Long‐term outcome of liver transplantation in childhood: A study of 20‐year survivors

We report the results of a study of survival, liver and kidney functions, and growth with a median follow‐up of 24 years following liver transplantation in childhood. From 1988 to 1993, 128 children underwent deceased donor liver transplantation (median age: 2.5 years). Twenty‐year patient and graft survival rates were 79% and 64%, respectively. Raised serum aminotransferase and/or γ‐glutamyl transferase activities were present in 42% of survivors after a single transplantation. Graft histology (35 patients) showed signs of chronic rejection in 11 and biliary obstruction in 5. Mean total fibrosis scores were 4.5/9 and 3/9 in patients with abnormal and normal serum liver tests, respectively. Glomerular filtration rate was <90 mL·min^?1 in 35 survivors, including 4 in end‐stage renal disease who were undergoing dialysis or had undergone renal transplantation. Median final heights were 159 cm for women and 172 cm for men; final height was below the target height in 37 patients. Twenty‐year survival after childhood liver transplantation may be close to 80%, and final height is within the normal range for most patients. However, chronic kidney disease or altered liver biochemistries are present in over one third of patients, which is a matter of concern for the future.     

Donor haptoglobin phenotype determines outcome following liver transplantation

Haptoglobin (Hp) is a polymorphic plasma protein with multiple functions defined by three major phenotypes (Hp 1‐1, Hp 2‐1, and Hp 2‐2). In this article, the effects of the donor Hp phenotype (determined by starch gel electrophoresis) on the outcome and the iron status after liver transplantation were investigated. A total of 450 liver transplant patients were enrolled in this study with a median follow‐up of 37 months. Kaplan–Meier and Cox regression survival analyses showed a significantly worse graft survival for liver transplantation cases with an Hp 2‐2 donor phenotype, which was associated with an increased mortality rate in this group. In male patients, the Hp 2‐2 phenotype was associated with higher serum ferritin concentrations, which may be linked to the significantly increased likelihood of infectious complications in this phenotype. Liver transplant patients with Hp 1‐1 and Hp 2‐1 grafts had a better outcome probability than recipients of an Hp 2‐2 graft, which may be explained by differences in iron metabolism induced by the Hp genotype of the graft.     

Long‐term outcome of patients with lamivudine after early cessation of hepatitis B immunoglobulin for prevention of recurrent hepatitis B following liver transplantation

Yuefeng M, Weili F, Wengxiang T, Ligang X, Guiling L, Hongwei G, Wencai L, Xiaoguang W, Wei M, Zhongyi F. Long‐term outcome of patients with lamivudine after early cessation of hepatitis B immunoglobulin for prevention of recurrent hepatitis B following liver transplantation.
Clin Transplant 2011: 25: 517–522. © 2010 John Wiley & Sons A/S. Abstract: Background: The aim of this study is to examine the efficacy of long‐term prophylaxis with lamivudine (LAM) after a course of post‐operative hepatitis B immunoglobulin (HBIG) in patients who underwent liver transplantation (LT) for hepatitis B virus (HBV)‐related disease. Result: The medical records of HBV‐infected patients who underwent a LT in our institution between July 2001 and May 2005 were reviewed. There were 15 liver transplant recipients who were administered HBIG for <18 months and used LAM as a maintenance prophylaxis regime enrolled in this study. At enrollment, all patients were hepatitis B surface antigen (HBsAg) positive and three patients were HBeAg positive. There were 13 patients who were HBV DNA positive with a mean viral load of 5.4 log copies/mL, and among them, 12 recipients were on antiviral therapy with LAM (100 mg/d orally) for 12–168 d, resulting in HBV DNA negative levels in nine patients prior to their transplant. HBV recurrence post‐LT was noted in two patients who had very high‐HBV DNA levels pre‐LT. Both of these patients showed LAM‐resistant mutation at the time of recurrence. The 11 patients who were HBV DNA negative before LT (low‐risk patients) had no HBV recurrence during a follow‐up at a median of 58 months post‐LT. This included five patients who had intermittent low‐level HBV DNA post‐LT (HBsAg negative), of whom two had YMDD mutation and these two were given adefovir in addition to LAM. Conclusion: Our retrospective study demonstrated excellent long‐term outcomes in the low‐risk patients treated with LAM after a short course of HBIG.     

