Donor Factors Similarly Impact Survival Outcome After Liver Transplantation in Hepatocellular Carcinoma and Non-hepatocellular Carcinoma Patients

Background

Many have advocated the preferential use of high risk allografts for hepatocellular carcinoma patients undergoing liver transplantation. Hepatocellular carcinoma (HCC) patients tend to have relatively preserved liver function, and their outcome is felt to be driven largely by tumor-related factors.

Aim

The aim of this study was to compare the relative importance of donor versus recipient factors on post-orthotopic liver transplantation survival among HCC and non-HCC recipients.

Methods

The study group included Scientific Registry of Transplant Recipients data on adult recipients of deceased donor liver transplants from February 2002 through December 2008. Recipients were classified as HCC based on MELD exception applications and were compared to all other recipients. Predictors of post-LT survival were identified by Cox regression. To test whether donor factors have less impact on survival in HCC patients, interaction terms were created between HCC diagnosis and donor factors.

Results

Of the 40,212 DDLTs during the study period, 29,020 (72 %) met study criteria. A total of 7,786 (27 %) were transplanted with a diagnosis of HCC. The mean donor risk index was 1.5 in both cohorts. The 1-/5-year survival was 88 %/68 % and 87 %/74 % among HCC and non-HCC recipients, respectively (p < 0.0001). On multivariate analysis, there was no statistically significant interaction between HCC diagnosis and DRI (HR 0.94, p = 0.317). Likewise, no interaction was seen between HCC diagnosis and individual donor factors. In both groups, donor and recipient factors carried similar weight in determining post-LT survival.

Conclusions

Contrary to previous assumptions, donor factors play a similar role in determining survival post-LT among HCC patients and non-HCC patients.     

Graft size and donor age are independent factors for graft loss in adult-to-adult living-donor liver transplantation using the left liver

Background/purpose

Graft survival is affected by various factors, such as preoperative state and the ages of the recipient and donor, as well as graft size. The objective of this study was to analyze the risk factors for graft survival.

Methods

From September 1997 to July 2005, 24 patients who had undergone living-donor liver transplantation (LDLT) were retrospectively analyzed. Sixteen patients survived and the eight graft-loss cases were classified into two groups according to the cause of graft loss: graft dysfunction without major post-transplantation complications (graft dysfunction group; n = 3), and graft dysfunction with such complications (secondary graft dysfunction group; n = 5). Various factors were compared between these groups and the survival group.

Results

Mean donor age was 31.9 years in the survival group and 49.2 years in the secondary graft dysfunction group (P = 0.024). Graft weight/recipient standard liver volume ratios (G/SLVs) were 36.7% in the survival group, and 26.2% in the graft dysfunction group (P = 0.037). The postoperative mean PT% for 1 week was 48.6% in the survival group and 38.1% in the secondary graft dysfunction group (P = 0.05).

Conclusions

Our surgical results demonstrated that G/SLV and donor age were independent factors that affected graft survival rates.     

The Outcomes of Patients with Severe Hyperbilirubinemia Following Living Donor Liver Transplantation

Background

Prolonged hyperbilirubinemia (HB) following living donor liver transplantation (LDLT) can be a risk factor for early graft loss and mortality. However, some recipients who present with postoperative hyperbilirubinemia do recover and maintain a good liver function.

Aim

The purpose of this study was to investigate the risk factors for hyperbilirubinemia following LDLT and to identify predictors of the outcomes in patients with post-transplant hyperbilirubinemia.

Methods

A total of 107 consecutive adults who underwent LDLT in Nagasaki University Hospital were investigated retrospectively. The patients were divided into two groups according to postoperative peak serum bilirubin level (HB group: ≥30 mg/dl; non-HB group: <30 mg/dl). These two groups of patients and the prognosis of patients in the HB group were analyzed using several parameters.

Results

Seventeen patients (15.9 %) presented with hyperbilirubinemia, and their overall survival was significantly worse than patients in the non-HB group (n = 90). Donor age was significantly higher in the HB group (P < 0.05). Of the 17 patients in the HB group, nine survived. The postoperative serum prothrombin level at the time when the serum bilirubin level was >30 mg/dl was significantly higher in surviving patients (P < 0.01).

