Comparing the Outcomes of Deceased-Donor and Living-Donor Liver Re-Transplantation In Adult Patients

BackgroundPatients with liver graft failures have an extremely low chance of finding a cadaveric graft in countries with a scarcity of deceased donors. We compared the outcomes of liver re-transplantation with living-donor liver grafts (re-LDLT) and deceased-donor liver grafts (re-DDLT) in adult patients (>18 years).MethodsThe medical records of 1513 (1417 [93.6%] LDLT and 96 [6.3%] DDLT) patients who underwent liver transplantation at Memorial Hospital between January 2011 and October 2022 were reviewed. Forty patients (24 adults and 16 pediatric) were re-transplanted (2.84%); 24 adult patients (2.72%: 25 re-LDLT, 1 patient with second re-LDLT) were divided into 2 groups: re-DDLT (n = 6) and re-LDLT (n = 18). The groups were compared in demographics, pre-, peri-, postoperative characteristics, and outcomes.ResultsThe overall survival rates were 91.7%, 79.2%, 75.0%, and 75% for <30 days, 31 to 90 days, 1, and 3 years, respectively. The LDLT group was significantly younger (P = .022), had smaller graft weight (P = .03), shorter mechanical ventilation (P = .036) but longer operation time (P = .019), and hospitalization period (P = .003). The groups were otherwise comparable. There was no statistically significant difference in survival rates between the groups (P = .058), although the re-LDLT group had an evidently higher survival rate (88.9% and 83.3 % vs 50.0%).ConclusionRe-LDLT has shown comparable outcomes to re-DDLT, if not better (even not far from significance P = .058). These results may encourage performing re-LDLTs in patients with indications for re-LT without worrying about low chances of survival, especially in countries with limited sources of deceased donors.     

Predicting Early Graft Dysfunction and Mortality After Liver Transplant Using the De Ritis Ratio

BackgroundPredicting complications after liver transplantation (LT) remains challenging. We propose incorporating the De Ritis ratio (DRR), a widely known parameter of liver dysfunction, into current or future scoring models to predict early allograft dysfunction (EAD) and mortality after LT.MethodsA retrospective chart review was conducted on 132 adults receiving a deceased donor LT from April 2015 to March 2020 and their matching donors. Donor variables, postoperative liver function, and DRR were correlated with the occurrence of EAD, post-transplant complications expressed by the Clavien-Dindo score, and 30-day mortality as outcome variables.ResultsEarly allograft dysfunction was observed in 26.5% of patients and 7.6% of patients who died within 30 days after transplant. Recipients were more likely to experience EAD when receiving grafts from donation after circulatory death (P = .04), donor risk index (DRI) >2 (P = .006), ischemic injury at time-zero biopsy (P = .02), longer secondary warm ischemia time (P < .05), or higher Clavien-Dindo scores (IIIb-V; P < .001). The DRI, total bilirubin, and DRR on postoperative day 5 yielded significant associations with the primary outcomes and were used to develop the Gala-Lopez score using a weighted scoring model. This accurately predicted EAD, high Clavien-Dindo, and 30-day mortality in 75%, 81%, and 64% of patients.ConclusionIncluding recipient and donor variables in predictive models, and for the first time DRR, as a constituent, should be regarded to predict EAD, severe complications, and 30-day mortality post-LT. Further studies will be required to validate the present findings and their applicability when using normothermic regional and machine perfusion technologies.     

Management of Liver Transplantation Waiting List for Decompensated Cirrhosis in a Spanish Tertiary Hospital: Differences Between Hepatitis C Virus Recipients and Other Etiologies

