Robert S. Rahimi M.D.

Alsahhar, J. S., D. Hansen, J. Page, U. Sandkovsky, S. Burdick, J. F. Trotter and R. S. Rahimi (2019). “An Atypical Biliary Fistula in a Liver Transplant Recipient.” Liver Transpl 25(4): 664-666.

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Biliary complications affect up to a third of patients after liver transplantation with bile leaks accounting for the majority of these complications. In this patient, we believe the fistula occurred as a complication of the second pericardiocentesis (likely intrahepatic puncture) because the initial pericardiocentesis resulted in drainage of bloody fluid. The exact etiology of the initial pericardial fluid is unknown despite the extensive infectious and rheumatologic workup. To our knowledge, this is the first case of a pericardiobiliary fistula reported as a complication of pericardiocentesis in a liver transplant recipient. There are 4 cases of pericardiobiliary fistula in the literature, 1 of which occurred after a liver biopsy, after penetrating abdominal trauma, and the last in the setting of an encroaching hydatid cyst. Our approach to managing this complication was with conservative measures using biliary stents to promote prograde biliary drainage along with infection control using antibiotics. This preferential flow of bile by using biliary stents promoted closure of the fistula and the prevention of surgery in a patient with a recent abdominal manipulation and medical instability. As the first reported case of pericardiobiliary fistula in a simultaneous liver‐kidney transplant recipient from pericardiocentesis, where no treatment or management has been reported, ERCP with stent placement can be considered for decompression. (Excerpt from text, p. 666; no abstract available.).

Alsahhar, J. S., D. Hansen, J. Page, U. Sandkovsky, S. Burdick, J. Trotter and R. S. Rahimi (2019). “An Atypical Biliary Fistula In A Liver Transplant Recipient.” Liver Transpl Jan 28. [Epub ahead of print].

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A 55-years-old Caucasian male presented with chest pain, dyspnea and hypotension four-months after simultaneous liver and kidney transplantation. His post-transplant course was complicated with only one episode of acute cellular rejection one month prior to presentation, successfully treated with steroids. His immunosuppression consisted of tacrolimus and mycophenolic acid. Transthoracic echocardiogram (TTE) in the emergency room showed a large pericardial effusion and tamponade physiology. Emergent pericardiocentesis removed 560 mL of bloody fluid (red blood cell count of 6.74 million) and a pericardial drain was placed. Fluid studies including bacterial, fungal, and acid-fast bacilli cultures, viral PCR (herpes simplex, adenovirus, human herpesvirus 6, cytomegalovirus), histoplasma, coccidioides antigens, and cytology were negative.

Soape, M. P., R. S. Rahimi, C. W. Spak and J. F. Trotter (2018). “Case Report of a Rare Presentation of Isolated Cytomegalovirus Hepatitis After Renal Transplantation.” Prog Transplant 28(3): 296-298.

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Although CMV infection and disease are recognized complications of renal transplant, CMV hepatitis is distinctly uncommon. A recent study showed kidney transplant recipients receiving CMV prophylaxis, and CMV disease incidence was 19.2%. Thus, CMV disease was not surprising in this case, given the multiple risk factors. Thymoglobulin induction alone increased the risk of CMV infection by 4 times. With these risk factors, the transplanted kidney was uncharacteristically spared. Our case reemphasizes the significance for CMV prophylaxis, which was not optimized with our patient, and stopping valganciclovir certainly contributed to disease progression. Prophylaxis is defined as administration of antiviral agents at the onset of the transplantation. Our institutional protocol outlines the prophylactic use of valganciclovir in all liver and kidney transplantations. Another form of preventive CMV therapy is preemptive, which involves periodic monitoring of viremia to allow for prompt treatment. It has been shown that any form of preventive treatment for any CMV serology status has decreased CMV-associated mortality, all-cause mortality, and clinically important diseases due to opportunistic infections. To our knowledge, it has been 20 years since an isolated CMV hepatitis in renal transplantation was reported in the United States and none since the advent of current CMV prophylaxis regimens. In conclusion, this case illustrates the importance of CMV prophylaxis while presenting a rare case of isolated CMV hepatitis. (Excerpt from text, p. 298; no abstract available.)

