A successful pregnancy following liver transplantation

Introduction N umerous reports of successful pregnancy following liver transplantation have been published in the world.[1, 2]Pregnancy and delivery are not a dream to female recipients despite pregnancies after organ transplantation have an increased risk of complications, which is similar to that of pregnancies before the transplantation.[3]The first report of China appeared in Taiwan in 1998.[3] In the mainland of China, however, little information is available regarding the incidence and…     

Domino liver transplantation

Orthotopic liver transplantation is today an established treatment for end stage liver diseases. However, the ongoing shortage of suitable livers together with progressively longer waiting lists prevents many patients from being transplanted, and many patients die while being on the waiting list. Using livers from living donors is one way to increase the supply of liver grafts. Another group of potential living liver donors are some selected liver recipients, whose native explanted liver in turn can be considered for transplantation into another patient. This unorthodox procedure have been named domino liver transplantation (DLT). The domino approach can be considered in patients with some genetic or biochemical disorders that today are treated by liver transplantation. The underlying rationale is that such livers ultimately cause severe systemic disease but are otherwise normal. In this review we present the current world status of DLT as well as updated results from the Domino Liver World Transplant Register (DLTR) and our own experience at the Karolinska University Hospital Huddinge with the DLT procedure.     

Chlormezanone-induced fulminant hepatitis in a pregnant woman: Successful delivery and liver transplantation

The case of a 29 year old woman affected by fulminant hepatitis during the third trimester of pregnancy, after a 3 week administration of chlormezanone is reported. Following induced Caesarean delivery, the patient underwent an orthotopic liver transplantation. The mother and her baby were in good condition 26 months after liver transplantation. In this case, chlormezanone was probably responsible for the fulminant hepatitis.     

2016年意大利肝病学会肝移植术后妊娠意见书

1 介绍有关器官移植后妊娠的报告大多数来源于肾移植.虽然不同的器官移植存在相似之处,但是即使是未孕患者自身条件也存在很大的差异.1978年第一例肝移植后妊娠,除了新生儿低体质量外,妊娠过程及结局非常完美.此后虽然开展了大量研究,包括个案、病例分析、调查研究、人群的基础研究、注册研究(如国家移植妊娠登记处和英国移植妊娠注册表),但是缺乏随机对照试验研究,所有的妊娠期用药安全性的论证均来自于动物实验.     

儿童肝移植的现状和未来

儿童肝移植已经成为儿童终末期肝病的标准治疗方法。发展儿童肝移植意义重大。本文从适应证、生存率、手术方式、技术性并发症、免疫抑制治疗、远期生存状况和受体危险度分层等方面对目前儿童肝移植的发展水平进行初步概述,并对未来发展作初步展望。     

Outcomes in partial liver transplantation: deceased donor split-liver vs. live donor liver transplantation

BackgroundOrgan shortage has resulted in greater emphasis on partial liver transplantation (PLT) as an alternative to whole-organ liver transplantation.MethodsThis study was conducted to assess outcomes in PLT and to compare outcomes of deceased donor split-liver transplantation (DD-SLT) and live donor liver transplantation (LDLT) in adults transplanted in the USA using data reported to the United Network for Organ Sharing in the era of Model for End-stage Liver Disease (MELD) scores.ResultsBetween 2002 and 2009, 2272 PLTs were performed in the USA; these represented 5.3% of all liver transplants carried out in the country and included 557 (24.5%) DD-SLT and 1715 LDLT (75.5%) procedures. The most significant differences between the DD-SLT and LDLT groups related to mean MELD scores, which were lower in LDLT recipients (14.5 vs. 20.9; P < 0.001), mean recipient age, which was lower in the LDLT group (50.7 years vs. 52.8 years; P < 0.001), and mean donor age, which was lower in the DD-SLT group (23.0 years vs. 37.3 years; P < 0.001). Allograft survival was comparable between the two groups (P= 0.438), but patient survival after LDLT was better (P= 0.04). In Cox regression analysis, LDLT was associated with better allograft (hazards ratio [HR]= 0.7, 95% confidence interval [CI] 0.630–0.791; P < 0.0001) and patient (HR = 0.6, 95% CI 0.558–0.644; P < 0.0001) survival than DD-SLT.ConclusionsPartial liver transplantation represents a potentially underutilized resource in the USA. Despite the differences in donor and recipient characteristics, LDLT is associated with better allograft and patient survival than DD-SLT. A different allocation system for DD-SLT allografts that takes into consideration cold ischaemia time and recipient MELD score should be considered.     

