Nutritional status using subjective global assessment independently predicts outcome of patients waiting for living donor liver transplant

Background

Malnutrition is an important risk factor for adverse outcomes in patients awaiting liver transplant. Living donor liver transplant, being an elective procedure, allows nutritional rehabilitation and optimization of these patients before transplant.

Aim

This paper aimed to evaluate the outcome of end-stage liver disease (ESLD) patients with various degrees of malnutrition waiting for living donor liver transplant.

Methods

Nutritional status was assessed using subjective global assessment (SGA) in patients who were evaluated for a liver transplant at our center from January 2015 to September 2015. All the data were collected prospectively. Predictive factors for mortality were analyzed using logistic regression and survival was obtained using Kaplan-Meier curves.

Results

One hundred and seventeen patients were grouped based on their nutrition status into normal, mild-moderate, and severe malnutrition. The groups were comparable in terms of age, sex, etiology of liver disease except alcoholic liver disease. Graft recipient weight ratio was comparable among groups. There was no significant difference in hospital stay. However, severe malnourished patients had higher incidence of sepsis (p=0.005) and death due to sepsis (p=0.01). Nutritional status was the only independent predictor of mortality on multivariate analysis.

Conclusion

Nutritional status measured with SGA independently predicts short-term outcome of ESLD patients waiting and after living donor liver transplant.

     

Body surface area index predicts outcome in orthotopic liver transplantation

Background/Purpose

In living donor liver transplantation (LDLT), matching of liver volume between donor and recipient is critical to the success of the procedure; mismatch can result in ??small- or large-for-size syndrome??. In orthotopic liver transplantation (OLT), matching criteria are less stringent and non-uniform. We sought to determine whether a new parameter, the ratio of donor to recipient body surface area (BSAi), is predictive of size mismatch and/or post-transplant morbidity or mortality.

Methods

We reviewed data on 1228 OLT recipients and stratified this data according to three categories: small-for-size (BSAi <0.6), control (BSAi?=?0.6?C1.4), and large-for-size (BSAi >1.4) donors.

Results

We found that: (1) matching of grafts at the upper and lower extremes of BSAi had significantly reduced graft survival; (2) matches with lower BSAi sustained a less severe form of intraoperative post-reperfusion syndrome, and the incidence of hepatic artery thrombosis was high postoperatively in these grafts; (3) BSAi and donor age correlated well with the severity of intraoperative post-reperfusion hypotension; and (4) small-for-size (BSAi <0.6) and large-for-size (BSAi >1.4) grafts, as well as preoperative total bilirubin, were significant risk factors for decreased graft survival.

Conclusion

We conclude that the BSAi can predict clinically significant size mismatch and adverse outcomes in cadaveric whole OLT.     

Donor Diabetes Mellitus Is an Independent Risk Factor for Graft Loss in HCV Positive but Not HCV Negative Liver Transplant Recipients

Background and Aims

Graft survival in HCV (hepatitis C virus) infected recipients is worse than those transplanted for other liver diseases. We studied whether several donor cardiovascular risk factors (including advanced age, smoking, hypertension, and diabetes mellitus) contribute to worse outcomes for HCV positive and HCV negative liver transplant recipients.

Methods

We obtained data from the United Network for Organ Sharing on all adult liver transplants performed in the United States between January 1, 1998 and December 31, 2003. In total, 27,033 transplant cases were evaluated. Independent predictors of graft survival were determined using Cox proportional hazards regression analysis after controlling for factors previously found to be associated with differences in transplant outcomes.

Results

Donor diabetes was a strong independent risk factor for graft failure [hazard ratio (HR) = 1.20, p = 0.006] only in HCV positive recipients. Neither donor smoking status nor hypertension predicted graft loss in either cohort. Consistent with previous studies, advanced donor age, donation after cardiac death, height, and African American donor all predicted graft loss amongst both cohorts.

