Anita Verma

King's College Hospital NHS Foundation Trust, Londinium, England, United Kingdom

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Publications (15)30.05 Total impact

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    ABSTRACT: Extension of invasive aspergillosis to the central nervous system is associated with high mortality, in part because of poor central nervous system penetration of antifungal drugs. Voriconazole yields fungicidal drug concentrations within the central nervous system, but use of this drug is limited in liver transplant recipients because of hepatotoxicity and drug interactions. We reviewed medical records and antifungal treatment for all liver transplant recipients from 2007 to 2009 who had cerebral aspergillosis (Proven [2]; Probable [1]; Possible [1]) at week 3, 4, 6, and 12 after transplant. A 33-year-old white man underwent orthotopic liver transplant for acute liver failure that was caused by acetaminophen overdosage. Risk factors for fungal infection included major blood loss (8 L), prolonged surgery (9 h), and emergency revision transplant that was done because of nonfunctioning of the primary transplant at 48 hours. He developed postoperative aspergillus pneumonia and invasive aspergillosis of the kidneys, brain, and eye. Treatment with voriconazole and amphotericin B was successful, with moderate residual renal impairment. Voriconazole was effective and safe in the treatment of cerebral aspergillosis in this liver transplant recipient.
    Experimental and clinical transplantation : official journal of the Middle East Society for Organ Transplantation. 10/2012; 10(5):482-6.
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    ABSTRACT: Several biomarkers of penetrating infections vs. rejection in liver transplant (LT) have been suggested; however, baseline values in paediatric LT recipients have not been studied. We evaluated the baseline concentration of procalcitonin (PCT), C-reactive protein (CRP) and interleukin-6 (IL-6) in a post-LT paediatric group. We measured serum PCT, CRP and IL-6 in 58 consecutive paediatric LT recipients. Specimens were collected for group 1 (n=22) at day 1, group 2 (n=12) at day 7 post-LT and group 3 (n=24) at onset of febrile episode. Day 7 samples were obtained from patients who had no graft dysfunction or signs/symptoms of sepsis. Median values for PCT were: group 1 was 5.16μg/L (95% CI, 2.18-21.13); group 2: 0.170μg/L (95% CI, 0.15-0.36) and, group 3: 1.93μg/L (95% CI, 1.36-2.66) for bacterial and fungal infection, 0.19μg/L (95% CI, 0.10-0.48) for rejection, and 0.31μg/L (95% CI, 0.15-0.44) for viral infection. The area under the ROC (AUROC) for PCT, CRP and IL-6 in bacterial infection vs. rejection was 1.0 (P<0.0001), 0.842 (95% CI 0.686-0.998; P<0.0001) and 0.739 (95% CI 0.559-0.919; P 0.0046), respectively. PCT levels were significantly higher in bacterial and fungal infection in comparison to other inflammatory markers. PCT proved to be the most specific parameter in differentiating bacterial infection from viral infection and allograft rejection.
    Gastroentérologie Clinique et Biologique 03/2012; 36(4):365-70. · 0.80 Impact Factor
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    ABSTRACT: CNI have improved the outcome of LT. However, their inherent potential to nephrotoxic and sometimes-inadequate immunosuppressive effect has lead to the usage of newer drugs like SRL. Aim of this study was to review children who received SRL. Thirty-seven (20 women) children post-LT, median age 10.4 yr (0.8-17.4) with a minimum follow-up of six months comprised the study group. Indications for SRL were biopsy-proven resistant acute allograft rejection (n = 12), early CR (n = 12), and CNI-induced nephropathy with MMF intolerance (n = 11). In two patients, the indication was the recurrence of BSEP disease in the allograft. In patients with acute rejection, AST normalized in 10/12 patients. In patients with CR, AST normalized in 6/12 patients. Those with renal impairment showed improvement in their creatinine levels from a mean baseline of 99-56.7 μm (p = 0.03) and their mean cystatin C was 1.02 after SRL. Side effects leading to discontinuation of SRL were seen in three patients. SRL was effective in rescuing patients with acute and chronic allograft rejection and improving renal function in CNI-induced nephropathy group.
    Pediatric Transplantation 11/2011; 15(7):722-7. · 1.50 Impact Factor