Review: Recent advances in liver transplantation

Liver transplant is a life-saving treatment with 1-year and 5-year survival rates of 90% and 70%, respectively. However, organ demand continues to exceed supply, such that many patients will die waiting for an available organ. This article reviews for the general gastroenterologist the latest developments in the field to reduce waiting list mortality and maximise utilisation of available organs. The main areas covered include legislative changes in organ donation and the new ‘opt-out’ systems being rolled out in the UK, normothermic machine perfusion to optimise marginal grafts, a new national allocation system to maximise benefit from each organ and developments in patient ‘prehabilitation’ before listing. Current areas of research interest, such as immunosuppression withdrawal, are also summarised.     

Successful liver transplantation and delivery in a woman with fulminant hepatic failure occurring during the second trimester of pregnancy.

BACKGROUND: Severe liver dysfunction occurring during pregnancy is an unusual but dramatic event that poses special technical and ethical issues because it involves two lives. METHODS AND RESULTS: We report the case of a 35-year-old woman with cryptogenic fulminant hepatic failure who underwent successful orthotopic liver transplantation at 22 weeks of pregnancy. After a relatively uneventful post-operative course she delivered a normal offspring at the 27th week of gestation. There were no obstetrical complications and neonatal outcome was excellent. After a year of follow-up, the patient is doing well,and the newborn has exhibited normal psychomotor and weight/height development. CONCLUSION: This case illustrates the challenge of treating fulminant hepatic failure during pregnancy and demonstrates that liver transplantation is a feasible therapeutic option for treatment of patients with this condition, allowing successful completion of pregnancy.     

Kidney transplantation after liver transplantation

Kidney transplantation after liver transplanta-tion (KALT) offers longer survival and a better quality of life to liver transplantation recipients who develop chronic renal failure. This article aimed to discuss the efifcacy and safety of KALT compared with other treatments. The medical records of 5 patients who had undergone KALT were retrospectively studied, together with a literature review of studies. Three of them developed chronic renal failure after liver transplanta-tion because of calcineurin inhibitor (CNI)-induced neph-rotoxicity, while the others had lupus nephritis or non-CNI drug-induced nephrotoxicity. No mortality was observed in the 5 patients. Three KALT cases showed good prognoses, maintaining a normal serum creatinine level during entire follow-up period. Chronic rejection occurred in the other two patients, and a kidney graft was removed from one of them. Our data suggested that KALT is a good alternative to dialysis for liver transplantation recipients. The cases also indicate that KALT can be performed with good long-term survival.     

Laparoscopic liver resection facilitates salvage liver transplantation for hepatocellular carcinoma

Background/Purpose

In patients with hepatocellular carcinoma (HCC), a previous liver resection (LR) may compromise subsequent liver transplantation (LT) by creating adhesions and increasing surgical difficulty. Initial laparoscopic LR (LLR) may reduce such technical consequences, but its effect on subsequent LT has not been reported. We report the operative results of LT after laparoscopic or open liver resection (OLR).

Methods

Twenty-four LT were performed, 12 following prior LLR and 12 following prior OLR. The LT was performed using preservation of the inferior vein cava. Indication for the LT was recurrent HCC in 19 cases (salvage LT), while five patients were listed for LT and underwent resection as a neoadjuvant procedure (bridge resection).

Results

In the LLR group, absence of adhesions was associated with straightforward access to the liver in all cases. In the OLR group, 11 patients required long and hemorrhagic dissection. Median durations of the hepatectomy phase and whole LT were 2.5 and 6.2 h, and 4.5 and 8.3 h in the LLR and OLR groups, respectively (P < 0.05). Median blood loss was 1200 ml and 2300 ml in the LLR and OLR groups, respectively (P < 0.05). Median transfusions of hepatectomy phase and whole LT were 0 and 3 U, and 2 and 6 U, respectively (P < 0.05). There were no postoperative deaths.