Long‐term outcome of antineutrophil cytoplasmic antibody‐associated small vessel vasculitis after renal transplantation

The survival after renal transplantation of patients with antineutrophil cytoplasmic antibody (ANCA)‐associated to systemic vasculitis is as good as in other diseases, although most of the reports are based on small numbers of patients. Furthermore, it is not known whether comorbidities (cardiovascular [CV] disease and cancer) are more frequent than in general population. We report our experience and the analysis of the published data on this topic. The outcome after transplantation in 49 patients with ANCA‐associated small vessel vasculitis was compared with a control group. The relapse rate of vasculitis was 0.01 per patient per year. Comparison with the control patients revealed no difference in long‐term outcome, CV mortality or incidence of malignancies. In the published literature, patients with ANCA at transplantation and with Wegener's granulomatosis are at greater risk of relapse. Taking our own results together with the review of the literature, we conclude that patient and graft survival rates compare favorably with those in control group that the recurrence rate is very low and that there is no increase in the incidence of cancer or in CV mortality. Patients with ANCA at transplantation and with Wegener's granulomatosis have a higher relapse rate.     

Dual‐graft adult living donor liver transplantation with ABO‐incompatible graft: short‐term and long‐term outcomes

ABO‐incompatible (ABOi) dual‐graft (DG) adult living donor liver transplantation (ALDLT) is not commonly performed due to its inherently intricate surgical technique and immunological complexity. Therefore, data are lacking on the short‐ and long‐term clinical outcomes of ABOi DG ALDLT. We performed a retrospective study by reviewing the medical records of patients who underwent ABOi DG ALDLT between 2008 and 2014. Additionally, computed tomography volumetric analysis was conducted to assess the graft regeneration rate. The mean age of a total of 28 recipients was 50.2 ± 8.5 years, and the mean model for end‐stage liver disease score was 12.2 ± 4.6. The 1‐, 3‐, and 5‐year patient survival rate was 96.4% during the mean follow‐up period of 57.0 ± 22.4 months. The 1‐, 3‐, and 5‐year graft survival rate was 96.4%, 94.2%, and 92.0%, respectively, and no significant differences were observed between ABO‐compatible (ABOc) and ABOi grafts (P = .145). The biliary complication rate showed no significant difference (P = .195) between ABOc and ABOi grafts. Regeneration rates of ABOi grafts were not significantly different from those of ABOc grafts. DG ALDLT with ABOi and ABOc graft combination seems to be a feasible option for expanding the donor pool without additional donor risks.     

Long‐term medical and psycho‐social evaluation of patients undergoing orthotopic liver transplantation for alcoholic liver disease

Abstract The major concern in transplanting patients with alcoholic liver disease (ALD) is the high rate of alcohol recidivism. Our aim was to assess the long‐term outcome of liver transplantation (OLT) in a group of ALD patients in terms of post‐OLT alcohol recidivism and its relationship with pre‐OLT psychosocial variables and medical follow up. Fifty‐one ALD patients underwent strict medical and psychosocial evaluation before and after OLT. Alcohol abuse was recorded in 60% and alcohol dependence in 40% of patients before OLT. The 5‐year survival was similar to the one observed in non‐ALD transplanted patients (64 vs 56%). Alcohol recidivism was observed in 33 % of transplanted patients, 64 % of whom were occasional and 36 % were heavy drinkers. The admission of alcoholism by the patient and his/her family prior to OLT significantly predicted abstinence after OLT. A multidisciplinary approach evaluating medical and psycho‐social variables before OLT and a close follow up after OLT are mandatory for ALD patients.     