Conclusion

Accounting for donor diabetes in relation to recipient HCV status in the selection of liver recipients may result in improved graft survival.

     

The impact of 3-D virtual hepatectomy simulation in living-donor liver transplantation

Background/Purpose

In living-donor liver transplantation, accurate assessments of liver graft volume and anatomical variation are mandatory for the preoperative planning of safe donor hepatectomy and successful recipient implantation. The aim of this study was to assess the feasibility and accuracy of novel three-dimensional (3-D) virtual hepatectomy simulation software in living-donor liver transplantation.

Methods

We developed the hepatectomy simulation software, which was programmed to analyze detailed 3-D vascular structure and to predict liver graft volume, based on hepatic circulation.

Results

In 101 individuals, including 4 living donors, the predicted liver resection volumes revealed a significant correlation with the actual value (P < 0.0001), with a mean difference of 7.9?ml. The drainage area by the individual hepatic vein branch was quantified to achieve reconstruction of the corresponding venous branch. The application of multidetector computed technology scanning and virtual cholangioscopy facilitated more detailed visualization of the 3-D hilar anatomy in a left trisectoral graft transplantation.

Conclusions

This hepatectomy simulation software reliably predicted accurate liver graft volume and the drainage volume of hepatic vein branches. This software may contribute to the preoperative planning of safe donor hepatectomy and implantation with satisfactory graft viability.     

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.     

Postoperative impaired glucose tolerance is an early predictor of pancreas graft failure

Aims/hypothesis

The management of pancreatic transplantation is limited by a lack of clinically relevant early markers of graft dysfunction to enable intervention prior to irreversible damage. The aim of this study was to assess the OGTT as an early predictor of pancreatic graft failure.

Methods

Patients with graft failure (return to insulin dependence) were identified from a prospectively maintained clinical database. Data from OGTTs performed within 2 weeks of the transplant were retrospectively collected for 210 subjects, 42 with graft failure (21 after simultaneous pancreas–kidney transplant and 21 after isolated pancreas transplant) matched to 168 with functioning grafts. The groups were compared to assess the relationship between early OGTT result and pancreas graft failure.

Results

Mean 2 h glucose from the OGTT was significantly higher in the overall graft failure group compared with the control group (8.36 vs 6.81 mmol/l, p?=?0.014). When interpreted in combination with fasting glucose, abnormal glucose tolerance was more common in the failed graft group (50% vs 22%, p?=?0.001). In an adjusted model, abnormal glucose tolerance emerged as the most predictive independent factor for graft failure, HR 1.66 (95% CI 1.22, 2.24), p?=?0.001. These findings were consistent between the different transplant procedures performed.

Conclusions/interpretation

We conclude that early post-transplant abnormal glucose tolerance is associated with later whole organ pancreas graft failure. An OGTT performed within the first month postoperatively provides an easily measurable assessment of an independent early risk factor of pancreatic graft dysfunction.     

Glucose stimulates human beta cell replication in vivo in islets transplanted into NOD�Csevere combined immunodeficiency (SCID) mice

Aims/hypothesis

We determined whether hyperglycaemia stimulates human beta cell replication in vivo in an islet transplant model

Methods

Human islets were transplanted into streptozotocin-induced diabetic NOD?Csevere combined immunodeficiency mice. Blood glucose was measured serially during a 2?week graft revascularisation period. Engrafted mice were then catheterised in the femoral artery and vein, and infused intravenously with BrdU for 4?days to label replicating beta cells. Mice with restored normoglycaemia were co-infused with either 0.9% (wt/vol.) saline or 50% (wt/vol.) glucose to generate glycaemic differences among grafts from the same donors. During infusions, blood glucose was measured daily. After infusion, human beta cell replication and apoptosis were measured in graft sections using immunofluorescence for insulin, and BrdU or TUNEL.