BackgroundDecompensated cirrhosis due to hepatitis C virus (HCV) is one of the main indications for liver transplantation (LT) in Spain. Recurrence of HCV after LT is the main cause of graft loss and death in HCV-positive recipients. Advanced donor age determines a more aggressive recurrence of HCV and a shorter survival. In this setting, in our liver unit, grafts from younger donors are allocated to HCV-positive recipients. The aim of this study was a comparative analysis of allocation of grafts in HCV-positive recipients versus other etiologies and the impact on waiting list time, Model for End-Stage Liver Disease (MELD) score progression until LT, need of admission in a hospital, survival until LT.MethodsThis was a retrospective study from the cohort of patients included in the waiting list for LT owing to decompensated cirrhosis in the Hospital Gregorio Marañón from January 2008 to June 2013.ResultsA total of 91 patients were included; 63 patients (69.23%) received LT; 19 (20.88%) retired from the waiting list: 6 because of improvement, 11 (12.08%) because of death. In both groups, the age of recipients was similar (HCV 52 y vs other 53 y; P = .549). HCV patients were included in the waiting list with lower MELD score than other etiologies (HCV 16.1 vs other 19.4; P = .010); nevertheless, MELD score was similar at the time of LT in both groups (HCV 18.9 vs other 19.4; P = .675). Time on waiting list was significantly longer in HCV patients (198 d vs 86 d; P = .002) and they were admitted in hospital more days (30 d vs 12 d; P = .03). Donor age in the HCV group was significantly lower (64.3 y vs 54.7 y; P = .006). The intention-to-treat survival analysis did not show differences between the groups (log rank = 0.504).ConclusionsHCV patients with decompensated cirrhosis receive grafts from younger donors. HCV patients remain waiting longer for an optimal organ and suffer MELD deterioration and more days admitted in hospital. These differences in allocation of grafts did not affect final survival. In our experience, designating younger organs to HCV-positive patients does not penalize neither HCV recipients nor recipients with other etiologies.     

Liver-Related and Cardiovascular Outcome of Patients Transplanted for Nonalcoholic Fatty Liver Disease: A European Single-Center Study

BackgroundThe increasing rate of liver transplantation (LT) for nonalcoholic fatty liver disease (NAFLD) raises concerns on cardiovascular morbidity and mortality after LT in these patients.MethodsWe collected variables regarding the presence of metabolic risk factors, NAFLD recurrence, cardiovascular morbidity, and overall survival at time of listing and after LT of 112 patients with NAFLD and a control group of 120 patients with hepatitis C (HCV).ResultsMetabolic syndrome and cardiovascular morbidity component rates (24.1% vs 12.5%) at the time of LT listing were higher in patients with NAFLD compared with patients with HCV (for all, P < .0390). Median follow-up after LT was 5.6 years in patients with NAFLD vs 13.5 years in patients with HCV (P = .0009). There was no difference in 6-weeks postoperative mortality (1.7% vs 2.5%) (P =1.0000). Metabolic syndrome components after LT were more frequent in patients with NAFLD than in patients with HCV (for all, P < .0008). The incidence of NAFLD 5 years after LT was higher in patients transplanted for NAFLD compared with HCV (43.5% vs 4.2%) (P < .0001). Patients with recurrent NAFLD more often had myocardial infarction compared with those without recurrence (8.3% vs 0%) (P = .0313). Five years after LT, cardiovascular morbidity was more frequent in the NAFLD group than in the HCV group (12.8% vs 9.3%) (P = .0256), whereas no difference in overall survival was observed.ConclusionLT for NAFLD is associated with satisfactory 5-year outcomes; however, our data underscore the need for close monitoring and aggressive management of cardiovascular risk factors in these patients.     

Hemoderivative Transfusion in Liver Transplantation: Comparison Between Recipients of Grafts From Brain Death Donors and Recipients of Uncontrolled Donors After Circulatory Death

IntroductionIntraoperative bleeding during liver transplantation has been correlated with a higher risk of morbidity and mortality and decrease in patient and graft survival.Materials and MethodsBetween January 2006 and December 2016 we performed 783 orthotopic liver transplants. After applying exclusion criteria, we found liver grafts from donors after circulatory death (DCD, group A) were used in 69 patients and liver grafts from donors after brain death (group B) were used in 265 patients.ResultsNo difference was found in terms of sex, body mass index, Model for End-Stage Liver Disease score, indication for transplantation, intensive care unit stay, and Child-Pugh score. The mean transfusion of hemoderivates was as follows: red blood cell 9 (0-28) units in group A vs 6 (0-20) units in group B (P = .004) and fresh frozen plasma 10 (0-29) units in group A vs 9.5 (0-23) in group B (P = .000). The only 2 factors related to massive blood transfusion (>6 units of red blood cell) were uncontrolled DCD condition (odds ratio = 2.38; 95% confidence interval, 1.32-4.31; P = .004), and higher Model for End-Stage Liver Disease score (odds ratio = 2.63; 95% confidence interval, 1.53-4.55; P = .001). Survival at 1, 3, and 5 years was 81.3%, 70.2%, and 68.9% in group A vs 89%, 83.7%, and 78% in group B (P = .070).ConclusionThe use of liver grafts from DCDs is associated with increased necessity of transfusion of hemoderivates in comparison with the use of liver grafts from donors after brain death.     

