Survival after pediatric liver transplantation: why does living donation offer an advantage?

HYPOTHESIS: Living donor liver transplantation (LDLT) results in improved survival compared with deceased whole and split organ transplantation in children. OBJECTIVE: To evaluate the effect of LDLT on graft and patient survival in pediatric liver transplantation. DESIGN: Retrospective cohort. METHODS: Data included all pediatric recipients (aged <18 years) registered in the UNOS (United Network for Organ Sharing) database from October 1, 1987, to May 24, 2004. Covariates predictive of survival by univariate analyses were included in the Cox proportional hazards regression models in a blockwise fashion to determine predictors of survival. RESULTS: Kaplan-Meier graft and patient survival rates were improved in LDLT recipients compared with recipients of deceased whole and split organ transplantations (P<.01). In the initial model (model P<.001), prognostic factors for graft and patient survival included recipient age, race, origin of liver disease, certain pretransplantation laboratory data, medical condition, multiorgan transplantation, retransplantation, recipient-donor ABO blood compatibility, and cold and warm ischemia times. The addition of graft type to the initial covariate set did not significantly change the model (P = .21, covariate P = .09). However, most of the positive prognostic factors identified in the model were inherent characteristics of LDLT recipients and the LDLT procedure. CONCLUSIONS: Graft and patient survival in the pediatric population is better with LDLT than deceased organ transplantation. Factors that contribute to this difference include recipients who are less ill, who have shorter cold and warm ischemia times, and those with a decreased need for retransplantation but not the type of graft per se.     

The evolution of anterior sector venous drainage in right lobe living donor liver transplantation: does one technique fit all?

In living donor liver transplantation (LDLT), an adequate hepatic venous outflow constitutes one of the basic principles of a technically successful procedure. The issue of whether the anterior sector (AS) of the right lobe (RL) graft should or should not be routinely drained has been controversial. The aim of this 10-year, single-center, retrospective cohort study was to review the evolution of our hepatic venous outflow reconstruction technique in RL grafts and evaluate the impact of routine AS drainage strategy on the outcome. The study group consisted of 582 primary RL LDLT performed between July 2004 and December 2014. The cases were divided into 3 consecutive periods with different AS venous outflow reconstruction techniques, which included middle hepatic vein (MHV) drainage in Era 1 (n=119), a more selective AS drainage with cryopreserved homologous grafts in Era 2 (n=391), and routine segment 5 and/or 8 oriented AS drainage with synthetic grafts in Era 3 (n=72). Intraoperative portal flow measurement with routine splenic artery ligation (SAL) technique (in RL grafts with a portal flow of ≥ 250 mL/min/100 g liver tissue) was added later in Era 3. These 3 groups were compared in terms of recipient and donor demographics, surgical characteristics and short-term outcome. The rate of AS venous drainage varied from 58.8% in Era 1 and 35.0% in Era 2 to 73.6% in Era 3 (P<0.001). Perioperative mortality rate of recipients significantly decreased over the years (15.1% in Era 1 and 8.7% in Era 2 vs. 2.8% in Era 3, P=0.01). After the addition of SAL technique in the 45 cases, there was only 1 graft loss and no perioperative mortality. One-year recipient survival rate was also significantly higher in Era 3 (79.6% in Era 1 and 86.1% in Era 2 vs. 92.1% in Era 3, P=0.002). Routine AS drainage via segment 5 and/or 8 veins using synthetic grafts is a technique to fit all RL grafts in LDLT. Addition of SAL effectively prevents early graft dysfunction and significantly improves the outcome.     

Does model for end-stage liver disease score predict the short-term outcome of living donor liver transplantation?

Objective

The objective of this study was to evaluate the predictive ability of the Model for End-Stage Liver Disease (MELD) score for short-term outcomes after living donor liver transplantation (LDLT).

Patients and Methods

The 135 consecutive patients who underwent LDLT did not include prisoners or their organs. Patients were divided into a low (group A; MELD score <15), a moderate (group B; MELD score ≥15 but <25), and a high MELD score (group C; MELD score ≥25) group according to their preoperative score. We retrospectively analyzed the data concerning complications, biochemical parameters, and survival over 90 postoperative days.

Results

Complications were similar among patients with a low, moderate, or high MELD score. The 90-day survival rates of group A, B, and C were 88%, 90%, and 90%, respectively (P = .960). Compared with groups A and B, group C showed a longer mean intensive care unit (ICU) stay.

Conclusion

Preoperative MELD score may not help to predict short-term outcomes of LDLT. However, a high MELD score may be related to a prolonged ICU stay.     

How does age affect the outcome of kidney transplantation in elderly recipients?