Results

Human islet grafts corrected diabetes in the majority of cases. Among grafts from the same donor, human beta cell proliferation doubled in those exposed to higher glucose relative to lower glucose. Across the entire cohort of grafts, higher blood glucose was strongly correlated with increased beta cell replication. Beta cell replication rates were unrelated to circulating human insulin levels or donor age, but tended to correlate with donor BMI. Beta cell TUNEL reactivity was not measurably increased in grafts exposed to elevated blood glucose.

Conclusions/interpretation

Glucose is a mitogenic stimulus for transplanted human beta cells in vivo. Investigating the underlying pathways may point to mechanisms capable of expanding human beta cell mass in vivo.     

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.     

Predicting survival after living and deceased donor liver transplantation in adult patients with acute liver failure

Background

Post-transplant outcomes for acute liver failure (ALF) are unsatisfactory, and there are debates about the most suitable type of graft. Given the critical shortage of donor organs, accurate assessment of post-transplant outcome in ALF patients is crucial to avoid a futile liver transplantation (LT).

Methods

A database of 160 consecutive adult ALF patients who underwent primary LT between 2000 and 2009 in a tertiary LT center was analyzed.

Results

The most common causes of ALF were hepatitis B virus infection (30%) and herbal/folk medicine use (30%). Thirty-six (22.5%) and 124 (77.5%) patients underwent deceased-donor LT (DDLT) and adult-to-adult living-donor LT (LDLT), respectively. During a median follow-up period of 38 (range 1–132) months, the DDLT and LDLT groups showed similar patient (P?=?0.99) and graft (P?=?0.97) survival rates. The overall 1- and 3-year patient survival rates were 78.8 and 74.6%, respectively. Five predictors of patient survival were identified by bootstrapping and multivariate analysis: vasopressor requirement, estimated glomerular filtration rate, serum sodium concentration, recipient age, and donor age, at the time of transplant. By summing scores weighted in each of these predictor categories, we designed a prognostic scoring system (scores from ?2 to 20) that estimated 1-year post-transplant mortality from 0 to 100% (c statistic 0.79).

Conclusions

Long-term outcomes after LDLT and DDLT were comparable in adult patients with ALF. A simple prognostic scoring system that includes 5 predictive variables at the time of LT may help estimate post-transplant survival in ALF patients, regardless of the type of transplant.     

Living donor pancreas transplantation in Japan

Background/purpose

Living-donor pancreas transplants (LDPs) were introduced at Chiba-East National Hospital in 2004, and 12 LDPs have been performed at this institution to date. Based on the outcome of these 12 LDPs, the efficacy and safety of LDPs are herein discussed.

Methods

Twelve diabetic patients underwent LDPs; ten had simultaneous pancreas and kidney transplants from living donors, one had pancreas transplant after a kidney transplant from a living donor, and one had a pancreas transplant alone from a living donor. The donors were parents or brothers and the ABO blood types were incompatible in three LDPs. The procedures for the donor and recipient operations were performed according to the technique established by the University of Minnesota. Bladder drainage was used in 11 recipients and enteric drainage was used in one patient. Tacrolimus, basiliximab, mycophenolate mofetil, and prednisone were used for induction and immunosuppressive treatment. A splenectomy, double-filtered plasmapheresis, and plasma exchange were added in the ABO-incompatible LDPs.

Results

No complications were observed in the donors during hospitalization. The 1-year survivals of the patients, kidney grafts, and pancreas grafts were 100, 100, and 100%, respectively. The 3-year survivals were 91.7, 90, and 91.7%, respectively. Three patients developed leakage of pancreatic juice and one patient required a surgical procedure. Cytomegalovirus antigenemia was detected in five patients (42%).

Conclusions

Based on the excellent outcome of the LDPs at this institution, LDPs is therefore expected to become a promising option for the treatment of patients with severe diabetes.     

Risk factors contributing to hepatic artery thrombosis following living-donor liver transplantation

Background/Purpose

This study was carried out to investigate the risk factors contributing to hepatic artery thrombosis in living-donor liver transplantation.

