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Indian J Crit Care Med. 2010 Apr-Jun; 14(2): 106–107.
PMCID: PMC2936732

Critical care issues in liver transplantation

Dear Editor,

I read with keen interest the review by Gopal et al. in the journal.[1] I am grateful for their great review. However, I would like to make some comments.

First, there are recent reports that demonstrate the superiority of quadruple or triple immunosupression versus traditional approach in terms of efficacy and safety.[2] This positive outcome is mainly related to the use of tacrolimus as the cornerstone within the immunosuppressive treatment.[3]

Second, in areas where Chagas disease is endemic, with migratory flows, reactivation should be considered when the donor has Latin-American origin, nowadays this complication has been recognized in USA and Europe.[45]

Third, the authors missed the important issue that transplant recipients may develop severe infection with Streptococcus pneumoniae, even in the early postransplant period.[6] Vaccination has been recommended in heart, renal and liver recipients. Available vaccines are the 23-valent polysaccharide and the hepta- and decavalent protein conjugate.[7]


1. Gopal PB, Kapoor D, Raya R, Subrahmanyam M, Juneja D, Sukanya B. Critical care issues in adult liver transplantation. Indian J Crit Care Med. 2009;13:113–9. [PMC free article] [PubMed]
2. Lu AW, Zheng SS, Wu J, Liang TB, Wang WL, Shen Y, et al. Dual, triple, and quadruple oral tacrolimus-based immunosuppression regimens after orthotopic liver transplantation: a randomised comparative study of regimens. Zhonghua Yi Xue Za Zhi. 2006;86:3389–92. [PubMed]
3. Jonas S, Neuhaus R, Junge G, Klupp J, Theruvat T, Langrehr JM, et al. Primary immunosuppression with tacrolimus after liver transplantation: 12-years follow-up. Int Immunopharmacol. 2005;5:125–8. [PubMed]
4. Souza FF, Castro-E-Silva O, Marin Neto JA, Sankarankutty AK, Teixeira AC, Martinelli AL, et al. Acute chagasic myocardiopathy after orthotopic liver transplantation with donor and recipient serologically negative for Trypanosoma cruzi: a case report. Transplant Proc. 2008;40:875–8. [PubMed]
5. D’Albuquerque LA, Gonzalez AM, Filho HL, Copstein JL, Larrea FI, Mansero JM, et al. Liver transplantation from deceased donors serologically positive for Chagas disease. Am J Transplant. 2007;7:680–4. [PubMed]
6. Engelhard D, Cordonnier C, Shaw PJ, Parkalli T, Guenther C, Martino R, et al. Early and late invasive pneumococcal infection following stem cell transplantation: a European Bone Marrow Transplantation survey. Br J Haematol. 2002;117:444–50. [PubMed]
7. Duchini A, Goss JA, Karpen S, Pockros PJ. Vaccinations for Adult Solid-Organ Transplant Recipients: Current Recommendations and Protocols. Clin Microbiol Rev. 2003;16:357–64. [PMC free article] [PubMed]

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