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    ABSTRACT: Acute liver failure (ALF) is rare in children but carries high mortality. Infectious complications (IC) in adults are an important cause of mortality; however, there are few data in the pediatric population. The aim of the study was to determine the incidence of IC and their effects on the outcome in children with ALF. The present study is a retrospective review of the case records of children presenting with ALF to our center. All patients with ALF received antibiotics and antifungal as prophylaxis from day 1 and high-dose acyclovir was given to neonates only (stopped when herpes simplex was ruled out). Biochemical parameters, duration of ventilation and intensive care, overall hospital stay, and patient outcome were compared between patients with IC and non-IC. A total of 145 children (78 boys), median (range) age 4.22 (1 day-16 years) years, were studied. Thirty-seven of 145 (25%) patients had proven IC. The predominant infections included 14 episodes of bacteremia in 13 patients and lower respiratory tract infection and urinary tract infection in 10 and 8 patients, respectively. IC occurred in patients after a median (range) duration of 16 (0-54) days of admission. Median (range) duration of hospital stay in patients with IC was 38 (1-201) days and was significantly higher than in those without IC (10 [1-74] days), P < 0.0001. Overall mortality was 21% (31), of which 7% (11) was from the IC group and 14% (20) from the non-IC group; the difference was not statistically significant. Infections were more frequent after 2 weeks of admission. Patients with sepsis had longer hospital stays and prolonged ventilation. Invasive fungal infections were rare in pediatric ALF with adequate doses of antifungal prophylaxis.
    Journal of pediatric gastroenterology and nutrition 05/2011; 53(3):320-5. · 2.18 Impact Factor
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    ABSTRACT: Acute liver failure in neonates is rare, but carries a high mortality. Neonatal liver failure can be defined as "failure of the synthetic function of liver within 4 weeks of birth". Encephalopathy is not essential for the diagnosis. Acute liver failure in neonates differs from children with regard to aetiology and outcome. Common causes of neonatal liver failure are neonatal hemochromatosis, haematological malignancies, viral infections and liver-based metabolic defects. Early diagnosis and referral to a paediatric liver centre is recommended as liver transplantation is the only definitive treatment when supportive or a disease-specific treatment fails.
    European Journal of Pediatrics 10/2010; 170(5):573-81. · 1.91 Impact Factor
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    ABSTRACT: Hepatocyte transplantation is being used in patients with liver-based metabolic disorders and acute liver failure. Hepatocytes are isolated from unused donor liver tissue under GMP conditions. Cells must be free of microbiological contamination to be safe for human use. The experience of microbiological screening during 72 hepatocyte isolation procedures at one center is reported. Samples were taken at different stages of the process and tested using a blood culture bottle system and Gram stain. Bacterial contamination was detected in 37.5% of the UW organ preservative solutions used to transport the liver tissue to the Cell Isolation Unit. After tissue processing the contamination was reduced to 7% overall in the final hepatocyte product, irrespective of the presence of initial contamination of the transport solution. The most common organisms recovered were coagulase-negative staphylococci, a skin commensal. A total of 41 preparations of fresh or cryopreserved hepatocytes were used for cell transplantation in children with liver-based metabolic disorders without any evidence of sepsis due to infusion of hepatocytes. In conclusion, the incidence of bacterial contamination of the final product was low, confirming the suitability of the organs used, hepatocyte isolation procedure, and the environmental conditions of the clean room.
    Cell Transplantation 06/2009; 18(8):941-7. · 4.42 Impact Factor