Conclusions

In our study, LLR facilitated the LT procedure as compared with OLR in terms of reduced operative time, blood loss and transfusion requirements. We conclude that LLR should be preferred over OLR when feasible in potential transplant candidates.     

Current developments in pediatric liver transplantation

In 1953, the pioneer of human orthotopic liver transplantation(LT), Thomas E Starzl, was the first to attempt an orthotopic liver transplant into a 3 years old patient suffering from biliary atresia. Thus, the first LT in humans was attempted in a disease, which, up until today, remains the main indication for pediatric LT(p LT). During the last sixty years, refinements in diagnostics and surgical technique, the introduction of new immunosuppressive medications and improvements in perioperative pediatric care have established LT as routine procedure for childhood acute and chronic liver failure as well as inherited liver diseases. In contrast to adult recipients, p LT differs greatly in indications for LT, allocation practice, surgical technique, immunosuppression and postoperative life-long aftercare. Many aspects are focus of ongoing preclinical and clinical research. The present review gives an overview of current developments and the clinical outcome of p LT, with a focus on alternatives to full-size deceased-donor organ transplantation.     

Live donors in liver transplantation

Living donor liver transplantation (LDLT) has been controversial since its inception. Begun in response to deceased donor organ shortage and waiting list mortality, LDLT was initiated in 1989 in children, grew rapidly after its first general application in adults in the United States in 1998, and has declined since 2001. There are significant risks to the living donor, including the risk of death and substantial morbidity, and 2 highly publicized donor deaths are thought to have contributed to decreased enthusiasm for LDLT. Significant improvements in outcomes have been seen over recent years, and data, including from the National Institutes of Health-funded Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL), have established a survival benefit from pursuing LDLT. Despite this, LDLT still composes less than 5% of adult liver transplants, significantly less than in kidney transplantation where living donors compose approximately 40% of all transplantations performed. The ethics, optimal utility, and application of LDLT remain to be defined. In addition, most studies to date have focused on posttransplantation outcomes and have not included the effect of the learning curve on outcome or the potential impact of LDLT on waiting list mortality. Further growth of LDLT will depend on defining the optimal recipient and donor characteristics for this procedure as well as broader acceptance and experience in the public and in transplant centers.     

肝癌肝移植的临床及基础研究

肝移植是对于肝癌最为有效的治疗方式。因为其可以根除肿瘤主体及镜下微小肿瘤病灶并提供给患者一个具备良好功能的肝脏。如今肝移植治疗小肝癌的5年成活率已经高达80%。但是由于肝移植手术仅能提供给一些本就预期预后良好的肝癌初期患者,所以只有小部分符合条件的肝癌患者能够受惠     

Using on-site liver 3-D reconstruction and volumetric calculations in split liver transplantation

BACKGROUND: Split liver transplantation increases the number of grafts available for transplantation. Pre-recovery assessment of liver graft volume is essential for selecting suit-able recipients. The purpose of this study was to determine the ability and feasibility of constructing a 3-D model to aid in surgical planning and to predict graft weight prior to anin situ division of the donor liver.
METHODS: Over 11 months, 3-D volumetric reconstruction of 4 deceased donors was performed using Pathifnder Scout? liver volumetric software. Demographic, laboratory, operative, perioperative and survival data for these patients along with donor demographic data were collected prospectively and analyzed retrospectively.
RESULTS: The average predicted weight of the grafts from the adult donors obtained from anin situ split procedure were 1130 g (930-1458 g) for the extended right lobe donors and 312 g (222-396 g) for left lateral segment grafts. Actual adult graft weight was 92% of the predicted weight for both the ex-tended right grafts and the left lateral segment grafts. The pre-dicted and actual graft weights for the pediatric donors were 176 g and 210 g for the left lateral segment grafts and 308 g and 280 g for the extended right lobe grafts, respectively. All grafts were transplanted except for the right lobe from the pediatric donors due to the small graft weight.
CONCLUSIONS: On-site volumetric assessment of donors provides useful information for the planning of anin situ split and for selection of recipients. This information may expand the donor pool to recipients previously felt to be unsuitable due to donor and/or recipient weight.     