Outcomes of Surgical Strategies for Living Donor Liver Transplantation in Patients With Portal Vein Thrombosis: A Cohort Study

BackgroundAdequate portal flow to the liver graft is the requirement of a successful liver transplant (LT). Historically, portal vein thrombosis (PVT) was a contraindication for LT, especially for living donor LT (LDLT), demanding technically more difficult operations and advanced technique. In this study, the outcomes of patients with and without PVT after LDLT were compared.MethodsAdult LDLTs performed by 2 centers (n = 335) between 2013 and 2020 were included into this large cohort study. PVT was classified based on Yerdel classification grade 1 to 4.ResultsSixty-two patients with PVT constituted 19% of the study cohort of 335 recipients. While mean platelet count was found to be lower (P = .011) in the PVT group, patient age (P = .035), operation duration (P = .001), and amount of intraoperative blood transfusion (P = .010) were found to be higher. Incidence of PVT was higher in female patients than males (22.7% vs 16.1%, P = .037). There was no significant difference in survival between patients with and without PVT on 30-day (P = .285), 90-day (P = .565), 1-year (P = .777), and overall survival (P = .917). Early thrombosis did not show a better survival rate than Grades 2, 3, or 4 PVT. Thrombosis limited to portal vein was not found to bring a survival advantage compared with Grade 3 and 4 thromboses. Eversion thrombectomy was the most common procedure (66%) to overcome PVT intraoperatively.ConclusionAlthough technically more challenging, PVT is not a contraindication of LDLT. Similar outcomes can be achieved in LDLT in patients with PVT after proper restoration of portal flow, which eliminates the default survival disadvantage of patients with PVT.     

Prognostic Factors Evaluation for Liver Transplant Mismatching: A New Way of Selecting and Allocating Organs

BackgroundLiver transplant (LT) is the standard therapy for end-stage liver disease. Advances in surgical techniques and immunosuppression protocols improved the results of LT by increasing long-term survival. Nevertheless, an adequate match between the donor and recipient is paramount for avoiding futile liver transplants. We aimed to identify the prognostic factors in donor-recipient LT matching.MethodsRetrospective analysis of adult LT was conducted from January 2006 to December 2018, which included the following transplant modalities: deceased donor LT (DDLT), living donor LT (LDLT), combined liver-kidney transplant (CLKT), and domino LT (DLT).ResultsAmong 1101 patients who underwent LT, 958 patients underwent DDLT, 92 patients underwent LDLT, 45 patients underwent CLKT, and 6 patients underwent DLT. The overall survival (OS) in 1, 5, and 10 years were 89%, 83%, and 82%, respectively. For DDLT, OS in 1, 5, and 10 years were 91%, 84%, and 82%, respectively. For LDLT, OS in 1, 5, and 10 years were 89%, 72%, and 69%, respectively. For CKLT, OS in 1, 5, and 10 years were 90%, 71%, and 71%, respectively. None of the DLT patients died. For DDLT, the factors that affected OS were the presence of fulminant liver failure (odds ratio [OR], 2.23; 95% CI, 1.18-4.18; P = .001), hemodialysis before LT (OR, 2.12; 95% CI, 1.27-3.5; P = .004), retransplant (OR, 4.74; 95% CI, 2.75-8.17; P = .000), and recipient age >60 years (OR, 1.86; 95% CI, 1.27-2.73; P = .001). For hospitalization before LT (due to an acute-on-chronic liver failure), the OR was 2.10 (95% CI, 1.29-3.42; P = .003). Donor intensive care unit time >7 days (OR, 1.46; 95% CI, 1.04-2.06; P = .02) was also associated with overall mortality.ConclusionsWe identified prognostic factors in donor-recipient LT matching. Furthermore, we demonstrated that an adequate organ allocation with donor-recipient selection might increase graft survival and reduce waiting list mortality.     