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    ABSTRACT: Mycophenolate mofetil (MMF) has been used to rescue liver allografts with steroid-resistant rejection (SRR). However, the long-term outcome of these patients is not known. This study evaluates the long-term outcome of MMF rescue therapy for SRR in pediatric liver allograft recipients. Twenty-six children (who received 28 liver transplants), including 16 girls, were given MMF for SRR. The median age at transplant was 1.7 (range 0.4-13.6) years. Primary immunosuppression was cyclosporine-based in 22 and tacrolimus-based in 6. All patients except one had been converted to tacrolimus prior to MMF, having already received a median of 2 (1-5) courses of high-dose intravenous methylprednisolone. The median time to MMF rescue therapy was 1.8 (0.4-35.8) months. Twenty-one of 28 episodes of SRR responded to MMF therapy. The median follow-up was 8.8 (7.7-11.5) years. In responders, there was 1 death from posttransplant lymphoproliferative disease, and no grafts were lost to chronic rejection. In the 7 nonresponders, 3 grafts were lost to chronic rejection with 2 patient deaths. Surviving children are clinically well with good liver function, and 17 remain on MMF. Three children have glomerular filtration < 80 mL/minute/1.73 m(2). Side effects of MMF were seen in 12 patients; diarrhea (n = 5) and leukopenia (n = 5) being the most common. MMF was found to be effective in treating SRR in pediatric allograft recipients, with good long-term graft function and an acceptable side-effect profile.
    Liver Transplantation 10/2008; 14(9):1303-8. · 3.94 Impact Factor
  • Anita Verma, Jim J Wade
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    ABSTRACT: Solid-organ transplant recipients are at risk from various infectious diseases, many of which can be prevented by immunizations that could reduce morbidity and mortality. However, it is not uncommon for children requiring transplantation to have received inadequate or no immunizations pre-transplant. Every effort should be made to immunize transplant candidates early in the course of their disease according to recommended schedules prior to transplantation. It is also important to immunize their household contacts and healthcare workers. In this review, we summarize the major immunization issues for children undergoing transplantation, the data currently available on immunization safety and efficacy, and suggest immunization practices to reduce vaccine-preventable disease. There is a real need for a standardized approach to the administration and evaluation of immunizations in this group of patients.
    Pediatric Transplantation 09/2006; 10(5):536-48. · 1.50 Impact Factor
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    ABSTRACT: Acute liver failure (ALF) in neonates is rare but carries a high mortality without liver transplantation. Herpes simplex virus (HSV) is one of the microbes that more commonly causes ALF and is potentially treatable; hence, early diagnosis and treatment are important to avoid progression to liver failure. We have analysed retrospectively the case notes of 11 patients with HSV-induced ALF. A history of possible herpes infection was elicited in 5 parents, but HSV had not been suspected clinically. All patients were asymptomatic when discharged from postnatal units and were presented with nonspecific symptoms of poor feeding and lethargy within 2 weeks from birth. Seven of the 11 patients had HSV-1 infection, 4 HSV-2. Only 2 patients who received early treatment with intravenous acyclovir survived. HSV-related ALF in the neonatal period carries high morbidity and mortality and needs a high index of suspicion so that life-saving treatment can be started promptly. Both HSV-1 and HSV-2 can cause severe neonatal infection. It is important to recognise HSV infection in women of childbearing age and their sexual partners.
    Journal of Pediatric Gastroenterology and Nutrition 04/2006; 42(3):282-6. · 2.20 Impact Factor
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    ABSTRACT: Fungal infection (FI) is a major and potentially fatal complication in liver transplantation (LT). Published experience of FI in paediatric LT is limited. We therefore reviewed case records of 79 children, aged between 0.16 and 16 yr, who underwent LT between 1997 and 1998 to document the incidence of, and identify risk factors for, FI. Sixty-eight pre-, peri- and post-LT variables were assessed in relation to FI by univariate and multivariate analyses. The major indications for LT were biliary atresia in 26 (33%) patients, fulminant hepatic failure in 16 (20%) and intrahepatic cholestasis in 11 (14%); eight patients required re-LT. Thirty-two (40.5%) children developed a FI within 1 yr of LT. The median time to FI was 42 days (range 1-342 days). Candida spp. caused 29 (90.7%) FIs; 21 (66%) of these were Candida albicans. Although FI was associated with increased mortality, most patients responded well to antifungal treatment. The variables independently associated with FI were pre-LT fungal colonization and pyrexia and, post-LT, bacterial infection, Epstein-Barr virus (EBV) infection and tacrolimus administration. Identifying risk factors for FI should contribute to the development of strategies for prophylaxis or preemptive therapy.