The aging of the on‐dialysis population raises the issue of whether to propose elderly patients for kidney transplantation and how to manage their immunosuppression. This study aimed to analyze the outcome of kidney transplantation on an Italian series of elderly recipients. We included in this retrospective study all patients over 60 years, receiving a deceased‐donor kidney transplantation from January 2004 to December 2014 in two north Italian Centers. We analyzed the correlation of recipient age with graft's and patient's survival, delayed graft function, acute cellular rejection (ACR), surgical complications, infections, and glomerular filtration rate. Four hundred and fifty‐two patients with a median age of 65 years were included in the study. One‐, 3‐, and 5‐year patient's and graft's survival were, respectively, of 98.7%, 93%, 89% and 94.4%, 87.9%, 81.4%. The increasing recipient age was an independent risk factor only for the patient's (P=.008) and graft's survival (P=.002). ACR and neoplasia were also associated to a worse graft survival. The reduced graft survival in elderly kidney recipients seems to be related more to the increasing recipient's age than to the donor's features. In this population, the optimization of organ allocation and immunosuppression may be the key factors to endorse improvements.     

A pilot study of the tolerability and efficacy of antiviral therapy in hepatitis C virus–infected patients awaiting liver transplantation

Decompensated liver disease associated with chronic hepatitis C virus (HCV) infection is the most common indication for liver transplantation. It was shown previously that greater pretransplantation HCV titers are associated with relatively poor patient and graft survival. The tolerability and efficacy of antiviral therapy in patients with decompensated liver disease are not known. We conducted a pilot study to determine the likely tolerability and efficacy of pretransplantation antiviral therapy with interferon alfa-2b, with or without ribavirin. HCV RNA–positive patients at or near the top of their respective waiting lists were randomly assigned to one of three treatment regimens until the time of liver transplantation: (1) group A, interferon alfa-2b, 1 × 10⁶ U/d; (2) group B, interferon alfa-2b, 3 × 10⁶ U three times weekly; or (3) group C, interferon alfa-2b, 1 × 10⁶ U/d, plus ribavirin, 400 mg twice daily. Less than half the patients screened met entry criteria, with thrombocytopenia and leukopenia the most common reasons for exclusion. Fifteen patients were administered antiviral therapy; three patients in group A and six patients each in groups B and C. Loss of detectable HCV RNA was seen in 33% of patients, whereas 55% had a decrease in viral titers on therapy. Twenty-three adverse events occurred, including 20 serious adverse events. Thrombocytopenia was the most common adverse event. Two infectious complications occurred; one of these had a fatal outcome. We conclude that although pretransplantation antiviral therapy may reduce HCV titers in a minority of patients who meet treatment initiation criteria, adverse events associated with therapy are frequent and often severe in patients with Child's class B and C cirrhosis. (Liver Transpl 2002;8:350-355.)     

Does graft hemodynamics affect the risk of hepatocellular carcinoma recurrence after liver transplantation?

Although experimental studies have reported that hepatic ischemia-reperfusion injury promotes tumor growth and metastases, the impact of graft hemodynamics on the recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) is unclear. To investigate the association between graft hemodynamics and HCC recurrence after LT, we conducted a retrospective analysis of 279 patients who underwent LT for HCC. Graft hemodynamics including portal vein flow (PVF), hepatic artery flow (HAF), and total hepatic flow (THF) was analyzed as a predictor of HCC recurrence, using competing risk regression analyses. The cutoff values of PVF, HAF, and THF were set at the lower quartile of distribution. A cumulative recurrence curve demonstrated that low THF (<1511 mL/min, P = .005) was significantly associated with increased recurrence, whereas neither low PVF (<1230 mL/min, P = .150) nor low HAF (<164 mL/min, P = .110) was significant. On multivariate analysis, outside Milan criteria (sub-hazard ratio [SHR] = 3.742; P < .001), microvascular invasion (SHR = 3.698; P < .001), and low THF (SHR = 2.359; P = .010) were independently associated with increased HCC recurrence. In conclusion, our findings suggest that graft hemodynamics may play an important role in HCC recurrence after LT.     

Long-term survival following radiofrequency ablation of colorectal liver metastases: A retrospective study