Conclusions

The use of a partial liver graft from an aged donor is a significant risk factor for severe hyperbilirubinemia and a poorer outcome. However, those patients who maintain their liver synthetic function while suffering from hyperbilirubinemia may recover from hyperbilirubinemia and eventually achieve good liver function, thus resulting in a favorable survival.     

Remnant left liver size and recovery of living right liver donors

Purpose

Living donor liver transplantation is a realistic life-saving treatment in regions where deceased donor organs are scarce. The minimum remnant left liver volume (RLLV) requirement for donor right hepatectomy (DRH) varies in different programs of living donor liver transplantation. The present study aimed to determine how significant the RLLV is in the recovery of right liver donors.

Method

A total of 349 consecutive donors who underwent DRH including the middle hepatic vein were divided into nine groups according to the percentage of the RLLV. The peak and recovery of the serum bilirubin level and prothrombin time (PT) in the 1st week after operation and postoperative complications were studied.

Results

The median RLLV was 35.5 (27–49.5) %. Postoperative peak serum bilirubin was highest [74 (25–133) μmol/L] in the group with RLLVs <30 %. This group also had the highest peak PT [18.9 (15.4–24.4) s], although results were similar between groups. Total bilirubin peaked on postoperative days 1–2 in groups with RLLVs ≥35 %. In groups with RLLVs <35 %, total bilirubin peaked on day 3. PT took 1–2 days to peak and nearly approached preoperative values on day 7 in all groups. Complication rates ranged from 0 to 75 %. The rates of complications of Clavien-Dindo grade 3 or above ranged from 0 to 3.8 %. Postoperative peak bilirubin was associated with severe complications (p = 0.031). Age, postoperative peak PT, and RLLV were independent risk factors for prolonged hospital stay.

Conclusion

There was a demonstrable trend of slower recovery of liver function in donors with smaller RLLVs.     

Readmission after living donor liver transplantation: Predictors,causes, and outcomes

Background

Complications following liver transplantation requiring readmission may be serious and potentially life threatening. Most reports on readmission have been about after deceased donor liver transplantation (DDLT). We hypothesized that readmission after living donor liver transplantation (LDLT) is due to different reasons and analyzed our experience.

Methods

We retrospectively analyzed the records of 172 consecutive patients who underwent liver transplantation at our institute between January 2010 and June 2012. The primary outcome measure was readmission. We classified readmission into early (<3 months after discharge) and late (>3 months).

Results

The study population was 140 after excluding pediatric patients (12), DDLT recipients (2), and those who died during the index admission (18). Their median age was 42 years, and there were 117 males and 23 females. Thirty-eight patients were readmitted (56 episodes) after LDLT. There were 35 early and 21 late readmission episodes. The most common cause for early readmissions was infection (46 %) and that for late readmissions was biliary stricture (62 %). On univariate analysis, pretransplant portal vein thrombosis, more than one bile duct in the liver graft, revised arterial anastomosis or two arteries in the graft, and higher serum alkaline phosphatase levels at discharge were significantly associated with readmission. Readmission was also significantly associated with a higher overall mortality than non-readmission in which there was no mortality.

Conclusion

Pretransplant portal vein thrombosis, more than one bile duct in the liver graft, revision of the arterial anastomosis or two arteries in the graft, and higher serum alkaline phosphatase levels at discharge were significantly associated with readmission. Infective and biliary complications were the commonest causes of early and late readmission after LDLT.     

Long-term outcome of endoscopic and/or percutaneous transhepatic therapy in patients with biliary stricture after orthotopic liver transplantation

Background

Biliary strictures are a serious complication after liver transplantation. Endoscopic and percutaneous transhepatic procedures have gained an increasing potential for the management of this problem.

Objective

Long-term follow-up of endoscopic and/or percutaneous transhepatic therapy of biliary strictures after liver transplantation was evaluated.

Patients and methods

Between January 1996 and December 2007, 47 patients with biliary stricture after liver transplantation were identified by analysing the endoscopic database, hospital charts and cholangiograms. Long-term follow-up was evaluated using cholangiograms, transabdominal ultrasound, laboratory parameters and physical examination.