Methods

Two hundred and twenty-two recipients (113 adults and 109 children) of living-donor liver transplantation were the subjects of this study. The diagnosis of hepatic artery thrombosis was made by color-Doppler ultrasonography and/or hepatic angiography. Parameters for this study were: (1) donor sex, age, and body weight; (2) recipient sex, age, body weight, liver disease, preoperative prothrombin time, and type of arterial reconstruction; and (3) previous liver transplantation.

Results

Hepatic artery thrombosis occurred in 12 patients (5.4%) at 3 to 15 days posttransplant. Recipient female sex and metabolic disorder as the original disease were found to be significantly associated with hepatic artery thrombosis. The 5-year patient survival rate in recipients with hepatic artery thrombosis (58.3%) was significantly lower than that in recipients without this complication (84.4%).

Conclusions

Female sex and metabolic disease may be factors contributing to hepatic artery thrombosis after living-donor liver transplantation. More intensive anticoagulation therapy for this patient population might decrease the incidence of hepatic artery thrombosis and, thus, posttransplant recipient mortality.     

Use of marginal grafts in deceased donor liver transplant: Assessment of early outcomes

Introduction

Orthotopic liver transplantation has become a routinely applied therapy for an expanding group of patients with end-stage liver disease. Shortage of organs has led centers to expand their criteria for the acceptance of marginal donors. There is current debate about the regulation and results of liver transplantation using marginal grafts.

Methods

The study included data of all patients who received deceased donor liver grafts between March 2007 to December 2011. Patients with acute liver failure, living donor transplantation, split liver transplantation, and retransplantation were excluded. Early allograft dysfunction, primary nonfunction, patient survival, and incidence of surgical complications were measured.

Results

A total of 33 patients were enrolled in this study. There were 20 marginal and 13 nonmarginal grafts. The two groups were well matched regarding age, sex and indication of liver transplantation, model for end-stage liver disease score, technique of transplant, requirement of vascular reconstruction, warm ischemia time, blood loss, mean operative time, etc. In our study, posttransplant peak level of liver enzymes, international normalization ratio, and bilirubin were not statistically significant in the marginal and nonmarginal group. Wound infection occurred in 10 % of marginal compared with 7.7 % of nonmarginal graft recipients (p?>?0.05). In the marginal group, the incidences of vascular complications, hepatic artery thrombosis (four), and portal vein thrombosis (one) were not statistically significant compared to the nonmarginal group. Acute rejection was observed in a total of seven patients (21.2 %)—five (25 %) in the marginal group and two (15.4 %) in the nonmarginal graft recipients. Primary nonfunction occurred in three (9.1 %) patients—two (10 %) in the marginal and one (7.7 %) in the nonmarginal group. Average patient survival for the whole group was 91 % at 1 week, 87.8 % at 3 months, and 84.8 % at 6 months.

Conclusion

Because organ scarcity persists, additional pressure will build to use a greater proportion of the existing donor pool. The study, although small, clearly indicates that marginal livers can assure a normal early functional recovery after transplantation.     

La thrombose veineuse portale de l’adulte: à propos de 28 cas

Aim

To study clinical, epidemiological character, aetiology and treatment of portal thrombosis in Morocco.

Material and method

A retrospective study of 28 cases of portal thrombosis at Gastroenterology Department of University Hospital Mohamed-VI Marrakech for a period of four years between January 2004 and December 2008.

Results

Twenty women and eight men of the average age of 40 were studied. The clinical symptoms included acute abdominal pain in 11 cases, a mesenteric infarct in one case, an assessment of portal hypertension in 14 patients and ascitis in two cases. The abdominal ultrasound combined with Doppler in patients showed portal thrombosis in 15 cases and portal cavernoma in 13 cases. Local cause was found in 21 patients. The assessment to find a prothrombotic disorder was required in 15 patients, but it was carried out in only five patients due to lack of means. The assessment results were deficiency in C and S proteins in three cases, a protein S deficiency in one case and an AC antiphospholipide syndrome in one case. Twelve patients in whom thrombosis was considered as acute according to clinical and radiological evidences were given anticoagulant treatment for six months, while eight patients received anticoagulant treatment for life. The prognosis was good for all medicated patients except one patient who died due to a mesenteric infarct.