Goldberg, D. S., C. Levy, K. Yimam, S. C. Gordon, L. Forman, E. Verna, L. Yu, R. Rahimi, K. Schwarz, B. Eksteen, D. Pratt, J. L. Boyer, D. Assis and C. Bowlus (2018). “Primary Sclerosing Cholangitis Is Not Rare Among Blacks in a Multicenter North American Consortium.” Clin Gastroenterol Hepatol 16(4): 591-593.

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In this multicenter North American consortium, we show that PSC is not rare among black patients. The proportional representation of PSC in black patients compared with each center’s MSA was variable across the 13 centers. Thus, although these data do not show that PSC is as common in black vs white patients, PSC in blacks is not as rare as what would be interpreted based on published data. This suggests that existing literature may reflect selection bias related to the demographics of the underlying population included in these studies, rather than a clinical disease largely restricted to white patients. The existing literature bias could prevent adequate evaluation and diagnosis of PSC in non-white patients by practicing clinicians. We were not able to compare the clinical characteristics of PSC in black vs white patients at each center, but have highlighted potential differences of PSC in black patients compared with published data of solely white patients: (1) 58.8% had inflammatory bowel disease, compared with 75% to 80% in white patients8; (2) 52.2% had isolated intrahepatic bile duct involvement (diagnosed using cholangiograms per American Association for the Study of Liver Diseases guidelines), compared with 20% to 30% in white patients; and (3) 51.3% were male, compared with 60% to 65% in whites. The time from diagnosis to transplant or death was similar to data from published cohort studies of white patients with PSC from tertiary care centers. We have provided evidence that PSC occurs in black patients and, in this cohort, has unique clinical features. The study had limitations because there was no direct comparator group or systematic evaluation of all included patients, thus validation of these findings is required to compare white vs black patients using detailed clinical data. This may lead to new insights into PSC in general and also particular subphenotypes. Ultimately, these results highlight the need for caution when generalizing findings in rare diseases derived from demographically homogenous groups, and the importance of conducting epidemiologic studies of diverse populations that represent the demographics of the US population. (Excerpt from text, p. 592; no abstract available.)

Goldberg, D., C. Levy, K. Yimam, S. Gordon, L. Forman, E. Verna, L. Yu, R. Rahimi, K. Schwarz, B. Eksteen, D. Pratt, T. Boyer, D. Assis and C. Bowlus (2017). “Primary sclerosing cholangitis is not rare among blacks in a multi-center north american consortium.” Clin Gastroenterol Hepatol: 1-9.

Full text of this article.

In this multi-center North American consortium, we demonstrate that PSC is not rare among black patients. The proportional representation of PSC in black patients compared to each center’s MSA was variable across the 13 centers. Thus although these data do not demonstrate that PSC is as common in black and white patients, PSC in blacks is not as rare as what would be interpreted based on published data. This suggests that existing literature may reflect selection bias related to the demographics of the underlying population from where these studies emerge, rather than a clinical disease largely restricted to white patients. The existing literature bias could prevent adequate evaluation and diagnosis of PSC in non-white patients by practicing clinicians. We were not able to compare the clinical characteristics of PSC in black versus white patients at each center, but have highlighted potential differences of PSC in black patients compared to published data of solely white patients: 1) 58.8% had IBD, compared to 75-80% in white patients; 8 2) 52.2% had isolated intra-hepatic bile duct involvement (diagnosed using cholangiograms per AASLD guidelines), compared to 20-30% in white patients; and 3) 51.3% were male, compared to 60-65% in whites.1 The time from diagnosis to transplant or death was similar to data from published cohort studies of white patients with PSC from tertiary care centers. 1,2,7