Early Postoperative Transaminase Activities Affecting Early and Late Liver Graft Survival

BackgroundThis study aimed to examine the effect of transaminases’ activities in the first posttransplant day on early (90-day) and late (5-year) graft survival.MethodsThis retrospective cohort study included 612 patients after liver transplantation (LT) in the period between 2015 and 2019. Patients with acute liver failure and with vascular complications after LT were excluded. The natural logarithms of alanine transaminase (ALT) and aspartate transaminase (AST) were used for analyses using the logistic regression and Cox proportional hazards regression models. The optimal cut-off point for transaminases was determined using receiver operating characteristic curves. The 5-year graft survival was calculated after previously excluding the patients with 90-day graft loss.ResultsThe ALT and AST were risk factors for 90-day graft loss (odds ratio 2.16; 95% CI 1.45-3.23; P < .001 and 2.23; 95% CI 1.55-3.19; P < .001, respectively). The optimal cut-off for ALT and AST in prediction of 90-day graft loss was ≥1030 and ≥3899 U/L; area under the curve 0.694 (95% CI 0.602-0.786; P < .001), with 11.3% and 97.1% positive predictive value (PPV) and negative predictive (NPV) value, and 0.673 (95% CI 0.575-0.772; P < .001), with 18.4% PPV and 95.6% NPV, respectively. The activities of AST and ALT on first posttransplant day were not identified as risk factors for late graft loss (P = .924 and P = .629, respectively).ConclusionsEarly post-transplant transaminase activities can be used to determine early liver graft loss; however, their utility is lost for assessing the late graft survival.     

Evaluation of Bone Mineral Metabolism After Liver Transplantation by Bone Mineral Densitometry and Biochemical Markers

AimThis study aimed to evaluate the course of bone and mineral metabolism after liver transplantation (LT) in patients with chronic liver disease.MethodsOne hundred four patients who had undergone LT and had a minimum of 6 months of follow-up after LT were included in this prospective cohort study. The following parameters were evaluated for each patient: preoperative and postoperative (postoperative day [POD]30, POD90, POD180) osteocalcin, bone-specific alkaline phosphatase (BALP), type 1 collagen, beta-C-terminal end telopeptide (β-CTx), vitamin D, parathyroid hormone (PTH), ALP, calcium, phosphate, sedimentation, and bone mineral densitometer scores (L2, L4, L total, and F total). The parameters were compared in terms of sex, presence of liver tumor (hepatocellular carcinoma [HCC; n = 19] vs non-HCC [n = 85]), and presence of autoimmune liver disease (autoimmune liver disease [ALD; n = 8] vs non-ALD [n = 96]).ResultsThe median age of the patients (n = 81 men and n = 23 women) was 52 years (95% CI, 50-56). There was a significant change in the defined time intervals in parameters such as osteocalcin (P < .001), BALP (P < .001), β-CTx (P < .001), vitamin D (P < .001), PTH (P < .001), ALP (P = .001), calcium (P < .001), phosphate (P = .001), L2 (P = .038), L total (P = .026), and F total (P < .001) scores. There was a significant difference in POD90 ALP (P = .033), POD180 calcium (P = .011), POD180 phosphate (P = .011), preoperative sedimentation (P = .032), and POD180 F total (P = .013) scores between both sexes. There was a significant difference in POD180 osteocalcin (P = .023), POD180 β-CTx (P = .017), and preOP calcium (P = .003) among the HCC and non-HCC groups. Furthermore, we found significant differences in preoperative ALP (P = .008), preoperative sedimentation (P = .019), POD90 (P = .037) and POD180 L2 (P = .005) scores, preoperative (P = .049) and POD180 L4 (P = .017), and POD180 L total (P = .010) and F total (P = .022) scores between the patients with and without ALD.ConclusionThis study shows that the bone and mineral metabolism of the LT recipients was negatively affected after LT. In addition, we showed that bone and mineral metabolism was more prominent in patients with HCC, and bone mineral density scores were higher in patients with ALD.     

Graft Regeneration in Pediatric Living Donor Liver Transplantation

Objective

Due to the shortage of cadaver liver grafts in Asia, more than 90% of biliary atresia (BA) patients require living donor liver transplantation (LDLT), but the factors that influence liver graft regeneration in pediatric patients are still unclear. The aim of this study was to evaluate the potential predisposing factors that encourage liver graft regeneration in pediatric liver transplantation (LT).