AIM: To retrospectively evaluate the long-term survivalof patients that received radiofrequency ablation(RFA) therapies of colorectal liver metastases. METHODS: In 2005 to 2008, RFA of 105 colorectal liver metastases(CRLM) were performed on 49 patients in our institution. The liver metastases were evaluated, both before and after ablation therapies, with contrast enhanced computerised tomography and contrast enhanced ultrasonography. Histological evidence of malignant liver metastases was obtained in the few instances where contrast enhanced ultrasonography gave equivocal results. Accesses to the CRLM were guided ultrasonically in all patients. The data obtained from records of these ablations were retrospectively analysed and survival data were compared with existing studies in the literature.RESULTS: 1-, 2-, 3-, 4- and 5-year survival rates, when no stringent selection criteria were applied, were 92%, 65%, 51%, 41% and 29% respectively. To explore the impact of the number and size of CRLM on patients' survival, an exclusion of 13 patients(26.5%) with number of CRLM ≥ 5 and tumour size ≥ 40 mm resulted in 1-, 2-, 3-, 4- and 5-year survival rates improving to 94%, 69%, 53%, 42% and 31% respectively. It is of note that 9 of 49 patients developed extra-hepatic metastases, not visible or seen on pretreatment scans, just after RFA treatment. These patients had poorer survival. The development of extra-hepatic metastases in nearly 20% of the patients included in our study can partly account for modestly lower survival rates as compared with earlier studies in the literature.CONCLUSION: Our study underscores the fact that optimum patients' selection before embarking on RFA treatment is vitally important to achieving a superior outcome.     

Outflow block secondary to stenosis of the inferior vena cava following living-donor liver transplantation?

Although it is well known that outflow block is caused by stenosis or occlusion of hepatic vein anastomoses following living donor liver transplantation (LDLT), there have been few reports on inferior vena cava (IVC) stenosis following LDLT. In this paper, we report two cases of IVC stenosis and hepatic vein outflow block following right hepatic LDLT in the absence of stenosis of any of the anastomoses. Both patients presented with liver dysfunction, an ascitic fluid volume of approximately 2000 mL, and congestion in their biopsy specimens, and venocavography demonstrated IVC stenosis with gradients of more than 10 mmHg in patients with a dominant inferior right hepatic vein (IRHV) anastomosis. After a Gianturco expandable metallic stent successfully implanted in the IVC, the patient's liver function recovered and the volume of ascitic fluid decreased. The pathogenesis of hepatic vein outflow block secondary to IVC stenosis following LDLT may involve the anastomosis with the IRHV, which is the dominant draining vein of the graft and larger than the RHV, caudal to the IVC stenosis and a significant IVC pressure gradient that results in increased IRHV pressure. In conclusion, it is important to include hepatic vein outflow block in the differential diagnosis when patients who have undergone right hepatic LDLT in which anastomosis of the large IRHV has been performed develop manifestations of liver dysfunction.     

How does the type of thoracotomy affect the patient quality of life? A short form-36 health survey study

Purpose

We evaluated whether the quality of life was affected in patients who had undergone various types of thoracotomy using the Short Form-36 Health Survey.

Methods

The patients who had undergone thoracotomy for diagnosis or treatment between January and September 2011 in the Thoracic Surgery Department were investigated to determine the effect of the type of thoracotomy on the quality of life using the Short Form-36 Health Survey. The patients were classified into three groups. In Group I, the latissimus dorsi and the serratus anterior had both been preserved, and there was no muscle dissection, in Group II the latissimus dorsi muscle had been dissected and only the serratus anterior muscle has been preserved, and in Group III both muscles had been dissected, and the standard posterolateral muscle dissection had been performed.

Results

A total of 101 patients comprising 64 males (63.37 %) and 37 females (36.63 %), with a median age of 38 years, were included in this study. There were significant differences in all quality of life subscales between Groups I and III and between Groups II and III. The patients in Group I had the highest scores, while the patients in Group III had the lowest scores. There were no significant differences in five of the eight Short Form-36 subscales and one of the two summary scores values between Group I and Group II in females.

Conclusions

We investigated the effect of the type of thoracotomy on the patient quality of life using the Short Form-36 Health Survey, and found that the standard posterolateral thoracotomy had a marked adverse effect on the quality of life compared to muscle-sparing thoracotomy. We also found that it is possible to use thoracotomy with serratus preservation rather than muscle-sparing thoracotomy in cases with benign diseases where a large field of view is required, such as for decortication and pulmonary hydatid cysts, without any significant decrease in the quality of life, especially in females.     

Use of stenting in living donor kidney transplantation: does it reduce vesicoureteral complications?

The risk of urologic complications after kidney transplantation is 0% to 30%. We studied the impact of prophylactic stent placement during transplantation by assessing the necessity for a percutaneous nephrostomy (PCN) after living kidney transplantation. From January 2003 to December 2007, 342 living donor kidney transplantations were performed. Intra- and postoperative data were collected retrospectively from 285 patients with stent and 57 without. Baseline characteristics were not significantly different between groups, except for the number of previous transplantations: 31 (11%) patients with versus 16 (28%) without stent had a history of >1 transplantation (P < .001). From patients with PCN, 55 (87%) patients in the stented group received a PCN <3 months versus 11 (100%) in the nonstented group (P = .71). The reoperation rate for urologic complications was similar in both groups (3% (stented) versus 5% (nonstented; P = .43). In multivariate analysis, risk for PCN was similar in both groups (odds ratio 1.21, 95% confidence interval 0.5-2.5). Recipient survival was not significantly different. One- and 3-year death-censored graft survival was not significantly different between stented (89% and 84%) and nonstented group (90% and 85%, P = .71 and P = .96). Ureteral stent insertion is not associated with a reduced rate of PCN placement in living donor kidney transplantation.     

