mycobacterium Tubercolosis
infection and a 4-fold increase in the case-fatality rate
(II A)
Prophylaxis of Tubercolosis Infection:
When?
PRE-OLT Prophylaxis of infections
Although it is optimal to treat LTB infection prior to OLT, it is
challenging due to potential hepatotoxicity of isoniazid.
Clinically
significant
hepatotoxicity
related
to
LTB
infection
treatment in liver transplant candidates was relatively uncommon:
-6% pts required discontinuation
-1% pts required emergent liver transplantation (ie, for drug-induced
hepatotoxicity with acute liver failure)
-no associated deaths
Mortality rate is higher in liver transplant recipients who developed
active TB infection within 5 months post-transplant versus pts who
developed active TB infection after 5 months (36% versus 17%,
P
0.04).
Strategy adopted to control CMV
:
73%
20%
7%
pre-emptive ther
prophylasis
none
Data from 15 out of the 22 Italian Liver Transplant Centres
* Main difference in CMV-DNA thershold
Strategy adopted to control de novo HBV infection
:
20%
80%
No
yes, in all pts
pre-OLT Vaccination
Prophylaxis of HBV recurrence in Liver Transplant
patient and control of de novo HBV infection
Antimicrobial Decontamination/ Prevention of PBS
:
Data from 15 out of the 22 Italian Liver Transplant Centres
Prophylaxis for fungal infections
(except acute liver failure)
Pre-OLT Vaccinations
INFECTIOUS SURVEILLANCE in liver
transplant candidates in WAITING LIST
Results from 15 out of the 22 Italian Liver Transplant Centres
no
80%
yes
20%
Surveillance of infectious in liver transplant
candidates in waiting list
HIV 1-2 Ab
If neg
Every 6 months
HBsAg, HBsAb, HBcAb
If positive
HBV DNA every 3 months
If vaccinated
HBsAb if low Ab titer
vaccine
boost, every 6 months
CMV Ab
(IgG)
If neg
Every 6 months
HSV 1-2 Ab
(IgG)
If neg
Every 6 months
VZV Ab
(IgG)
If neg
Every 6 months
EBV Ab (EBNA-Ab, VCA IgG- IgM)
if VCA-IgG neg
Every 6 months
Toxoplasma Ab (IgG)
If neg
Every 6 months
Other test according to clinical indications
IIIC
STATMENT’S PROPOSAL:
During the waiting list time a periodically surveillance for infectious
risk should be performed (table below)
Daniela Dalla Gasperina
Andrea Gori
Manuela Merli
Massimo Siciliano
Marcello Tavio
PRE-OLT INFECTIOUS WORK UP
Thanks
•
Centres and Investigators who accept to
partecipate the survey:
• Torino (Salizzoni - Marzano)
• Milano Policlinico (Rossi – Caccamo)
• Milano Ist Tumori (Mazzaferro- Guarnieri)
• Bergamo (Colledan - Fagiuoli)
• Padova ( Cillo - Burra)
• Udine (Bresadola - Toniutto)
• Bologna (Pinna – Morelli)
• Modena (Gerunda – Codeluppi)
• Pisa (Filipponi – Balzano)
• Roma Gemelli (Agnes - Siciliano)
• Roma Policlinico Umberto I (Rossi- Ferretti)
• Napoli (Calise - Di Costanzo)
• Napoli (Cuomo - Di Costanzo)
• Ancona (Risaliti -Svegliati Baroni)
• Palermo ISMET (Gridelli - Volpes)
Segreteria AISF