Methods

Case notes and Doppler ultrasound and computed tomography studies performed before and 6 months after transplantation of 103 BA patients who underwent LDLT were reviewed. The predisposing factors that triggered liver regeneration were compiled from statistical analyses and included the following: age, gender, body weight and height, spleen size, graft weight–to–recipient weight ratio (GRWR), post-transplantation total portal flow, and vascular complications.

Results

Seventy-two pediatric recipients were enrolled in this study. The liver graft regeneration rate was 29.633 ± 36.61% (range, −29.53–126.27%). The size of the spleen (P = .001), post-transplantation portal flow (P = .004), and age (P = .04) were correlated lineally with the regeneration rate. The GRWR was negatively correlated with the regeneration rate (P = .001) and was the only independent factor that affected the regeneration rate. When the GRWR was >3.4, patients tended to have poor and negative graft regeneration (P = .01).

Conclusion

Large-for-size grafts have negative effect on regeneration rates because liver grafts that are too large can compromise total portal flow and increase vascular complications, especially when the GRWR is >3.4. Thus, optimal graft size is more essential than other factors in a pediatric LDLT patient.     

Oral Ribavirin for Treatment of Respiratory Syncytial Virus in Lung Transplantation Recipients

BackgroundRespiratory syncytial virus (RSV) can cause severe respiratory infection and is a risk factor for development of bronchiolitis obliterans syndrome (BOS) in patients who have undergone lung transplantation (LT). The treatment options are limited in this population. We assessed the efficacy of oral administration for the treatment of RSV infection after LT.MethodsA retrospective case-control was conducted in LT patients who documented RSV infection. Demographic, clinical, and efficacy variables (resolution infection, recovery of lung function, incidence of BOS, mortality) was compared between the oral ribavirin (RBV) group and the control group.ResultsThirty-six LT patients were included (19 RBV group, 17 control group). Significant differences were found for age, sex and coinfections. However, no differences of immunosuppressive level and baseline forced expiratory volume in the first second of expiration (FEV₁) were found. RSV clearance was evident in 5 patients (26.3%) of the RBV group vs 2 patients (11.8%) in the control group (odds ratio [OR], 0.37; P = .282). At 3 months, FEV₁ remained stable in 12 patients (80%) of the RBV group vs 13 patients (81.3%) of the control group (OR, 0.92; P = .321). At 6 months, FEV₁ remained stable in 11 patients (73.3%) of the RBV group and 12 patients (75%) of the control group (OR, 1.25; P = .779), and BOS appeared in 6 patients (31.6%) vs 4 patients (23.5%) of the control group (OR, 1.50; P = .591). Mortality rates were 26% (5 patients) in the RBV group vs 29.4% (5 patients) in the control group (OR, 1.40; P = .637).ConclusionsNo significant differences in efficacy parameters were found between groups; however, stabilization without worsening of respiratory function was observed at 3 and 6 months. Because of the variability in the treatment regimen and the heterogeneity of groups, a protocol was developed to standardize and evaluate the use of oral RBV as treatment for RSV in LT.     

Acute Kidney Injury After Pediatric Liver Transplantation

BackgroundThe aim of the present study is to assess acute kidney injury (AKI) incidence according to the pRIFLE and AKIN criteria and to evaluate the risk factors for early developing AKI in postoperative intensive care unit after pediatric liver transplantation (LT).MaterialsAfter exclusion of retransplantations, 7 cadaveric and 44 living donors, totaling 51 pediatric LT patients that were performed between 2005 and 2017, were reviewed retrospectively. AKI was defined according to both pediatric RIFLE (Risk for renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage renal disease) and Acute Kidney Injury Network (AKIN) criteria. Documented data were compared between AKI and non-AKI patients.ResultsAKI incidences were 17.6% by AKIN and 37.8% by pRIFLE criteria. AKIN-defined AKI group had statistically lower serum albumin level, higher serum sodium level, higher furosemide dose, and higher rate of red blood cell (RBC) transfusion than the non-AKI group (P = .02, P = .02, P = .01 and P = .04, respectively). AKI patients had significantly prolonged mechanical ventilation (P = .01) and hospital LOS (P = .02). The pRIFLE-defined AKI group had significantly lower serum albumin level, higher blood urea nitrogen (BUN) level, and higher ascites drained and also showed higher requirement for RBC and 20% human albumin transfusions than the non-AKI group (P = .02, P = .04, P: =.007, P = .02 and P = .05, respectively).ConclusionWe evaluated that hypoalbuminemia, high requirement for RBC and 20% human albumin transfusions, high serum sodium, high furosemide use, and high flow of ascites are risk factors for AKI and high BUN levels can be predictive for AKI in pediatric LT patients. The effect of AKI on outcome variables were prolonged mechanical ventilation and hospital LOS.     

The Significant Prognostic Factors in Prolonged Intensive/High Care Unit Stay After Living Donor Liver Transplantation

BackgroundProlonged stay in an intensive/high care unit (ICU/HCU) after living donor liver transplantation (LDLT) is a significant event with possible mortality.MethodsAdult-to-adult LDLTs (n = 283) were included in this study. Univariate and multivariate analyses were performed for the factors attributed to the prolonged ICU/HCU stay after LDLT.ResultsRecipients who stayed in the ICU/HCU 9 days or longer were defined as the prolonged group. The prolonged group was older (P = .0010), had a higher model for end-stage liver disease scores (P < .0001), and had higher proportions of patients with preoperative hospitalization (P < .0001). Delirium (P < .0001), pulmonary complications (P < .0001), sepsis (P < .0001), reintubation or tracheostomy (P < .0001), relaparotomy due to bleeding (P = .0015) or other causes (P < .0001), and graft dysfunction (P < .0001) were associated with prolonged ICU/HCU stay. Only sepsis (P = .015) and graft dysfunction (P = .019) were associated with in-hospital mortality among patients with prolonged ICU/HCU stay or graft loss within 9 days of surgery. Among these patients, grafts from donors aged <42 years and with a graft-to-recipient weight ratio of >0.76% had significantly higher graft survival than grafts from others (P = .0013 and P < .0001, respectively).ConclusionProlonged ICU/HCU stay after LDLT was associated with worse short-term outcomes. The use of grafts of sufficient volume from younger donors might improve graft survival.     

The Impact of Tenofovir Disoproxil Fumarate on Reduced Bone Mineral Density and Fractures in Liver Transplant Recipients

BackgroundTenofovir disoproxil fumarate (TDF) is associated with reduced bone density in patients with human immunodeficiency virus, but the effect of TDF on bone density in liver transplant (LT) recipients is unknown.MethodsWe performed a single-center, retrospective study of LT recipients with hepatitis B taking TDF compared to a control group with non-hepatitis B virus viral hepatitis. The primary outcome was reduced bone density, defined as femoral neck or lumbar T-score less than ?1. Other outcomes included mean T-score and fractures.ResultsThree hundred ninety-three patients were studied: 52 patients in the TDF group and 341 patients in the control group; 64.3% patients in the TDF group had reduced bone density vs 71.4% in the control group (P = .58) before LT, compared to 75% and 81.5% (P = .57), respectively, after LT. Mean posttransplant lumbar T-scores were lower in the TDF group (?1.74 vs ?0.75, P = .04). There was no difference between the 2 groups for the other outcomes. In a multivariate Cox proportional hazards model, TDF use did not affect the risk of post-LT reduced bone density (hazard ratio = 0.99; 95% confidence interval, 0.56-1.76; P = .97).ConclusionTDF use was not associated with reduced bone mineral density or increased rates of fractures in LT recipients compared to controls in this study.     

The impact of postreperfusion syndrome during liver transplantation using livers with significant macrosteatosis

The impact of postreperfusion syndrome (PRS) during liver transplantation (LT) using donor livers with significant macrosteatosis is largely unknown. Clinical outcomes of all patients undergoing LT with donor livers with moderate macrosteatosis (30%‐60%) (N = 96) between 2000 and 2017 were compared to propensity score matched cohorts of patients undergoing LT with donor livers with mild macrosteatosis (10%‐29%) (N = 96) and no steatosis (N = 96). Cardiac arrest at the time of reperfusion was seen in eight (8.3%) of the patients in the moderate macrosteatosis group compared to one (1.0%) of the patients in the mild macrosteatosis group (P = .02) and zero (0%) of the patients in the no steatosis group (P = .004). Patients in the moderate macrosteatosis group had a higher rate of PRS (37.5% vs 18.8%; P = .004), early allograft dysfunction (EAD) (76.4% vs 25.8%; P < .001), renal dysfunction requiring continuous renal replacement therapy following transplant (18.8% vs 8.3%; P = .03) and return to the OR within 30 days (24.0% vs 7.3%; P = .002), than the no steatosis group. Both long‐term patient (P = .30 and P = .08) and graft survival (P = .15 and P = .12) were not statistically when comparing the moderate macrosteatosis group to the mild macrosteatosis and no steatosis groups. Recipients of LT using livers with moderate macrosteatosis are at a significant increased risk of PRS. If patients are able to overcome the initial increased perioperative risk of using these donor livers, long‐term graft survival does not appear to be different than matched recipients receiving grafts with no steatosis.     

