Clostridium difficile-associated diarrhea after living donor liver transplantation

Table 1 Background of the 242 patients

Age (yr)	51 (18-67)1
Gender, male/female	132/110
Underlying Liver disease
Hepatitis C	66
Primary biliary cirrhosis	52
Hepatitis B	35
Fulminant hepatitis	27
Biliary atresia	14
Autoimmune hepatitis	9
Primary sclerosing cholangitis	9
Metabolic disease	9
Cryptogenic cirrhosis	6
Alcoholic cirrhosis	4
Other	11
Hepatocellular carcinoma	68
Child-Pugh score	10 (5-10)1
MELD score	13 (-3-48)1

¹Median and range. MELD: model for end stage liver diseases.

Table 2 Characteristic of patients with postoperative CDAD in 11 patients

Onset of CDAD (postoperative day)	19 (5-54)1
Symptoms other than diarrhea
Fever	9
Abdominal pain	3
Duration	11 (5-43)1
Treatment
Oral vancomycin	8
Conservative management	3
Recurrence	2
Use of antibiotics one month prior to LDLT	9

¹Median and range. CDAD: clostridium difficile associated diarrhea.

Table 3 Microbiological data of patients with postoperative CDAD and asymptomatic carriage of C. difficile

	Positive microbiological test
	Culture	ICA for toxin A	Latex test3	Total
CDAD1	5	10	1	11
Asymptomatic carriage2	16	1	0	16
Total	21	11	1	27

¹C. difficile was detected both by stool culture and ICA for toxin A in 4 patients, and both by stool culture and latex agglutination test for C. difficile protein (glutamate dehydrogenase) in one patient;

²C. difficile was detected both by stool culture and ICA for toxin A in one patient;

³Detection for C. difficile protein (glutamate dehydrogenase). ICA: immunochromatography assay; C. difficile: Clostridium difficile; CDAD: Clostridium difficile associated diarrhea.

Table 4 Association between postoperative CDAD and preoperative variables

Variables	CDAD (-)(n = 231)	CDAD (+)(n = 11)	P
Age (yr)	51 (18-67)1	55 (26-64)1
< 55	161	5	0.1
≥ 55	70	6
Gender, male/female	123/108	9/2	0.07
Underlying liver disease
Hepatitis C	62	4
PBC	49	3
Hepatitis B	33	2
Fulminant hepatitis	26	1
Biliary atresia	14	0
Autoimmune hepatitis	9	0
PSC	9	0
Metabolic disease	8	1
Cryptogenic cirrhosis	6	0
Alcoholic cirrhosis	4	0
Other	11	0
Hepatocellular carcinoma	63	5	0.3
Child-Pugh score	10 (5-14)1	9 (7-14)1
< 10	107	6	0.76
≥ 10	124	5
MELD score	13.3 (-3.4-48.2)1	15.9 (5.3-33.9)1
< 20	153	6	0.52
≥ 20	78	5
Ascites	110	6	0.76
Use of Diuretics	123	8	0.23
Encephalopathy	39	3	0.41
Preoperative apheresis	50	3	0.71
PT-INR	1.61 (0.89-7.48)1	1.56 (1.33-2.73)1
< 2.0	187	8	0.45
≥ 2.0	44	3
Serum bilirubin (mg/dL)	4.4 (0.3-40.0)1	5.1 (0.8-17.9)1
< 10.0	163	9	0.52
≥ 10.0	68	2
Serum albumin (mg/dL)	2.9 (1.5-4.4)1	2.6 (1.8-3.3)1
< 2.5	37	194	0.03
≥ 2.5	5	6
Serum creatinine (mg/dL)	0.69 (0.2-7.7)1	1.02 (0.4-4.4)1
< 1.5		6	0.0003
≥ 1.5	219	5
	12
Use of steroid	28	1	1
Preoperative antibiotics use	58	3	1
Beta lactam	45	3	0.46
Second or third generation cepharosporins	17	0	1
Glycopeptide	3	2	0.02
Fluroquinolone	15	2	0.18
Aminoglycoside	5	1	0.25
Other	4	1	0.21
History of abdominal surgery	108	5	1
Diabetes mellitus	29	0	0.37
Preoperative ICU stay			0.35
Yes	25	2
No	206	9

¹Median and range. PBC: primary biliary cirrhosis; PSC: primary sclerosing cholangitis; MELD: model for end stage liver diseases; PT-INR: the international normalized ratio of prothrombin time; ICU: intensive care unit.

Table 5 Association between postoperative CDAD and surgical and postoperative variables

Variables	CDAD (-)(n = 231)	CDAD (+)(n = 11)	P
Surgical variables
Operation time (h)	15.3 (10.7-40.1)1	14.9 (12.5-19.8)1
< 16	143	8	0.54
≥ 16	88	3
Blood loss (mL)	5150 (830-55 165)1	5155 (1555-17 475)1
< 10 000	191	9	1
≥ 10 000	40	2
Blood transfusion (mL)	7000 (900-46 120)1	8640 (2860-14 800)1
< 10 000	169	8	1
≥ 10 000	62	3
GV/SLV ratio (%)	46 (25-88)1	46 (36-67)1	0.75
< 50	152	8
≥ 50	79	3
Duct to duct biliary reconstruction	160	9	0.51
Postoperative variables
Postoperative ICU stay (d)	5 (3-242)1	6 (3-22)1
< 10	205	10	1
≥ 10	26	1
Postoperative apheresis	28	3	0.15
Reoperation after LDLT	86	2	0.37
Acute rejection	66	2	0.73
Cytomegalovirus infection	105	3	0.35
Variation number of antibiotics administered after LDLT	5 (3-9)1	5 (3-8)1	1
< 6	159	72
≥ 6	72	3

¹Median and range. GV: graft volume; SLV: standard liver volume; ICU: intensive care unit; LDLT: living donor liver transplantation.

Table 6 Multivariate analysis of risk factors for CDAD after LDLT

Variable	Odds ratio (95% CI)	P
Age ≥ 55	3.56 (0.92-15.0)	0.07
Male gender	4.56 (1.02-33.3)	0.05
Serum creatinine (mg/dL) ≥ 1.5	15.99 (3.85-68.3)	0.0003