What do we know about the clinical impact of complete withdrawal of immunosuppression in liver transplantation?

The liver is a privileged organ with a lower incidence of rejection than other organs. However, immunosuppressive regimens are still required to control the alloreactive T-lymphocyte response after transplantation. These treatments may lead to severe complications, such as infectious diseases, cancers, cardiovascular diseases, and chronic renal insufficiency. In clinical transplantation, there is increasing evidence that some liver transplant recipients who cease taking immunosuppressive drugs maintain allograft function, suggesting that tolerance is already present. This strategy is feasible in 25% to 33% of liver transplant recipients. Few of the studies performed so far have provided a detailed analysis of the impact of immunosuppression (IS) withdrawal on pre-existing complications derived from the long-term administration of immunosuppressive drugs and the side effects associated with it. In preliminary studies, IS withdrawal was safely achieved in selected liver transplant patients, and improved not only kidney function, but also other IS-associated side-effects such as hypercholesterolemia, hyperuricemia, hypertension, and diabetes control. However, longer follow-up periods are needed to confirm the benefits of IS withdrawal in liver transplant patients.     

Does obesity affect the plasma level of Plasminogen Activator Inhibitor-1? And does CO2 pneumoperitoneum affect it?

BackgroundThis prospective controlled study was designed to evaluate the effect of obesity on the plasma level of Plasminogen Activator Inhibitor-1 (PAI-1) and also to evaluate the effect of CO₂ pneumoperitoneum on the plasma level of PAI-1 in patients underwent laparoscopic surgery.MethodsThe study included two groups; first group (non obese) included 30 patients with normal average BMI underwent laparoscopic cholecystectomy while the second group included 30 obese patients with BMI > 30 kg/m² underwent laparoscopic band ligation or fundoplication surgery. Five ml of venous blood was collected from each patient in the non obese group once before induction of anesthesia while three venous blood samples (5 ml) were collected from each patient in the obese group as follows: first sample was taken before induction of anesthesia to compare it with the non obese group, second sample was taken after 1 h of CO₂ insufflations (to know the effect of CO₂ insufflations on PAI-1 level) and third sample was taken 1 week after surgery (to know the remaining effect in the postoperative period).ResultsThe level of PAI-1 was significantly high (5.423 ± 2.5 ng/ml) in the obese patients compared to non obese patients (1.4 ± 0.641 ng/ml) (P value = 0.001). The level of PAI-1 was significantly high after CO₂ insufflations compared to baseline level (6.396 ± 2.542 ng/ml vs. 5.423 ± 2.5 ng/ml) in obese group (P value = 0.001). And this level also showed significant increase up to 1 week (6.01 ± 2.492 ng/ml vs. 5.423 ± 2.5 ng/ml) (P value = 0.028) in the obese group.ConclusionThe PAI-1 level was higher in obese patients when compared to non obese patients. PAI-1 level was elevated after CO₂ insufflations and this elevation did not reach base line level up to 1 week after laparoscopic surgery.     

Impact of stable PGI₂ analog iloprost on early graft viability after liver transplantation: a pilot study

Bärthel E, Rauchfuß F, Hoyer H, Habrecht O, Jandt K, Götz M, Voigt R, Heise M, Marx G, Settmacher U. Impact of stable PGI₂ analog iloprost on early graft viability after liver transplantation: a pilot study.
Clin Transplant 2012: 26: E38–E47.
© 2011 John Wiley & Sons A/S. Abstract: Background: Ischemia/reperfusion injury after liver transplantation (LT) may be associated with primary graft dysfunction (PDF) or non‐function. Prostaglandins were demonstrated to be beneficial in reducing ischemic injury by improving microcirculation and protecting endothelial cells. The aim of this study was to analyze the effect of the continuously administered prostaglandin I₂ analog iloprost on allograft function after LT. Methods: Eighty patients were prospectively randomized and assigned to two groups. Patients in the treatment group received iloprost for seven d after transplantation, and those in the control group did not. The primary end point was graft dysfunction. Results: The incidence of PDF was 20% (n = 8) in the control group and 5% (n = 2) in the treatment group, respectively (p = 0.087). Four patients in the control group underwent re‐transplantation for initial non‐function (INF). There was no evidence for INF in the treatment group. Iloprost was associated with improved allograft function. Clinical course and outcome were comparable. Conclusions: We suggest iloprost to be beneficial for early post‐transplant liver function. If the rate of PDF can be significantly reduced with this treatment concept, it should be analyzed in a larger number of patients (ISRCTN95672167).