The Requirement of Isoflurane and Remifentanil During Liver Transplantation Using Bispectral Index and Surgical Pleth Index: An Observational Study

BackgroundDuring liver transplantation (LT), patients and surgical factors potentially influence the pharmacokinetics of the anesthetic agents. The aim of this study was to investigate the requirement of isoflurane and remifentanil according to severity of liver disease during LT under balanced anesthesia.MethodsWe enrolled 44 patients undergoing LT. Anesthetic depth was maintained within the bispectral index score of 40 to 60 and Surgical Pleth Index of 20 to 60. Patients were divided into 2 groups according to their median Model for End-Stage Liver Disease (MELD) score: low MELD group and high MELD group. We compared end-tidal inhaled anesthetics and remifentanil consumption.ResultsPatients were divided into 2 groups according to median value of MELD score: MELD score <16 (low MELD group; n = 20) or MELD ≥16 (high MELD group; n = 20). There was no significant difference between the 2 groups in end-tidal concentration of isoflurane during 3 phases. However, the remifentanil requirement was lower in the high MELD group during the dissection and anhepatic phases (mean (SD), 0.105 (0.067) vs 0.064 (0.055) µg/kg/min; P = .037, and 0.167 (0.096) vs 0.108 (0.079) µg/kg/min; P = .039, respectively; low MELD group vs high MELD group) with no significant difference during the neohepatic phase.ConclusionsThe severity of liver dysfunction based on MELD score affected the intraoperative remifentanil requirement during LT. Patients with cirrhosis are required to use analgesics appropriate to their individual patient characteristics in clinical practice.     

The Lactate-to-Platelet Ratio: A Novel Predictor for Short-Term Early Allograft Failure After Liver Transplantation

BackgroundEarly allograft dysfunction (EAD) is a criterion to evaluate initial graft dysfunction associated with inferior graft survival and postoperative complications after liver transplantation (LT). This study defined the lactate-to-platelet ratio (LPR) as lactate level immediately post-LT/platelet count on postoperative day 1 and evaluated its association with EAD and short-term graft failure.Materials and methodsThis study reviewed 434 deceased-donor LTs from individuals with confirmed brain death between January 2008 and December 2014. The area under the curve (AUC) was used to compare the predictive capacity for 3-month graft survival between EAD and the LPR. Along with LPR, the risk factors for 3-month graft failure were analyzed by multivariate analysis.ResultsEAD was reported in 127 patients (31%). The LPR in patients with EAD was significantly higher than that in patients without EAD (9.8 vs 5.9, P < .001). In the multivariate analysis, both the LPR (per 1.0 increase) and EAD were independent risk factors for 3-month graft failure (hazard ratio [HR] =1.03, P = .03; and HR = 9.14, P = .001). The comparison of the AUCs between the LPR and EAD showed no significant difference (0.79 vs 0.78, P = .84), whereas the combination of EAD and LPR had a better predictive capacity than EAD alone (0.86 vs 0.78, P < .001). The LPR showed an inverse relationship for predicting 3-month graft survival.ConclusionsThe LPR is a continuous parameter that enables prediction of initial graft function and estimation of the 3-month graft failure rate with the advantages of early availability and simple calculations.     

