title: Liver graft failure and hyperbilirubinemia in liver transplantation recipients after Clostridium difficile infection.
abstract: BACKGROUND
  Liver transplant recipients are at high risk for Clostridium difficile infection. We have recently encountered multiple cases of CDI in our liver transplant recipients and for some of them it led to severe hyperbilirubinemia, liver failure, and even death. Our goals are to report our experience and analyze the factors that contributed to unfavorable outcomes.
  
  
  METHODS
  All liver transplant recipients diagnosed with CDI between December 1, 2007, and January 30, 2009, were included and retrospectively reviewed.
  
  
  RESULTS
  Twenty-four patients were identified, 14 men and 10 women. Fourteen patients experienced hyperbilirubinemia after the infection and 7 progressed to liver failure. Pre-CDI biopsy-proven liver abnormality, use of extended-criteria donors (ECDs) and a donor risk index (DRI) greater than 1.9 were associated with a higher risk of graft failure (P<.05). Hepatitis C, inpatient versus outpatient diagnosis, and a donor age greater than 50 years were not associated with a higher risk of graft failure. Use of ECDs and timing of the infection at more than 1 month but less than 1.5 years posttransplant were also associated with higher chances of sustained hyperbilirubinemia (P<.05).
  
  
  CONCLUSIONS
  CDI in liver transplant patients can be very serious and may lead to sustained hyperbilirubinemia or graft failure. Marginal grafts are more susceptible to decompensate after such an infection than standard criteria grafts; moreover, already abnormal grafts do not tolerate this infection well and decompensate to complete failure in 85% of the cases.
authors.affiliation: Transplant Center of Excellence, Westchester Medical Center, Valhalla, New York 10595, USA. rochonc@wcmc.com
authors.forename: C
authors.initials: C
authors.lastname: Rochon
authors.forename: A
authors.initials: A
authors.lastname: Kardashian
authors.forename: B
authors.initials: B
authors.lastname: Mahadevappa
authors.forename: G
authors.initials: G
authors.lastname: Gunasekaran
authors.forename: J
authors.initials: J
authors.lastname: Sharma
authors.forename: P
authors.initials: P
authors.lastname: Sheiner
mesh_terms: D016009:Chi-Square Distribution; D016360:Clostridioides difficile / Q000472:pathogenicity*; D004761:Enterocolitis, Pseudomembranous / Q000150:complications / Q000382:microbiology* / Q000401:mortality; D005260:Female; D006801:Humans; D006932:Hyperbilirubinemia / Q000382:microbiology* / Q000401:mortality; D053208:Kaplan-Meier Estimate; D017093:Liver Failure / Q000382:microbiology* / Q000401:mortality; D016031:Liver Transplantation / Q000009:adverse effects* / Q000401:mortality; D008297:Male; D009518:New York; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome