Simultaneous living donor liver transplant with sleeve gastrectomy for metabolic syndrome and NASH-related ESLD—First report from India

Nonalcoholic steatohepatitis (NASH) with morbid obesity and metabolic syndrome is now a common cause of end-stage liver disease (ESLD). These patients are high-risk candidates for liver transplant, and require bariatric surgery to prevent recurrent disease in the new liver. Data reports bariatric surgery after transplant, which maybe difficult because of adhesions between the stomach and liver in living donor liver transplant (LDLT) recipient. We report the first case of combined LDLT with sleeve gastrectomy (SG) from India. A morbidly obese diabetic woman with NASH-related ESLD was planned for combined right lobe LDLT with open SG, in view of failed diet therapy, musculo-skeletal complaints, and restricted mobility. Postoperatively, with liver graft functioning adequately, bariatric diet restrictions resulted in maximum reduction of 25% weight, achieving a target BMI below 30 kg/m² within 2 months, along with complete cure of diabetes and better ambulation. Thus, combination of LDLT and bariatric surgery in the same sitting is safe and effective in management of metabolic syndrome and associated NASH-related ESLD.     

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.     

Cost analysis of adult�Cadult living donor liver transplantation in Tokyo University Hospital

Background and purpose

Living donor liver transplantation (LDLT) is now a well established treatment modality for end-stage liver diseases, but the financial aspects of LDLT have not yet been fully investigated. The purpose of this study was to determine the overall direct cost of adult?Cadult LDLT in Japan and to identify the factors associated with the high cost.

Materials and methods

The direct cost of initial admission for LDLT was determined in a retrospective analysis of data from hospital charts and databases. The records for 100 consecutive adults who underwent LDLT from January 2004 to February 2006 at our center were reviewed, and clinical and financial data of all recipients and donors were analyzed.

Results

The median direct total cost for LDLT was $82,017 (range $51,189?C438,295). Of this, the median cost for donors was $15,011 (range $12,354?C23,251). A multivariate stepwise logistic regression model for overall cost of transplantation revealed that donor age [odds ratio (OR)?=?1.1, p?=?0.02], acute renal failure (OR?=?24, p?=?0.007), and posttransplant plasma exchange (OR?=?72, p?=?0.01) were associated with higher cost. When the models were repeated with preoperative patient and donor factors alone, donor age (OR 1.1, p?=?0.008) and model for end stage liver disease score (OR 1.2, p?=?0.003) were associated with higher cost.

Conclusions

Donor age, acute renal failure, and posttransplant plasma exchange were independent risk factors for the high cost of LDLT in Japan.     

Dualistic role of platelets in living donor liver transplantation: Are they harmful?

Platelets are anucleate fragments mainly involved in hemostasis and thrombosis, and there is emerging evidence that platelets have other nonhemostatic potentials in inflammation, angiogenesis, regeneration and ischemia/reperfusion injury (I/R injury), which are involved in the physiological and pathological processes during living donor liver transplantation (LDLT). LDLT is sometimes associated with impaired regeneration and severe I/R injury, leading to postoperative complications and decreased patient survival. Recent studies have suggested that perioperative thrombocytopenia is associated with poor graft regeneration and postoperative morbidity in the short and long term after LDLT. Although it is not fully understood whether thrombocytopenia is the cause or result, increasing platelet counts are frequently suggested to improve posttransplant outcomes in clinical studies. Based on rodent experiments, previous studies have identified that platelets stimulate liver regeneration after partial hepatectomy. However, the role of platelets in LDLT is controversial, as platelets are supposed to aggravate I/R injury in the liver. Recently, a rat model of partial liver transplantation (LT) was used to demonstrate that thrombopoietin-induced thrombocytosis prior to surgery accelerated graft regeneration and improved the survival rate after transplantation. It was clarified that platelet-derived liver regeneration outweighed the associated risk of I/R injury after partial LT. Clinical strategies to increase perioperative platelet counts, such as thrombopoietin, thrombopoietin receptor agonist and platelet transfusion, may improve graft regeneration and survival after LDLT.     

Problems in adult living donor liver transplantation using the right hepatic lobe

BACKGROUND: Adult living donor liver transplantation (LDLT) is now widely applied to patients, children or adults, and the graft extends from the left hepatic lobe to the right hepatic lobe. Harvesting the right hepatic lobe would mean putting the donor at high risk. The congestion of a graft may cause small-for-size syndrome. The safety of the donor and its evaluation, which are related to the outcome for the recipient,play an important role in LDLT. How to decrease the congestion of the graft is another challenge to transplant experts. DATA SOURCES: A literature search from MEDLINE about adult LDLT in recent years was made to analyze the safety of the living donor and the innovation of surgical techniques for preventing small-for-size syndrome. RESULTS: The top priority for adult LDLT is donor safety. Preoperative donor evaluation consists of three stages: phase 1 for general evaluation, phase 2 for laboratory tests, and phase 3 for radiological evaluation of graft volume and vessel anatomy. The potential pathogenic mechanisms of small-for-size syndrome seem to be related to persistent portal hypertension and portal overperfusion. Improved surgical techniques for decreasing portal hypertension and preventing congestion of a graft may reduce the incidence of small-for-size syndrome. The improved techniques include reconstruction of the tributaries of the middle hepatic vein, end-to-side portocaval shunting, ligation of the splenic artery, dual-graft transplantation, and modified reconstruction of hepatic veins. CONCLUSION: With the careful preoperative assessment and the safety of the living donor, as well as improved surgical techniques, adult LDLT using the right lobe is safe.     