Results

The type of biliary stricture after liver transplantation was subdivided into anastomotic stricture (n = 29), non-anastomotic stricture (n = 14) and bilioenterostomy stricture (n = 4). Of the patients, 38/47 were treated by endoscopic procedures (ERCP), and 9/47 patients were treated by percutaneous transhepatic procedures (PTBD). In 2 of 47 patients combined approaches (rendezvous technique) were performed. Overall, 23/29 patients in the anastomotic group, 12/14 patients in the non-anastomotic group, and 3/4 patients in the bilioenterostomy group had successfully completed endoscopic and/or percutaneous transhepatic therapy. Biliary drainage could be respectively terminated after median 9 (1–83), 11 (1–89) and 10 (4–14) months.

Conclusions

Endoscopic as well as percutaneous transhepatic approaches in combination or as monotherapy are effective in the management of anastomotic and non-anastomotic strictures after liver transplantation.     

Discrepancy between estimated and actual weight of partial liver graft from living donors

Background/purpose

A discrepancy between the actually obtained graft weight and the preoperative volumetric estimation is often observed in living donor liver transplantation. The aim of the study reported here was to clarify the prevalence and degree of this discrepancy between estimated and actual liver volume.

Materials and methods

Preoperative volumetric evaluations of 26 live donor livers were performed using three-dimensional computed tomography software. The weight of the liver graft and blood contained in the graft were measured immediately after procurement and compared with the preoperative estimate. The graft was also weighed after perfusion and after back-table procedures.

Results

Analysis of the results revealed that blood-free graft weight was significantly overestimated (p = 0.02) and blood weight was significantly underestimated (p < 0.001). The sum of the weight of the graft and blood best corresponded to the preoperative volume estimate (R ² = 0.64, p < 0.001). The back-table procedures significantly decreased the weight of the liver graft (p < 0.001). Graft weight after perfusion and after venous reconstruction corresponded to 95 and 90% of the weight obtained before perfusion, respectively. Multivariate analysis revealed that donor age had the most significant influence on the ratio of the weight decrease in the University of Wisconsin solution (p = 0.03).

Conclusions

The weight of liver grafts decreases significantly during back-table procedures. Underestimation of the blood weight contained in the graft is one cause of the graft weight discrepancy, but weight loss while the graft was immersed in the University of Wisconsin solution was also observed. These phenomena should be taken into account when graft size is being determined.     

New-onset diabetes mellitus developing in Asian adult living donor liver transplant recipients: a single-center experience

Background

New-onset diabetes mellitus (NODM) after liver transplantation is a common complication with a potentially negative impact on patient outcome.

Methods

To evaluate the incidence of NODM and its impact on Asian adult living donor liver transplant (LDLT) recipients, we investigated 369 adult LDLT cases in our institute.

Results

Preoperative diabetes mellitus (DM) was diagnosed in 38 (9 %) patients. NODM was observed in 128/331 (38 %) patients, 56 (44 %) with persistent NODM and 72 (56 %) with transient NODM. The mean interval between LDLT and the development of NODM was 0.6 ± 1.8 (range 0–1.4) months. Multivariate analyssis revealed that older age, being male and having a higher body mass index were independent risk factors among recipients for developing NODM, while hepatitis C virus infection was not a significant risk factor, and DM had no impact on patient outcome.

Conclusions

Although the long-term effect of DM on outcome remains to be investigated, the presence of DM after liver transplant, whether it was NODM or preexisting DM, had no impact on LDLT recipients’ outcomes in mid-term.     

Endoscopic stent placement above the intact sphincter of Oddi for biliary strictures after living donor liver transplantation

Background and study aims

Biliary complications are one of the most serious morbidities after liver transplantation. Inside-stent is a plastic stent placed above the sphincter of Oddi without endoscopic sphincterotomy against biliary strictures. Our aims were to analyze the long-term efficacy of inside-stent placement in patients with biliary stricture after living donor liver transplantation.

Patients and methods

Ninety-four patients who experienced biliary stricture that employed duct-to-duct reconstruction were treated with inside-stent placement. Treatment outcomes, including stricture resolution, recurrence, inside-stent patency, and morbidity rate were evaluated retrospectively.

Results

Ninety-two patients could be evaluated. Resolution of stricture was eventually observed in 81 of 92 patients with an average of 1.4 sessions of endoscopic retrograde cholangiography. Of the 81 patients who achieved the resolution of the stricture, recurrent biliary stricture that required intervention occurred in 8 patients. Conversely, stricture remission was achieved 73 patients (90.1 %) during 53 months follow-up after stent removal. Median duration of patency of the initial stent was 189 (range 2–1228) days. Stent dislocation occurred in 10 patients. Adverse event related to inside-stent placement was pancreatitis in 18 cases (mild 13, moderate 5).

Conclusions

Inside-stent placement achieved long-term patency and high remission rate in patients with biliary stricture after liver transplantation.     

Which patients respond best to hepatitis B vaccination after a hepatitis B virus-related liver transplantation?

Background

A combination of hepatitis B immunoglobulin and nucleos(t)ide analogues is the current standard of care for controlling hepatitis B recurrence after orthotopic liver transplantation (OLT). However, frequent immunoglobulin treatment is expensive and inconvenient. This study investigated the efficacy of hepatitis B virus (HBV) vaccination in preventing the recurrence of hepatitis B after living donor OLT.

Methods

Twenty-seven patients who had undergone living donor OLT participated in the study; five had acute HBV infected liver failure (ALF-OLT) and 22 had HBV related liver cirrhosis (LC-OLT). Hepatitis B surface antigen (HBsAg)-containing vaccine was administered to them for at least 1 year after transplantation and continued once monthly for up to 36 months post-OLT. Patients who had anti-HBs antibody titers above 100 mIU/mL for a minimum of 6 months without immunoglobulin administration were defined as good responders; the others were defined as poor responders. Interferon-γ enzyme-linked immunospot assays against HBs and HBc antigens were used to assay cellular immune responses.

Results

All five of the ALF-OLT patients had good responses after a median of four (range 2.5–5) vaccinations. Nine of the 22 LC-OLT patients had good responses after a median of 19 (range 11.5–30) vaccinations. Among the LC-OLT group, those with livers donated by relatively higher-aged, marital and high-titer anti-HBs antibody donors were good responders. LC-OLT patients classed as good responders showed interferon-γ responses comparable to those of the ALF-OLT patients.

Conclusions

The ALF-OLT and LC-OLT patients who received livers from relatively higher-aged, marital, high-titer anti-HBs antibody donors were the best candidates for HBV vaccine administration. Boosting donors before transplantation may facilitate later vaccine response of the recipients.     

Fulminant hepatitis due to human adenovirus

Purpose

To describe the demographics, clinical manifestations, treatment and outcomes of patients with human adenovirus (HAdV) hepatitis.

Methods

A case of fulminant HAdV hepatitis in a patient with chronic lymphocytic leukemia receiving rituximab and fludarabine is described. We conducted a comprehensive review of the English-language literature through May, 2012 in search of definite cases of HAdV hepatitis.

Results

Eighty-nine cases were reviewed. Forty-three (48 %) were liver transplant recipients, 19 (21 %) were bone marrow transplant recipients, 11 (12 %) had received chemotherapy, five (6 %) had severe combined immunodeficiency, four (4 %) were HIV infected, two had heart transplantation, and two were kidney transplant recipients. Ninety percent (46/51) of patients presented within 6 months following transplantation. Fever was the most common initial symptom. Abdominal CT scan revealed hypodense lesions in eight of nine patients. Diagnosis was made by liver biopsy in 43 (48 %), and on autopsy in 46 (52 %). The HAdV was isolated at other sites in 54 cases. Only 24 of 89 patients (27 %) survived: 16 whose immunosuppression was reduced, six with liver re-transplantation, and two who received cidofovir and intravenous immunoglobulin.

Conclusion

HAdV hepatitis can manifest as a fulminant illness in immunocompromised hosts. Definitive diagnosis requires liver biopsy. Early consideration of a viral etiology, reduction in immunosuppression, and liver transplantation can be potentially life-saving.     