Long‐term follow‐up after endovascular treatment of hepatic venous outflow obstruction following liver transplantation

Hepatic venous outflow obstruction (HVOO) is a rare complication after liver transplantation (LT) associated with significant morbidity and reduced graft survival. Endovascular intervention has become the first‐line treatment for HVOO, but data on long‐term outcomes are lacking. We have analysed outcomes after endovascular intervention for HVOO in 905 consecutive patients who received 965 full‐size LT at our unit from January 2007 to June 2014. There were 27 (3%) patients who underwent hepatic venogram for suspected HVOO, with persistent ascites being the most common symptom triggering the investigation (n = 19, 70%). Of those, only 10 patients demonstrated either stricture or pressure gradient over 10 mmHg on venogram, which represents a 1% incidence of HVOO. The endovascular interventions were balloon dilatation (n = 3), hepatic vein stenting (n = 4) and stenting with dilatation (n = 3). Two patients required restenting due to stent migration. The symptoms of HVOO completely resolved in all but one patient, with a median follow‐up period of 74 (interquartile range 39–89) months. There were no procedure‐related complications or mortality. In conclusion, the incidence of HVOO in patients receiving full‐size LT is currently very low. Endovascular intervention is an effective and safe procedure providing symptom relief with long‐lasting primary patency.     

Long‐term functional and morphological outcome after pyeloplasty for huge renal pelvis

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

? To evaluate the functional and morphological outcome after open pyeloplasty for ureteropelvic junction obstruction (UPJO) with huge renal pelvis.

PATIENTS AND METHODS

? A retrospective review of all cases who underwent pyeloplasty for huge renal pelvis was conducted. ? Records were evaluated with respect to age at presentation, preoperative imaging, surgical details and postoperative course. Patients were followed up regularly for both functional and morphological outcome. ? Success was defined as both symptomatic relief and radiographic resolution of obstruction at last follow‐up.

RESULTS

? Between 1998 and 2008, 526 cases of primary UPJO underwent open dismembered pyeloplasty at our centre. ? Of these patients, 41 (8%) had UPJO with huge renal pelvis. ? No perioperative complications were encountered in the study group. Mean (range) follow‐up was 34 (18–84) months and nine patients were lost to follow‐up. The overall success rate was 91%. ? Two patients underwent redo pyeloplasty, whereas secondary nephrectomy was necessary in one. ? Improvement of hydronephrosis was evident in all patients, except in three patients who underwent secondary procedures. ? However, persistent obstruction on diuretic renography was seen in most cases (65%).

CONCLUSIONS

? Open pyeloplasty for huge pelvis UPJO is feasible with a high success rate. ? Varying degrees of hydronephrosis and radiological obstruction after pyeloplasty are not uncommon. ? Nephrectomy is rarely indicated in cases with severely deteriorated renal function.     

肝移植术后精神并发症的早期诊断与治疗

目的探讨肝移植术后精神并发症的早期诊断和治疗。方法回顾性分析24例原位肝移植患者的临床资料,分析肝移植术后精神并发症的发生原因和诊断,总结治疗经验。结果15例患者于术后1周内出现不同程度的精神并发症,其中5例症状较为明显。临床表现为亢奋、蹂狂、抑郁、焦虑、睡眠障碍、震颤及认知改变等。术前有无肝性脑病、术后感染及使用免疫抑制剂与术后精神并发症的发生有关。结论肝移植术后精神并发症的发生率较高。病因与多种因素有关,临床表现形式多样。需排除脑桥中央髓鞘溶解症。针对不同病因和及时处理,可有效改善与控制症状。     

Eurotransplant donor‐risk‐index and recipient factors: influence on long‐term outcome after liver transplantation – A large single‐center experience

The organ shortage has led to increased use of marginal organs. The Eurotransplant Donor‐Risk‐Index (ET‐DRI) was established to estimate outcome after Liver Transplantation (LT). Currently, data on impact of ET‐DRI on long‐term outcome for different indications and recipient conditions are missing. Retrospective, single‐center analysis of long‐term graft survival (GS) of 1767 adult primary LTs according to indication, labMELDcategory (1: ≤18; 2: >18–25; 3: >25–35; 4: >35), and ET‐DRI. Mean ET‐DRI in our cohort was 1.63 (±0.43). One‐, 10, and 15‐yr GS was 83.5%, 63.3%, and 54.8%. Long‐term GS was significantly influenced by ET‐DRI. Accordingly, four ET‐DRI categories were defined and analyzed with respect to underlying disease. Significant impact of these categories was observed for: Alcohol, cholestatic/autoimmune diseases (CD/AIH), and HCV, but not for HCC, HBV, cryptogenic cirrhosis, and acute liver failure. labMELD categories showed no significant influence on graft, but on patient survival. Matching ET‐DRI categories with labMELD revealed significant differences in long‐term GS for labMELDcategories 1, 2, and 3, but not 4. In multivariate analysis, HCV combined with ET‐DRI > 2 and labMELDcategory 3 combined with ET‐DRI > 2 emerged as negative predictors. To achieve excellent long‐term graft survival, higher risk organs (ET‐DRI > 1.4) should be used restrictively for patients with CD/AIH or HCV. Organs with ET‐DRI > 2 should be avoided in patients with a labMELD of >25–35.     