First two cases of living related liver transplantation with complicated anatomy of blood vessels in Beijing

AIM:Living related liver transplantation(LRLT)has beendeveloped in response to the paediatric organ donor shortage.Though it has been succeeded in many centers worldwide,the safety of the donor is still a major concern,especiallyin donors with anatomy variation.We succeeded in performingthe first two cases of living related liver transplantationwith complicated anatomy of blood vessels as a way toovercome cadaveric organ shortage in Beijing.METHODS:Two patients,with congenital liver fibrosis andcongenital biliary atresia were performed with living donorliver transplantation in our hospital and then followed upfrom November 12 to December 13,2001.The two livingdonors,mother and father,were healthy aged 34 and 35years.One right lobe(segment Ⅴ,Ⅵ,Ⅶ,Ⅷ)and oneleft lateral lobe(segment Ⅱ and Ⅲ)were used.The graftsweighed 394 g and 300 g.The ratio of graft weight to thestandard liver volume(SLV)of donors was 68% and 27%.The graft weight to recipient body weight ratio was 3.2%and 4.4%.The graft weight to recipient estimated standardliver mass(ESLM)ratio was 63% and 85%.The two donorshad complicated blood vessel variation.RESULTS:Two patients undergone living donor livertransplantation had good results.Abnormal liver functionwith high bilirubin level appeared in a few days afteroperation,but liver function returned to normal one monthafter operation with bilirubin level almost decreased tonear normal.No bleeding,thrombosis,infection and bileleakage occurred.One had an acute rejection and recovered.The two donors recovered in two weeks.One had slightfever because of a little collection in abdomen and recoveredafter paracentesis and drainage.CONCLUSION:Living donor liver transplantation has beenproved to be a good way that offers a unique opportunityof getting a timely liver graft as a response to shortage ofpediatric donors,though it could be a technically difficultoperation if there is anatomical variation.     

First two cases of living related liver transplantation with complicated anatomy of blood vessels in Beijing

AIM: Living related liver transplantation (LRLT) has been developed in response to the paediatric organ donor shortage. Though it has been succeeded in many centers worldwide, the safety of the donor is still a major concern, especially in donors with anatomy variation. We succeeded in performing the first two cases of living related liver transplantation with complicated anatomy of blood vessels as a way to overcome cadaveric organ shortage in Beijing. METHODS: Two patients, with congenital liver fibrosis and congenital biliary atresia were performed with living donor liver transplantation in our hospital and then followed up from November 12 to December 13, 2001. The two living donors, mother and father, were healthy aged 34 and 35 years. One right lobe (segment V, VI, VII, VIII) and one left lateral lobe (segment II and III) were used. The grafts weighed 394 g and 300 g. The ratio of graft weight to the standard liver volume (SLV) of donors was 68% and 27%. The graft weight to recipient body weight ratio was 3.2% and 4.4%. The graft weight to recipient estimated standard liver mass (ESLM) ratio was 63% and 85%. The two donors had complicated blood vessel variation. RESULTS: Two patients undergone living donor liver transplantation had good results. Abnormal liver function with high bilirubin level appeared in a few days after operation, but liver function returned to normal one month after operation with bilirubin level almost decreased to near normal. No bleeding, thrombosis, infection and bile leakage occurred. One had an acute rejection and recovered. The two donors recovered in two weeks. One had slight fever because of a little collection in abdomen and recovered after paracentesis and drainage. CONCLUSION: Living donor liver transplantation has been proved to be a good way that offers a unique opportunity of getting a timely liver graft as a response to shortage of pediatric donors, though it could be a technically difficult operation if there is anatomical variation.     

Therapy of central pontine myelinolysis following living donor liver transplantation： Report of three cases

We analyzed the clinical manifestations and experiences of diagnosing and treating central pontine myelinolysis following living donor liver transplantation. The clinical data of three patients with central pontine myelinolysis following living donor liver transplantation from January 2005 to November 2007 were retrospectively analyzed at the West China Hospital, Sichuan University, China. The three patients developed hyponatremia prior to surgery. Case 1 suffered locked-in syndrome following surgery, and received a large dose of gamma globulin, and subsequently recovered. Case 2 was in a coma for three days, and received hyperbaric chamber treatment. This patient remained in a mild coma for six months following surgery. Case 3 developed consciousness disturbances, gradually went into a coma following surgery, and died due to pulmonary infection. Central pontine myelinolysis is a severe complication in patients following living donor liver transplantation. Largedose gamma globulin treatment, as well as hyperbaric oxygen, might be effective therapeutic methods.