Clostridium difficile Infection in Hospitalized Liver Transplant Patients

at a considerable risk to develop de novo malignancies after OLT. They can be efficiently prevented by tailored surveillance programs for selected groups of patiens. If precisely applied, de novo malignancies do not influence the outcome of OLT. Mo1046 Clostridium difficile Infection in Hospitalized Liver Transplant Patients Muhammad Ali, Nilay Kumar, Jayshil Patel, Shahryar Ahmad, Gagan Kumar, Kia Saeian Background: Clostridium difficile infection is common in hospitalized patients and in patients on antibiotics and immunosuppressive therapy. Aim of study: Determine the prevalence of Clostridium difficile Associated Diarrhea (CDAD) in patients with a liver transplant. Methods: Using the Nationwide Inpatient Sample 2004-2008, patients older than 18 years, discharged with any diagnosis of Liver Transplant and CDAD were identified through appropriate ICD9-CM codes. Outcome variables included frequency, in-hospital mortality and length of stay (LOS). Multivariate logistic regression was used to adjust for age, sex, race and Elixhauser Co-morbidity index. Appropriate survey commands allowed weighting of the stratified data to give a national estimate. Results: There were 193,174 estimated adult discharges with Liver transplant in 2004-2008. The odds of having CDAD in Liver Transplant related admission were 2.7 (95% CI 2.31-2.96). In-hospital mortality in Liver transplant patients was significantly higher in CDAD patients (5.4% vs 3.2%, p<0.001). Hospitalization at a high volume hospital (OR 1.76, 95% CI 1.30-2.38) and an increased severity of illness increased the odds of dying. The adjusted odds for mortality from CDAD in liver transplant patients were 1.57 (95% CI 1.2-2.1) times higher than Non-CDAD patients. The median LOS in liver transplant patients with CDAD was significantly higher than Non-CDAD patients (9 days vs. 4 days). Conclusion: In this nationally representative sample, CDAD increases the mortality in hospitalized patients with a liver transplant. CDAD is also associated with an increased length of stay among hospitalized liver transplant patients. Further studies looking into the factors responsible for this are warranted.

LRT: pre-transplant loco-regional therapy

AASLD Abstracts

Mo1044 Outcome of Liver Transplantation in Older Recipients Emily Carey, Nizar N. Zein, Rocio Lopez Liver transplantation (LT) for older patients remains controversial with limited data on shortand long-term outcome. Our aim was to assess morbidity and survival in older (>65 yrs) compared to younger (<65 yrs) LT recipients. Methods: We identified all older LT recipients between 2005-2009 (n=77) and compared outcomes with randomly selected younger recipients (n=171). Survival analysis was performed in both groups and regression analysis was used to identify factors associated with mortality in both groups. Results: Mean age at LT of the entire group was 55 + 12 years (18-76 years). Older pts were more likely to have NASH (21% vs. 7%; p=0.001) or cryptogenic cirrhosis (26% vs. 7%; p =0.015) while HCV was more common in younger group (39% vs. 13%; p<0.001). The older group was more likely to have comorbid conditions before LT including cardiovascular disease (p<0.001), DM (p<0.001) and renal insufficiency (p<0.001) and were more likely to have encephalopathy during the wait time for LT (p=0.032). Waitlist times were similar for both groups (median 11.8 month vs. 16.5; p= 0.22). Hospital stay at LT was similar in both groups (13 days). There was no difference in overall mortality between the older and younger groups (17% in each group; p=0.92). Survival of both groups at multiple time points is shown in the Table. In regression analysis, the diagnosis of cryptogenic cirrhosis (HR=2.4, 95% CI: 1.02, 5.5) and post-LT neurological disorders (HR=2.6, 95% CI: 1.02, 6.8) were associated with decreased survival while older age was not (HR= 0.59, 95% CI: 0.27, 1.3). Conclusion: Medically, older age alone should not preclude patients from LT listing. The ethics of LT in older patient will need to be addressed, as well, especially in the era of organ shortage. Survival Post Liver Transplant: Kaplan-Meier Estimates

