title: Biliary casts after orthotopic liver transplantation: clinical factors, treatment, biochemical analysis.
abstract: OBJECTIVE
  Biliary casts develop in up to 18% of liver transplant recipients. Casts are associated with morbidity, graft failure, need for retransplantation, and mortality. Proposed etiological mechanisms include acute cellular rejection, ischemia, infection, and biliary obstruction. We aimed to identify clinical features associated with biliary cast formation, review treatments, and analyze the biochemical composition of casts at a single, large, liver transplant center.
  
  
  METHODS
  Patient records were reviewed retrospectively to identify patients who developed casts. Data were collected with attention to ischemia, rejection, obstruction, infection, immunosuppression, postoperative biliary drain use, and cast-directed management, and were compared with data from controls. Cast specimens, retrieved at cholangiography, were analyzed with chromatography techniques.
  
  
  RESULTS
  Ischemic factors were noted in 70% (7/10) of cast patients versus 15% (6/40) of controls (OR = 13.2; 95% CI = 2.7-66.0; p = 0.001). Biliary strictures were present in 50% of cast patients versus 10% of controls (OR = 9.0; 95% CI = 1.8-45.2; p = 0.01). Differences in cold ischemia time, acute cellular rejection, cyclosporin use, infection, and postoperative biliary drain use were not significant. Casts were successfully treated by endoscopic and percutaneous methods in 60% of patients. One patient died of cast-related complications (mortality 10%). Four casts were in satisfactory condition for biochemical analysis. Bilirubin was the main component ( approximately 10-50%). Bile acid synthesis products and cholesterol comprised smaller percentages, and protein comprised only 5-10%.
  
  
  CONCLUSIONS
  Biliary casts are more likely to develop in the setting of hepatic ischemia and biliary strictures. Endoscopic and percutaneous cast extraction might achieve favorable results and should be attempted before surgical therapy.
authors.affiliation: Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
authors.forename: Janak N
authors.initials: JN
authors.lastname: Shah
authors.forename: W Geoffrey
authors.initials: WG
authors.lastname: Haigh
authors.forename: Sum P
authors.initials: SP
authors.lastname: Lee
authors.forename: Michael R
authors.initials: MR
authors.lastname: Lucey
authors.forename: Colleen M
authors.initials: CM
authors.lastname: Brensinger
authors.forename: Michael L
authors.initials: ML
authors.lastname: Kochman
authors.forename: William B
authors.initials: WB
authors.lastname: Long
authors.forename: Kim
authors.initials: K
authors.lastname: Olthoff
authors.forename: Abraham
authors.initials: A
authors.lastname: Shaked
authors.forename: Gregory G
authors.initials: GG
authors.lastname: Ginsberg
mesh_terms: D000328:Adult; D001649:Bile Duct Diseases / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D001652:Bile Ducts / Q000503:physiopathology; D016022:Case-Control Studies; D003251:Constriction, Pathologic / Q000150:complications; D005260:Female; D006801:Humans; D007511:Ischemia / Q000150:complications*; D008099:Liver / Q000098:blood supply*; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D019737:Transplants / Q000009:adverse effects*