Discussion

Portal thrombosis is the main cause of portal vein occlusion outside malignancy obstructive tumor. It’s a rare pathology with prevalence between 0.05 and 0.5% according to series; in our study, it represents 1% of hospitalised patients. Because of the low specificity of clinical presentation dominated by abdominal pain, it is usually discovered in late stage after the occurrence of portal cavernome. Abdominal ultrasounds accompanied by Doppler is an effective exam, which confirms the diagnosis in 85% of patients. Angiotomography gives more precisions. Many factors are often responsive of portal thrombosis. Etiological investigation is required to make treatment.

Conclusion

Portal thrombosis is a frequent pathology in our context. Its therapeutic care is difficult because of the high cost of its etiological analysis and its occurrence in particular patients.     

Organspendebereitschaft an einer Universit?tsklinik

Introduction

Despite all the success of modern transplant surgery, about a thousand patients on waiting lists die every year in Germany. The persisting shortage of organs for transplantation could be minimized by increasing the willingness to donate. Since the staff of a university hospital is directly involved in transplant medicine, their opinion concerning organ donation is of special interest.

Methods

In 2007, a voluntary survey of the University Hospital of Essen staff concerning organ donation was conducted. The questionnaires were returned to the company doctor. Analyses were performed using Fisher’s exact and the Chi square test.

Results

In total, 242 questionnaires were analyzed. A donor card is carried by 55% of the hospital staff. There is a statistically significant difference in carriers of an organ donor card between men (46%) and women (60%). A high percentage of carriers of an organ donor card are among 21- to 30-year-olds (60%), among singles (61%) and among medical personnel (63%). After this survey, an additional 19% of the hospital staff can imagine carrying an organ donor card in the future.

Conclusion

Hospital staff also need education concerning organ donation. However, the willingness to carry an organ donor card is much higher compared to that of the general population. More information, education and increased transparency of transplant medicine are necessary for hospital staff to act successfully as multipliers for the general public.     

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.     

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.     

Significance of serum ��-d-glucan levels in recipients of living donor liver transplantation

Background/purpose

Early identification and treatment of fungal infections is essential for recipients of liver transplants, but the sensitivity of surveillance culture is insufficient. Measurement of the serum level of ??-d-glucan is a rapid diagnostic strategy for invasive fungal infection. We aimed to evaluate the significance of serum ??-d-glucan levels in transplant recipients after living donor liver transplantation (LDLT).

Methods

We retrospectively analyzed the clinical and laboratory data of 100 consecutive adult transplant recipients after LDLT performed between August 1997 and August 2009.

Results

Seventy-one had high serum ??-d-glucan levels (>20?pg/ml) after LDLT. Nearly half (47.2%) of the episodes of increase occurred within the first 5?days after surgery. The mortality rate of the recipients with high serum ??-d-glucan levels was similar to that of the recipients without high levels. However, in terms of the time line of increase, the recipients with high serum ??-d-glucan levels from 15?days onward after surgery showed a significantly higher mortality rate than those with high levels before 15?days after surgery (33.3 and 4.3%, respectively; p?Conclusions High serum levels of ??-d-glucan at late time points after LDLT indicate established fungal infection and higher mortality.     

Portal Vein Thrombosis in Patients with End Stage Liver Disease Awaiting Liver Transplantation: Outcome of Anticoagulation

Background

The prevalence of portal vein thrombosis (PVT) increases with the severity of liver disease. Development of PVT is often accompanied by increased rate of morbidity and mortality and may affect patient candidacy for liver transplant. There is limited data regarding the role of anticoagulation therapy in patients with PVT and liver cirrhosis.

