PRE-OLT INFECTIOUS WORK UP

Transcription

1 PRE-OLT INFECTIOUS WORK UP Barbara Coco, Coordinator Daniela Dalla Gasperina Andrea Gori Manuela Merli Massimo Siciliano Marcello Tavio

2 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.

3 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

4 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

5 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)

6 Screening for TB andlatent TB

7 Screening for HBV infection

8 Screening for CMV infection

9 Virological screening (except HBV and CMV)

10 Screening for foci

11 Screening for other bacteria, parasites and fungal infections

12 PRE-OLT screening for infections

13 PRE-OLT screening for infections Datafrom 15 out of the 22 Italian Liver Transplant Centres

14 PRE-OLT Prophylaxis of infections Prophylaxis for Latent TB: 40% Prophylaxis schedule post-olt 13% 13% 13% 6% INH 6-9 m INH for 3 m INH for 12 m L-flox for 9 m Not specify

15 PRE-OLT Prophylaxis of infections Prophylaxis of Tubercolosis Infection 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) HoltyJEetal,LiverTranspl2009;15:894

16 PRE-OLT Prophylaxis of infections Prophylaxis of Tubercolosis Infection: When? 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

17 Strategy adopted to control CMV: 73% * Main difference in CMV-DNA thershold 20% 7% pre-emptive ther prophylasis none

18 Strategy adopted to control de novo HBV infection: pre-olt Vaccination 80% 20% No yes, in all pts

19 Prophylaxis of HBV recurrence in Liver Transplant patient and control of de novo HBV infection

20 PRE-OLT Prophylaxis of infections Antimicrobial Decontamination/ Prevention of PBS:

21 Prophylaxis for fungal infections (except acute liver failure)

22 Pre-OLT Vaccinations

23 INFECTIOUS SURVEILLANCE in liver transplant candidates in WAITING LIST Virological screen every 6 m yes 20% no 80% Results from 15 out of the 22 Italian Liver Transplant Centres

24 Surveillance of infectious in liver transplant candidates in waiting list STATMENT S PROPOSAL: During the waiting list time a periodically surveillance for infectious risk should be performed (table below) 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

25 PRE-OLT INFECTIOUS WORK UP Thanks Daniela Dalla Gasperina Andrea Gori Manuela Merli Massimo Siciliano Marcello Tavio Segreteria AISF Spazio Congressi 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)