PACE Hospitals team thwarts Klebsiella Infection after Liver Transplantation

Pace Hospitals' transplant team successfully performed a deceased donor liver transplant for a 52-year-old female patient with decompensated chronic liver disease. Post operation she developed Klebsiella pneumoniae infection but the timely intervention by PACE team cured the disease.

A female patient (Lakshmi) of 52 years is a known case of decompensated chronic liver disease and was presented to the hospital with complaints of jaundice and intermittent fever.

Medical History

Delving deeper, it was understood that the patient had been experiencing jaundice for 4 months, which was frequently associated with intermittent fever. Understanding the severity of the situation, the patient was asked to get admitted to the PACE Hospitals for further treatment.

Diagnosis

Upon being admitted to PACE Hospitals and understanding the history and physical examination, the patient was subjected to imaging tests and liver biopsy, among other investigations. The biopsy provided impressions of distorted hepatic parenchymal architecture with complete nodule formation. The fibrous septae surrounding the nodules depicted inflammatory cells. All these depictions are consistent with: 

Liver cirrhosis of the liver (possibly arising from non-alcoholic steatohepatitis) with COPD

Treatment

The team of liver transplant doctors, including Dr. CH Madhusudhan, Dr. Ravula Phani Krishna, Dr. Govind Verma, and Dr. Suresh Kumar S, asserted that a liver transplant was the only way to save the patient.

The patient was kept on multiple lifesaving supports. Efforts were made to obtain a liver from donors after the party was counseled about the urgency of a liver transplant. Promptly, she was registered to Jeevandan Cadaver Transplantation Programme, Telangana, since there hadn't been any suitable family members who were able to donate a part of their liver.

Thanks to the efforts of Jeevandan, they could obtain a liver from a cadaver. With necessary investigations done & clearances obtained, which included pre-anesthesia checkup, the patient underwent deceased donor liver transplantation (DDLT). The procedure was supervised by the liver transplant surgeon Dr. CH Madhusudhan, and it was accomplished devoid of any complications. 

The aftermath

The post-operative period was uneventful which can be evidenced by the results of thromboelastography which provided an overall assessment of clot formation, strength, and longevity of coagulation components. The coagulation components from thromboelestography were well within the normal range.

Development of fever after the transplantation prompted the surgeons for a procalcitonine test. Procalcitonine is a biomarker, the pro-peptide precursor of calcitonin, which is mainly produced by the thyroid gland, but the levels are usually very low as it is quickly converted to calcitonin.

It is believed that in the setting of bacterial infection, peripheral blood monocytes, the liver, and other tissues release procalcitonin in response to cytokines such as tumor necrosis factor, interleukin-6, and granulocyte colony-stimulating factor and endotoxin from the bacterial cell wall. Cytokines and endotoxin are also believed to halt the conversion from procalcitonine to calcitonin, thus increasing the concentrations of procalcitonine. Although procalcitonin levels were high, since no bacterial cultures were seen in either blood or drain fluid, only symptomatic treatment was provided to cure fever rather than administering antibiotics.

In post operative period gradually, the patient developed cough with expectoration which requiring prolonged oxygen support. The pulmonologist was contacted who opinionated for a sputum culture. It was revealed that Klebsiella pneumonia was the source of infection. Promptly an antibiotic course was started to counter the infection.

The necessary medicines, immunosuppressives, antibiotics, proton pump inhibitors, multivitamins, antiemetics, analgesics, antipyretics & other supportive care were given along with the counselling. With the gradual development of liver enzymes in the patient’s body, the immunosuppression doses adjusted accordingly.

Once the patient achieved hemodynamic stabilisation, she was discharged with the necessary medications and advice for follow-up.

A short colloquy on Klebsiella pneumoniae infections after liver transplantation

Klebsiella pneumonia has been a known human pathogen since the late nineteenth century when it was first isolated by Edwin Klebs.

Although Klebsiella is most often thought of as a nosocomial pathogen (disease originating from a hospital), it can also be a cause of serious infection acquired outside the hospital. It is estimated to be responsible for 6-8.6% of community acquired pneumonias. Humans are the primary reservoir for Klebsiella, although these organisms may also be found in soil and water. Klebsiella is a common inhabitant of the upper respiratory tract and the bowel.

While the nasopharyngeal infection of Klebsiella pneumonia in the general population could range from 1-6%, it is exponentially increased in patients who are at an increased risk.

There had been a recent increase in the share of Klebsiella pneumoniae. It could be attributed to the evolution of multidrug-resistant strains that produce antibiotic resistance to more than one antibiotic. As a result, the treatment of infections with these bacteria has limited therapeutic options. K. pneumoniae is one of the most common species isolated from infections in the bone marrow and solid organ transplant patients. In many case-studies the source of blood infection of K. pneumoniae seen in liver transplantation was due to the contaminated organ preservative fluid.

The most common mortality reasons during 30–180 days after liver transplantation are graft infections. The frequency of contamination of organ preservation fluids varies from 9.5-98.4%.

Pneumonia, tertiary peritonitis, and surgical site infections have been reported as complications of K. pneumoniae infections in liver transplant recipients.

Department of Liver Transplant