Objectives

The aims of this study were to describe the prevalence of hypercoagulable disorders in patients with liver cirrhosis and PVT, and to describe the outcome of anticoagulation in patients with liver cirrhosis and PVT.

Methods

A retrospective chart review was conducted of patients with liver cirrhosis awaiting liver transplant who were diagnosed with PVT between January 2005 and November 2011.

Results

During the study period, 537 patients were evaluated for liver transplant. Sixty-nine (13 %) patients were diagnosed with portal vein thrombosis. Chronic hepatitis C was the cause of liver disease in 24/69 (35 %) patients, and hepatocellular carcinoma was present in 39 % of patients. In 22 patients screened for hypercoagulable disorders, hypercoagulable disorder was diagnosed in one patient (5 %). Twenty-eight (28/69) patients were treated during the study period with warfarin: PVT resolved in 11/28 (39 %), no change in 5/28 (18 %), and 12/28 (43 %) patients showed partial resolution of thrombus. Eight patients received liver transplant while on anticoagulation, and operative notes confirmed patency of PV in all eight patients.

Conclusions

PVT is frequently seen in patients with end stage liver disease with prevalence of 13 %. Hypercoagulable disorder was detected in 5 % of the patients screened. Careful use of anticoagulation is safe and effective in patients with PVT.     

Intravenous Interferon Administered During Liver Transplantation Is Not Effective in Preventing Hepatitis C Reinfection

Background

Post-transplant hepatitis C is a major challenge after liver transplantation (LT). Antiviral therapy is associated with lower efficacy in the post-transplant setting.

Aims

The purpose of this study was to determine the safety and effect of intravenous interferon (IFN) during the anhepatic phase of LT on hepatitis C viral load.

Methods

Fifteen consecutive subjects undergoing liver transplant for hepatitis C cirrhosis were enrolled in the study, ten of which received study drug and five subjects served as controls. Cases received weight-based ribavirin and subcutaneous IFN at time of incision followed by intravenous IFN at the start of the anhepatic phase. Adverse events and viral levels were recorded. Repeated measures ANOVA was employed to test for differences over time, between the groups, and time by group interaction.

Results

All subjects had genotype 1 virus. Hepatitis C viral load was lower at week 4 in cases compared to controls (769,004 ± 924,082 IU/ml and 2,329,896 ± 3,731,749 IU/ml, respectively), but did not reach statistical significance (p = 0.50). Three subjects developed adverse events related to IFN including pulmonary edema, rejection, and neutropenia.

Conclusions

Intravenous IFN administered during the anhepatic phase of liver transplant did not prevent graft reinfection and was associated with manageable adverse events. This regimen could be further studied if direct acting antiviral agents alone are insufficient for treating post-transplant hepatitis C.     

Laparoscopic-assisted distal pancreatectomy and nephrectomy from a live donor

Background

The simultaneous transplantation of pancreas and kidney from live donors is performed in select countries. One of the reasons for this reduced applicability is the invasiveness of the donor operation. We propose the method of laparoscopic-assisted operation to be performed on live donors with minimal invasion.

Method

The donor was placed in the right lateral decubitus position. A 7-cm upper midline incision was made, and a handport was installed in addition to two or three 12-mm ports. After the removal of the left kidney graft, the spleen and the distal part of the pancreas were completely mobilized. The splenic vein and artery were identified and mobilized. The donor was then rotated to a supine position. Dissection of the pancreatic parenchyma using ultrasound shears and ligation of the splenic vessels were performed through midline incision under direct vision. The distal part of the pancreas and the spleen were extracted.

Results

Since December 2007, 3 donors have undergone this operation. In all 3 cases, the postoperative course was uneventful, and both the renal and pancreatic grafts functioned well.

Conclusion

This technique is minimally invasive and safe, and may become the standard method of live donor operation for simultaneous pancreas–kidney transplantation.