Combinations of simple baseline variables accurately predict sustained virological response in patients with recurrent hepatitis C after liver transplantation

Background

The efficacy of antiviral therapy in patients with hepatitis C recurrence after liver transplantation (LT) is far from optimal and a careful selection of candidates with the best chances to achieve sustained virological response (SVR) is relevant. Moreover, investigating the effects of sustained viral clearance on clinical outcomes is particularly significant. We aimed to identify and combine the best baseline predictors of SVR and to assess the clinical outcomes of antiviral therapy after LT.

Methods

We studied 144 hepatitis C virus (HCV)-infected LT recipients who underwent antiviral therapy following transplantation. Baseline predictors of SVR including donor and recipient interleukin IL28B (IL28B) rs12979860 genotype were evaluated, and the long-term effects of antiviral therapy on clinical outcomes were assessed.

Results

The presence of an IL28B CC genotype with either low viral load (VL), young donor age, or cyclosporine A (CsA)-based immunosuppression identified individuals with 69–80 % probabilities of SVR. In contrast, only 20 % of recipients with a CT/TT IL28B genotype and either high VL, old donor age, or non-CsA immunosuppression achieved an SVR (p = 0.004). Regarding clinical outcomes, the 5-year cumulative probability of graft loss was 2 % for the SVR patients and 48 % for non-responders (p < 0.001).

Conclusions

The use of simple combinations of baseline variables including IL28B polymorphisms identifies HCV-infected LT recipients with different probabilities of response to antiviral treatment. SVR is associated with improved clinical outcomes.     

Living donor liver transplantation for patients immunized against human leukocyte antigen

Background/purpose

The clinical features and perioperative management of liver transplant recipients who are already sensitized against human leukocyte antigen (HLA) prior to transplantation are not yet clear.

Materials and methods

Medical records of living donor liver transplant recipients were reviewed and clinical features of the patients possessing anti-HLA antibodies were studied.

Results

Among the 470 consecutive living donor liver transplant recipients, 6 patients (1.3%) had preformed anti-HLA antibodies. A review of the postoperative courses of these patients revealed that the problems included platelet transfusion refractoriness (PTR) due to immune-mediated destruction of platelet and thrombotic microangiopathy (TMA). PTR was observed in patients with anti-HLA class I antibodies and only HLA-matched platelet concentrate (HLA-matched PC) relieved thrombocytopenia. Intravenous gammaglobulin had an additive effect to HLA-matched PC in some cases, and platelet transfusion from close relatives might be a substitute for HLA-matched PC in life-threatening situations. Although the etiology of TMA is unremarkable, the incidence was high (67%, 4/6) compared with that in patients who were not sensitized against HLA (5.6%, 26/464; p < 0.01). Of the four patients, three were complicated with late-onset TMA.

Conclusions

Considering these clinical features, careful preparation and postoperative management are needed for liver transplant candidates with anti-HLA antibodies.     

Strategies to treat interferon-induced graft dysfunction after living donor liver transplantation for hepatitis C

Purpose

Interferon-induced graft dysfunction (IGD) is a poorly defined, unrecognized, but potentially serious condition for patients receiving antiviral drugs after liver transplantation for hepatitis C.

Methods

We evaluated the characteristics of 80 patients who received pegylated interferon-based antiviral treatment for hepatitis C after living donor liver transplantation (LDLT).

Results

Eight patients experienced IGD either during (n = 6) or after completing (n = 2) antiviral treatment. Pathological diagnosis included acute cellular rejection (ACR, n = 1), plasma cell hepatitis (PCH, n = 2), PCH plus ACR (n = 3), and chronic rejection (CR, n = 2). One patient with CR initially presented with PCH plus ACR and the other presented with ACR; both had apparent cholestasis. The six patients with ACR or PCH without cholestasis were successfully treated by discontinuing antiviral treatment and increasing immunosuppression, including steroids. By contrast, both of the patients with CR and cholestasis experienced graft loss, despite aggressive treatment. Univariate analysis showed that pegylated interferon-α2a-based treatment (75 vs. 26.4 %, p < 0.01) was the only significant factor for IGD, and was associated with decreased 5-year graft survival (93.4 vs. 71.4 %, p = 0.04).

Conclusions

IGD is a serious condition during or even after antiviral treatment for hepatitis C after LDLT. Early recognition, diagnosis, discontinuation of interferon, and introduction of steroid-based treatment may help to save the graft.     