Long‐term follow‐up of immunosuppressive monotherapy in liver transplantation: tacrolimus and microemulsified cyclosporin

Cholongitas E, Shusang V, Germani G, Tsochatzis E, Raimondo ML, Marelli L, Senzolo M, Davidson BR, Patch D, Rolles K, Burroughs AK. Long‐term follow‐up of immunosuppressive monotherapy in liver transplantation: tacrolimus and microemulsified cyclosporin.
Clin Transplant 2011: 25: 614–624. © 2010 John Wiley & Sons A/S. Abstract: Background: Early withdrawal of steroids after liver transplantation has benefits, but rarely is total avoidance of steroids used. We evaluated long‐term results of patients with ab initio monotherapy with cyclosporin (CYA) vs. tacrolimus (TAC), in randomized and cohort studies. Methods: We evaluated long‐term outcomes in 66 adults randomized to TAC or CYA and 94 subsequent patients who received TAC. Protocol liver biopsies were performed. Rejection was treated with three 1 g/d methylprednisolone. Further rejection after two courses of methylprednisolone was defined as monotherapy failure. Results: Actuarial five‐yr survival was 68% in TAC and 70% CYA. Monotherapy failed in 8% TAC and 13% CYA patients; no rejection in 24% TAC and 19% CYA patients; 42% TAC and 33% CYA patients were not exposed to any steroids. Rejection episodes were less with TAC, compared to CYA: mean 1.8 vs. 2.5, p = 0.042. Chronic rejection occurred in only 4 (11%) CYA patients. During follow‐up of median 97 months (range: 0.06–145), there were 16 (44%) deaths in CYA and 48 (39%) in TAC patients (p > 0.05). Conclusions: TAC monotherapy ab initio is a viable immunosuppressive strategy in liver transplantation and was associated with lower rejection rates and renal complications, compared to CYA.     

Full-left-full-right split liver transplantation for adult recipients: a systematic review and meta-analysis

Full-left-full-right split liver transplantation (FSLT) for adult recipients, may increase the availability of liver grafts, reduce waitlist time, and benefit recipients with below-average body weight. However, FSLT may lead to impaired graft and patient survival. This study aims to assess outcomes after FSLT. Five databases were searched to identify studies concerning FSLT. Incidences of complications, graft- and patient survival were assessed. Discrete data were pooled with random-effect models. Graft and patient survival after FSLT were compared with whole liver transplantation (WLT) according to the inverse variance method. Vascular complications were reported in 25/273 patients after FSLT (Pooled proportion: 6.9%, 95%CI: 3.1–10.7%, I²: 36%). Biliary complications were reported in 84/308 patients after FSLT (Pooled proportion: 25.6%, 95%CI: 19–32%, I²: 44%). Pooled proportions of graft and patient survival after 3 years follow-up were 72.8% (95%CI: 67.2–78.5, n = 231) and 77.3% (95%CI: 66.7–85.8, n = 331), respectively. Compared with WLT, FSLT was associated with increased graft loss (pooled HR: 2.12, 95%CI: 1.24–3.61, P = 0.006, n = 189) and patient mortality (pooled HR: 1.81, 95%CI: 1.17–2.81, P = 0.008, n = 289). FSLT was associated with high incidences of vascular and biliary complications. Nevertheless, long-term patient and graft survival appear acceptable and justify transplant benefit in selected patients.