CORRESPONDENCE

Is Absolute Lymphocyte Count a Good Prognostic Predictor in Recurrence of Hepatocellular Carcinoma After Liver Transplantation? e read with great interest the report by Nagai et al. (1), which was recently published in Transplantation. The authors proposed peritransplant absolutely lymphocyte count (ALC) is a strong predictor for recurrence of hepatocellular carcinoma (HCC) after liver transplantation. In their investigation, peritransplant persistent lymphopenia was associated with increased risk of recurrence after liver transplantation. However, we suggested some issues should be clarified. Hepatocellular carcinoma frequently arises in the setting of cirrhosis. Patients with underlying cirrhosis may have hypersplenism, which may cause pancytopenia. In this situation, the pretransplant ALC of patients with HCC may be in a very low level. Moreover, for patients with severe hypersplenism or patients received a small for size graft during living donor liver transplantation, we may perform simultaneous liver transplantation and splenectomy (2, 3). Compared with pretransplant situation, the white blood cell counts, including ALC, will increase after splenectomy. However, Nagai et al. (1) did not mention whether hypersplenism and/or splenectomy are independent risk factors associated with peritransplant lymphopenia. Accordingly, the authors should explain whether their conclusion pertains to patients with HCC and hypersplenism, especially for patients who received simultaneous liver

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transplantation and splenectomy. We acknowledge that recipient’s immunization status plays a key role in overcoming HCC recurrence. In our previous study, we observed low pretransplant percentage of lymphocyte contributed to posttransplant HCC recurrence when we excluded patients with pretransplant infections (4). In our study, we used percentage of lymphocyte, but not ALC, because of both pancytopenia due to hypersplenism and white blood cell increasing after splenectomy could significantly impact the ALC but have less influence on percentage of lymphocyte. Infection is a common complication after liver transplantation, which could also affect the ALC of patients (5). For instance, the ALC of patients will significantly increase when patients experience postoperative virus infection after liver transplantation. However, this ‘‘high’’ level of ALC does not really mean that patients have a strong antitumor and immunomodulation abilities. Accordingly, the authors should exclude patients had peritransplant infections in the present study. Chuan Li1 Tian-Fu Wen1 Lu-Nan Yan1 1

Department of Liver Surgery and Liver Transplantation Center West China Hospital of Sichuan University Chengdu, China

The authors declare no funding or conflicts of interest. Address correspondence to: Tian-Fu Wen M.D., Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu (610041), China. E-mail: [email protected] Received 3 December 2013. Accepted 20 December 2013. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/9706-e33 DOI: 10.1097/TP.0000000000000036

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Nagai S, Abouljoud MS, Kazimi M, et al. Peritransplant lymphopenia is a novel prognostic factor in recurrence of hepatocellular carcinoma after liver transplantation. Transplantation 2013. DOI: 10.1097/ 01.TP.0000437426.15890.1d. Li DW, Du CY, Fan B, et al. Impact of simultaneous splenectomy and orthotopic liver transplantation in patients with endstage liver diseases and splenic hyperfunction. Hepatobiliary Pancreat Dis Int 2012; 11: 489. Yoshizumi T, Taketomi A, Soejima Y, et al. The beneficial role of simultaneous splenectomy in living donor liver transplantation in patients with small-for-size graft. Transpl Int 2008; 21: 833. Li C, Wen TF, Yan LN, et al. Scoring selection criteria including total tumour volume and pretransplant percentage of lymphocytes to predict recurrence of hepatocellular carcinoma after liver transplantation. PLoS One 2013; 8: e72235. Lee SO, Kang SH, Abdel-Massih RC, et al. Spectrum of early-onset and late-onset bacteremias after liver transplantation: implications for management. Liver Transpl 2011; 17: 733.

The Authors’ Reply e appreciate the comments of Li et al. as there is increasing interest in neutrophils and lymphocytes as novel predictive factors for the recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) (1Y3).

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Transplantation

However, the underlying etiologies have yet to be elucidated. We agree that it is quite important to investigate its biological rationale and its clinical implications. Absolute lymphocyte counts (ALCs) are affected by a variety of factors such

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as severity of liver disease (model of end stage liver disease [MELD] score), surgical stress, and immunosuppression including rabbit anti-thymocyte globulin, which was demonstrated in our study (1). We also recognize that www.transplantjournal.com

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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Is absolute lymphocyte count a good prognostic predictor in recurrence of hepatocellular carcinoma after liver transplantation?

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