    Pediatric Transplantation 05/2005; 9(2):220-5. · 1.50 Impact Factor
  • Anita Verma, Anil Dhawan
    Pediatric Transplantation 03/2005; 9(1):132. · 1.50 Impact Factor
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    ABSTRACT: Hepatocyte transplantation has been investigated in patients with liver-based metabolic disorders and acute liver failure. We report the first use of hepatocyte transplantation in two brothers with severe inherited coagulation factor VII deficiency. Patient 1 received a total of 1.09x10(9) cryopreserved hepatocytes, and patient received 2.18x10(9) fresh and cryopreserved hepatocytes through a Hickman line inserted in the inferior mesenteric vein. Infusion of isolated human hepatocytes improved the coagulation defect and markedly decreased the requirement for exogenous recombinant factor VII (rFVIIa) to approximately 20% of that before cell transplantation. In both patients, episodes of line sepsis were associated with an increase in rFVIIa requirement. Six months posthepatocyte transplantation, higher rFVIIa doses were required, suggesting loss of transplanted hepatocyte function. Because of increasing problems with venous access and long-term uncertainty of the efficacy of hepatocyte transplantation, orthotopic liver transplantation was performed successfully in both cases.
    Transplantation 01/2005; 78(12):1812-4. · 3.78 Impact Factor
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    ABSTRACT: We report a case of neonatal herpes presenting with liver failure and disseminated coagulopathy which followed unrecognised maternal primary genital herpes and was diagnosed by herpes simplex virus DNA detection in blood by polymerase chain reaction 2 weeks after initiation of empiric intravenous aciclovir. The child underwent liver transplantation while receiving suppressive antiviral therapy and remains well after 10 months of follow-up. CONCLUSION: our case highlights potential pitfalls in the diagnosis of neonatal herpes and indicates a role for blood herpes simplex virus polymerase chain reaction as a sensitive diagnostic tool in disseminated infection. It is one of very few reports where liver transplantation has been successfully carried out in a neonate with herpes simplex virus-induced liver failure.
    European Journal of Pediatrics 04/2004; 163(3):166-9. · 1.91 Impact Factor
  • Anita Verma, Jim J Wade
    Journal of Pediatric Gastroenterology and Nutrition 09/2003; 37(2):213-4. · 2.20 Impact Factor
  • Anita Verma, Jim J Wade
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    ABSTRACT: The function and anatomy of the liver renders this organ peculiarly susceptible to bacterial and parasitic infections; fungal infections are increasingly recognised in the immunocompromised. As biochemical abnormalities of liver function can be non-specific, a high index of suspicion of liver or biliary infection is required. A need for prompt investigation is emphasised by the potentially rapid progression and poor prognosis of some bacterial and fungal infections, and the public health implications of parasitic diseases. This review encompasses the major infections of the liver and biliary tree other than viral hepatitis and includes aspects of pathogenicity, epidemiology, clinical presentation, diagnosis and management.
    The Indian Journal of Pediatrics 10/2002; 69(9):793-9. · 0.72 Impact Factor

Publication Stats

195 Citations
30.05 Total Impact Points

Institutions

  • 2012
    • King's College Hospital NHS Foundation Trust
      Londinium, England, United Kingdom
  • 2002–2012
    • King's College London
      • Department of Immunobiology
      Londinium, England, United Kingdom
  • 2005–2006
    • Nottinghamshire Healthcare NHS Trust
      Nottigham, England, United Kingdom
  • 2003
    • The Kings College
      Denmark, South Carolina, United States