Barbara Coco, Coordinator

Daniela Dalla Gasperina

Andrea Gori

Manuela Merli

Massimo Siciliano

Marcello Tavio

PRE-OLT INFECTIOUS WORK UP

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

d) Pre-emptive therapy

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)

•Palermo ISMET (Gridelli - Volpes)

Screening for TB and Latent TB

Data from 15 out of the 22 Italian Liver Transplant Centres

Screening for HBV infection

Data from 15 out of the 22 Italian Liver Transplant Centres

Screening for CMV infection

Data from 15 out of the 22 Italian Liver Transplant Centres

Virological screening (except HBV and CMV)

Data from 15 out of the 22 Italian Liver Transplant Centres

Screening for “foci”

Data from 15 out of the 22 Italian Liver Transplant Centres

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

PRE-OLT screening for infections

Data from 15 out of the 22 Italian Liver Transplant Centres

PRE-OLT screening for infections

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 schedule post-OLT

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)

Holty JE et al, Liver Transpl 2009; 15: 894

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).

Holty JE et al, Liver Transpl 2009; 15: 894

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

Data from 15 out of the 22 Italian Liver Transplant Centres

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

PRE-OLT Prophylaxis of infections

Prophylaxis for fungal infections

(except acute liver failure)

Data from 15 out of the 22 Italian Liver Transplant Centres

Pre-OLT Vaccinations

Data from 15 out of the 22 Italian Liver Transplant Centres

INFECTIOUS SURVEILLANCE in liver

transplant candidates in WAITING LIST

Results from 15 out of the 22 Italian Liver Transplant Centres

no

80%

yes

20%

Virological screen every 6 m

Surveillance of infectious in liver transplant

candidates in waiting list

HIV1-2Ab Ifneg Every6months

HBsAg,HBsAb,HBcAb

Ifpositive HBVDNAevery3months

Ifvaccinated HBsAbiflowAbtiter�vaccine

boost,every6months

CMVAb(IgG) Ifneg Every6months

HSV1-2Ab(IgG) Ifneg Every6months

VZVAb(IgG) Ifneg Every6months

EBVAb(EBNA-Ab,VCAIgG-IgM) ifVCA-IgGneg Every6months

ToxoplasmaAb(IgG) Ifneg Every6months

Othertestaccordingtoclinicalindications

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

Spazio Congressi