Favorable clinical outcome using a covered stent following transjugular intrahepatic portosystemic shunt in patients with portal hypertension

Aims

To compare retrospectively the clinical outcomes in patients treated with transjugular intrahepatic portosystemic shunt (TIPS) using the novel polytetrafluoroethylene-covered stents (Fluency) and bare stents.

Materials and methods

Sixty consecutive patients with portal hypertension treated with TIPS from April 2007 to April 2009 were included. TIPS creation was performed with Fluency stent grafts in 30 patients (group A) and with bare stents in 30 patients (group B). Liver function, TIPS patency and clinical outcomes were evaluated every 3 months after procedures.

Results

During hospitalization, there were no cases of hepatic encephalopathy (HE) and recurrence of variceal bleedings. Acute shunt occlusion was found in one patient in each group. Follow-ups were performed in group A with average time of 6.16 ± 3.89 months and in group B with 8.34 ± 4.42 months. The rates of recurrent bleeding, shunt occlusion, HE and mortality were 0.03, 0.0, 16.7 and 0% in group A, and 20.0, 30.0, 20.0 and 13.3% in group B, respectively. There was no difference of HE between group A and group B. The decrease of portal pressure and portosystemic pressure gradient, and the increase of portal flow were 34.1 and 23.3%, 60.0 and 52.8%, and 189.5 and 111.1% in group A and B, respectively. There were no differences of liver function between group A and B.

Conclusion

The Fluency stent graft is relatively safe and effective in TIPS creation, with a high patency rate compared with bare stents.     

Cytokine gene polymorphisms in acute cellular rejection following living donor liver transplantation: analysis of 155 donor-recipient pairs

Purpose

Despite improvements in immunosuppressive therapy, acute cellular rejection (ACR) remains an important cause of graft loss in patients undergoing liver transplantation. Recently, associations between cytokine gene polymorphisms in recipients and the occurrence of ACR have been reported. However, most studies did not investigate gene polymorphisms in donors or were limited by the number of cases investigated.

Methods

We examined 155 living donor liver transplantation (LDLT) patients treated at Nagoya University or Kyoto University from 2004 to 2009. The following gene polymorphisms in recipients and donors were analyzed: tumor necrosis factor A (TNF-A) T-1031C, interleukin 2 (IL-2) T-330G, IL-10C-819T, IL-13C-1111T, and transforming growth factor B (TGF-B) T29C.

Results

Forty-seven recipients (30.3 %) developed early ACR. Of the investigated gene polymorphisms, the IL-13 ?1111C/C genotype in recipients was significantly associated with a higher incidence of ACR relative to the other two genotypes (OR = 2.64, 95 % CI 1.19–5.86, p = 0.017), while we showed the lack of association between investigated gene polymorphisms in donors and ACR incidence.

Conclusion

The IL-13 ?1111C/C genotype in recipients might be a risk factor for ACR in LDLT, and this might contribute to individualized immunosuppression strategies for recipients. On the other hand, the current study showed no associations of cytokine gene polymorphisms in donors with ACR incidence.     

Long-term outcome of ABO-incompatible living-donor liver transplantation: a single-center experience

Purpose

We report the long-term outcome of ABO-incompatible living donor liver transplantation (LDLT) performed in our hospital.

Methods

We started the LDLT program in 1991 and from that year up to now (2008) 11 patients have received an ABO-incompatible graft.

Results

Nine out of the 11 cases have survived from 3.7 years to 13.9 years (mean 7.3 years) and they are in good conditions at present. Seven patients were subjected to preoperative apheresis. Eight patients experienced acute rejection and of them, 6 experienced steroid-resistant rejection that was treated with deoxyspergualin and apheresis. One patient who suffered rapidly progressing rejection died due to liver failure. Three patients who were administered rituximab did not suffer severe rejection nor adverse effects. During the long-term follow up 5 recipients had major complications such as postoperative lymphoproliferative disease, post-transplantation diabetes mellitus, portal vein occlusion and biliary stenosis. But those complications were controlled under stable conditions.

Conclusions

We concluded that long-term survival can be expected after ABO-incompatible LDLT provided perioperative complications such as humoral rejection are overcome.     