Mo1047 Differentiating Acute Cellular Rejection vs. Biliary Tract Pathology After Orthotopic Liver Transplantation: Is a Non-Invasive Approach Feasible? Anil B. Seetharam, John M. Iskander, Joseph T. Merrill, Sreenivasa S. Jonnalagadda, Jeffrey Crippin, Riad R. Azar Background: Allograft rejection and biliary tract complications are common causes of elevated liver function tests (LFTs) after orthotopic liver transplantation (LTx). While studies have identified risk factors for development of either condition individually, little is known about potential factors that differentiate these conditions upon presentation when non-invasive imaging or clinical history is equivocal. Knowledge of such factors would facilitate directed therapy, potentially eliminating an invasive procedure such as biopsy or endoscopic retrograde cholangiopancreatography (ERCP). Aim: To identify demographic or clinical characteristics of a post-LTx population that predict occurrence of acute cellular rejection (ACR) versus biliary tract pathology. A secondary aim was to describe ERCP findings in this population. Methods: The Washington University Adult Liver Transplant Database was retrospectively reviewed to identify patients undergoing ECRP for elevated LFTs between 2003 and 2007 and liver biopsy within 3 months. Liver biopsy results were reviewed for ACR. Demographic variables were tabulated and compared between subjects with and without ACR using unpaired t-tests. Results of ERCP were tabulated for those with and without ACR Results: 36 patients underwent ERCP after LTx for elevated LFTs and underwent liver biopsy within 3 months. 36% had ACR (ACR group, n=13) and 64% had no ACR (no ACR group, n=23) with alternative histology on biopsy. Among demographic variables: age, gender, and indication for transplant were not significantly different. No patient was transplanted for Primary Sclerosing Cholangitis and primary duct to duct anastomosis without use of T-tube was performed in 21 of 23 no ACR (85%) and 11 of 13 ACR patients (85%). Time from transplant to ERCP was 3.27 ± 0.55 months (no ACR) vs. 2.64 ± 0.76 (ACR), p=0.497. Laboratory profile on presentation for ERCP was similar (Table 1). Pre-ERCP noninvasive imaging modality showed extrahepatic ductal dilatation (>8mm on ultrasound, CT, or MRI) in 6/23 (26%) no ACR patients and 6/13 ACR patients (46%). ERCP findings in the no ACR group included: 16 (70%) anastomotic strictures, 2 (9%) bile leaks, 2 (9%) sludge, 2 normal (9%), and 1 choledocholithiasis (3%). ERCP findings in the ACR group included: 11 (85%) anastomotic stricture and 2 (15%) bile leaks. Conclusions: In a cohort of post LTx patients with increased LFTs within 4 months of surgery, no significant differences in laboratory parameters or non-invasive imaging reliably differentiated ACR from biliary tract pathology. Importantly, in patients with biopsy proven ACR, coexisting biliary pathology was demonstrated on ERCP. Clinicians should have a low threshold to perform both ERCP and liver biopsy in the post-operative LTx period, as the occurrence of ACR and biliary tract pathology often occur simultaneously. Labarotory Parameters Between No ACR and ACR Groups

Data presented as % (95% confidence interval) Mo1045 De novo Malignancies After Orthotopic Liver Transplantation (OLT) Do Not Compromise the Outcome Julius Spicak, Jan Sperl, Milos Adamec, Pavel Trunecka, Sona Frankova Introduction: Solid organ transplant recipients are at a high risk to develop malignancies, constituing generally a major cause of late death after transplantation. The aim of our study was to assess the impact of the malignancies on the outcome of our OLT program. Patients and methods: We retrospectively reviewed a historic cohort of 699 adult liver transplant recipients from cadaveric donors performed from 1994 to 2010. Patients underwent a screening program consisting of yearly skin examination, chest X-ray, abdominal ultrasound, mammography, gynecology exam and colonoscopy tailored according to individual risk. Results: Among the 699 patients after orthotopic liver transplantation (OLT) with a mean follow-up of 74 months (1-192 months), 67 patients developed de novo malignancy (overal incidence of 9,5%). The mean time from OLT to tumor diagnosis was 55 months (1-149 months). Non-melanoma skin cancer appeared in 17 patients, postransplant lymfoproliferative disorder was diagnosed in 14 patients, head and neck cancer in 10 patients, lung cancer in 7, 6 women presented with cervical cancer and 4 with breast cancer. Thirty-four tumors were diagnosed during regular screening examinations. Twenty patients with de novo malignancy died, from whom only 12 patients (1,7% of all recipient) consequently to malignant disease progression. None of the patients who were diagnosed through a screening procedure died. Five patients died of head and neck cancer, 4 died due to lymphoma, 2 patient due to lung cancer a 1 who had pancreatic cancer. Conclusion: OLT recipients are

AASLD Abstracts

values expressed as mean units +/- SEM

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