Single vs Multiple Arterial Reconstructions in Living Donor Liver Transplant

BackgroundIt is true that multiple arterial reconstructions are sometimes required in living donor liver transplant (LDLT). However, the best procedure is still controversial regarding arterial reconstruction in liver grafts with multiple arteries.MethodsA total of 93 patients, 55 right lobe grafts and 38 left lobe grafts, who underwent LDLT at our university from 2003 to 2017 were enrolled for this study. Regarding arterial reconstruction in grafts with multiple hepatic arteries, the dominant artery was reconstructed first. Subsequently, when both the pulsating arterial flow from the remaining artery stumps and the intra-graft arterial flow by Doppler ultrasonography were confirmed, the remaining arteries were not reconstructed. The patients were divided into the following 3 groups: (1) single artery/single reconstruction (n = 81), (2) selective arterial reconstruction of multiple arterial grafts (n = 7), and (3) multiple arterial reconstructions (n = 5).ResultsA total of 12.9% (12/93; right lobe: 2/55; left lobe 10/38) of grafts had multiple arteries. The incidence of multiple arteries was significantly higher in the left lobe grafts (P = .0029). The arterial diameters (SD) of multiple arterial grafts were narrower (2.43 [0.84] mm) than single arterial grafts (3.70 [1.30] mm) (P = .0135). Extra-anatomic arterial reconstruction were frequently required in multiple arterial reconstructions (group 1 and 2 vs 3) (P = .0007). The strategy of selective arterial reconstruction with the above criteria did not negatively affect the rates of biliary complications or the overall patient survival (P = .52).ConclusionsIt can be argued that selective arterial reconstructions demonstrated acceptable outcomes in LDLT, provided that the above criteria were satisfied.     

Transplantation Using Renal Grafts With Multiple Renal Arteries: A Putative Study on the Impact of Arterial Reconstruction Technique and Site of Implantation on Outcomes

BackgroundIn the present retrospective study, we analyzed the outcomes of patients transplanted with grafts with multiple renal arteries (MRAs).Patients and MethodsIn total, 89 patients were transplanted with renal grafts with MRAs from 2003 to 2018. Demographic characteristics; type of donor; warm and cold ischemia times; arterial anastomosis technique; complications; graft function at first month, first year, and last outpatient clinic visit; and patient and graft survival were all retrospectively evaluated.ResultsThe mean age of the patients was 40.4 ± 13.3 years. Fifty-six patients (62.9%) were male. In total, 42 patients (47.2%) received renal grafts from living related donors. In group A (n = 24; 27%), anastomosis was performed separately to the recipient external or internal iliac arteries; in group B (n = 38; 42.7%), the secondary artery was anastomosed to the main artery in a side-to-side fashion to form a single common orifice; in group C (n = 27; 30.3%), secondary arteries were anastomosed to the main renal artery in an end-to-side fashion. Creatinine clearance at the first month was significantly lower for deceased-donor grafts compared to living-donor renal grafts (P < .05). Creatinine clearance in the first postoperative month was significantly lower in group A and creatinine clearance in the first year was significantly lower in group C (P < .05). The best survival was found for anastomosis to the internal iliac artery (P < .05).ConclusionMRAs can be safely used and the reconstruction technique does not matter if the graft kidney’s arterial supply is preserved and the internal iliac artery is chosen for anastomosis.     

Indication for Liver Transplantation After Direct-Acting Agents in the Treatment of Patients With Hepatitis C

BackgroundThe development of new direct-acting antivirals (DAA) for hepatitis C virus (HCV) treatment has reduced the indications for liver transplantation (LT). We analyzed the indications, characteristics, and evolution of patients with HCV infection who were treated with DAA-based therapies and who underwent LT.Material and methodsA retrospective single-center study was performed. Data were collected of patients undergoing LT owing to HCV infection between January 2016 and August 2020. Overall characteristics of the patients were analyzed and divided into 2 groups according to the indication for LT: hepatocellular carcinoma (HCC) or decompensated cirrhosis (DC). Differences between biliary and vascular complications after surgery and survival time were compared.ResultsOf 156 LTs, 33 (22%) were performed in patients with HCV infection in this period, which shows a decrease of nearly 16% when comparing this period with the interferon/ribavirin era. Indications for LT were 56.7% in patients with HCC and 43.3% in patients with DC. After DAA treatment, all patients developed a sustained viral response. Mean age of the global series, HCC group, and DC group were 56.9, 58.71, and 54.4 years, respectively (P = .041); 53.8% of the HCV-DC group initiated DAA treatment by the time to be included at the waiting list, compared with 17.6% of HCV-HCC group (P = .045). There were no statistically significant differences in terms of survival or biliary and vascular complications after LT.ConclusionPatients with HCV are still part of the waiting list, mainly because of HCC. No statistical differences were shown in terms of postoperative complications or survival. Studies with a higher number of patients are needed.