Radiofrequency-Assisted Versus Clamp-Crushing Parenchyma Transection in Cirrhotic Patients with Hepatocellular Carcinoma: A Randomized Clinical Trial

Background

Surgical resection remains the optimal therapy for cirrhotic patients with hepatocellular carcinoma (HCC) that are not suitable for liver transplantation (LT). Recently, various innovative techniques for liver resection have been developed.

Aim

The aim of the study was to compare radiofrequency-assisted parenchyma transection (RF-PT) with the traditional clamp-crushing (CC) technique to explore the preferred therapy in cirrhotic patients with HCC.

Methods

From January 2009 to December 2010, 75 cirrhotic patients with HCC who underwent hepatectomy were randomized to RF-PT (group 1, n = 38) or CC-PT (group 2, n = 37) groups. The primary endpoint was intraoperative blood loss. The secondary endpoints included hepatic transection time, total operating time, postoperative morbidity, mortality, length of intensive care unit and hospital stays, and liver function.

Results

The characteristics of the two patient groups were closely matched. The Pringle maneuver was not used in RF-PT patients. The blood loss of the RF-PT group, total or during transection, was significantly lower than that of the CC-PT group (385 vs. 545 ml, p = 0.001; 105 vs. 260 ml, p = 0.000, respectively). Compared with CC-PT patients, the morbidity of the RF-PT group was lower though not statistically significant (28.9 vs. 38.8 %, p = 0.197). One death occurred in the RF-PT group 12 days postoperative due to a large area cerebral embolism.

Conclusion

RF-PT is a safe and feasible surgical resection method for patients with cirrhosis and concomitant HCC. In addition, RF-PT results in lower blood loss and lower morbidity than the CC technique during liver resection.     

Extracranial glioblastoma in transplant recipients

Purpose

Traditionally, gliomas are considered to be confined to the central nervous system. The shortage of solid donor organs resulted in consideration of organs from patients with primary malignancy such as glioblastoma multiforme (GBM) for transplantation into patients suffering from end-stage organ disease.

Methods

We performed a PubMed search including all studies that documented patient demographics, pre- and post-transplantation conditions as well as time to metastasis and overall survival in recipients of organ transplants from donors suffering from GBM.

Results

A total of 11 studies with 11 patients were included in this review. Three patients had liver, three had kidney, and five had lung transplantation. For kidney transplants, average time to metastasis was 17.3 months post-surgery. The average follow-up time was 32.3 months, and all patients were doing well. All liver transplant recipients succumbed due to GBM metastasis. The average survival was 7 months for all three patients. For lung-receiving patients, two patients died at an average of 9.5 months post-transplantation, with a mean time to metastasis of 9 months. Two patients were doing well at 17- and 20-month follow-up. One patient was diagnosed with metastasis 12 months after transplantation, but no follow-up data were provided.

Conclusions

These studies emphasize the disadvantage of transplanting an organ of an individual with GBM. However, it should be noted that these cases do not make up a large percentage of overall transplantations, and donors with primary central nervous system malignancies also do not represent the whole pool of organs available.     

The reduction rate of serum C3 following liver transplantation is an effective predictor of non-anastomotic strictures

Purpose

Non-anastomotic biliary strictures (NAS) are considered to be the thorniest complications following liver transplantation (LT). How to predict and adopt specific measures early to minimize the occurrence of it remains unclear. In this study, we aimed to find the relationship between the change rate of serum complement level and NAS.

Methods

In a series of 232 adult patients who underwent their first LT, serum C3 and C4 concentrations at predetermined time points were collected. The correlation between the change rate of serum complement level following LT and the clinical outcome of NAS was retrospectively studied.

Results

The reduction rate of serum C3 at the 1st day following LT in NAS patients was significantly different from that in non-NAS patients (p < 0.01). Receiver operating characteristic curve analysis demonstrated that the reduction rate of serum C3 is an effective predictor of NAS with an area under curve of 82.5 % (95 % CI 77.0–87.2 %). The reduction rate of C3 in the severe NAS group was significantly higher than that in the mild NAS group and the non-NAS group (p < 0.01).

Conclusions

Complement activation plays important roles on the progression of NAS. The reduction rate of serum C3 is an effective predictor of NAS.