Hepatitis C and liver transplantation

Hepatitis C virus (HCV) is important to the liver transplant recipient for several reasons. First, chronic HCV infection is a frequent cause of end-stage liver disease in North America and Europe, where the majority of liver transplants are performed. Second, recurrence of HCV after liver transplantation is almost universal so that many liver transplant recipients with and without overt hepatitis are viraemic. Third, HCV infection in the organ donor and/or in the blood transfused in the peri-transplant period make acquisition of HCV possible. Finally, liver transplantation for chronic HCV infection represents a major financial burden to the health-care system in the USA and worldwide. Histological hepatitis not due to HBV or cytomegalovirus (CMV) is present in 14–35% of allografts from patients undergoing liver transplantation, and the majority of this is due to HCV infection. HCV infection recurs post-transplant in almost all patients with pre-transplant infection. Proof that HCV does recur has been provided by the sequencing of the hypervariable domain of the E2/NS1 region. The magnitude of HCV infection is underestimated by using serological assays in this immunosuppressed population. Using the b-DNA assay, HCV-RNA levels have been shown to increase in patients with recurrent infection. The long-term consequences remain to be defined but post-transplantation HCV infection is generally much less devastating than post-transplantation HBV infection, and many patients have clinically silent disease. It is likely that a carrier state exists in immunosuppressed transplant recipients since high HCV-RNA levels occur in the absence of liver damage. In one study, 1, 2 and 3 year patient survival rates were shown to be comparable in patients with chronic active HCV infection and with cryptogenic cirrhosis (94, 89 and 87%, and 84, 84 and 73%, respectively). A more recent study from the University of Pittsburgh which compared the outcome of a larger number of HCV-infected patients (n= 237) with a large number of control patients with non-viral disease (n= 801), showed that indeed HCV infection does impact negatively on both patient and graft survival (1, 2 and 3 year patient survival in the study and control groups of 78, 68 and 66% and 84, 82 and 78%, respectively, P= 0.001). Undoubtedly with time, the full impact of recurrent HCV infection will become apparent, although short-term survival is sufficiently good to warrant continued transplantation of this group of patients. While the disease course in many patients is benign, aggressive post-transplant HCV infection leading to liver failure is well documented. Factors which determine why some patients are more susceptible to liver damage than others are currently under study. It is likely that many interrelated variables are involved, including the level of pre-transplant viraemia, genotype of the virus, amount of post-transplantation immunosuppression, and ability of the host immune system to recognize HCV and mount an immune response.     

肝移植在中国的发展现状

作为治疗各种终末期肝病唯一有效的方法,肝移植近年在国内发展迅速。叙述了肝移植在国内的最新发展成果,包括肝癌肝移植受者选择标准——杭州标准的确立;挽救性肝移植及降期治疗在肝癌肝移植中的最新应用;肝移植联合人工肝技术治疗急性重症肝衰竭的进展;活体肝移植技术创新和心脏死亡器官捐献移植在中国的突破性发展。面临器官短缺,应建立符合中国国情的科学规范的器官捐献体系,在造福于广大人民的同时也将进一步提升我国器官移植学界在国际上的声誉。     

The need for venovenous bypass in liver transplantation

Since introduction of the conventional liver transplantation (CLTx) by Starzl, which was based on the resection of recipient inferior vena cava (IVC) along the liver, the procedure has undergone several refinements. Successful use of venovenous bypass (VVB) was first introduced by Shaw et al., although in recent decades there has been controversy regarding the routine use of VVB during CLTx. With development of piggyback liver transplantation (PLTx), the use of caval clamping and VVB is avoided, leading to fewer complications related to VVB. However, some authors still advocate VVB in PLTx. The great diversity among centers in their use of VVB during CLTx, or even along the PLTx technique, has led to confusion regarding the indication setting for VVB. For this reason, we present an overview of the use of VVB in CLTx, the target of patients for whom VVB could be beneficial, and the needs assessment of VVB for patients undergoing PLTx. Recent studies have shown that with the advancement of surgical skills, refinement of surgical techniques, and improvements in anesthesiology, there are only limited indications for doing CLTx with VVB routinely. PLTx with preservation of IVC can be performed in almost all primary transplants and in the majority of re-transplantations without the need for VVB. Nevertheless, in a few selective cases with severe intra-operative hemodynamic instability, or with a failed test of transient IVC occlusion, the application of VVB is still justifiable. These indications should be judged intra-operatively and the decision is based on each center's preference.