Donor safety in adult living donor liver transplantation using the right lobe： Single center experience in China

AIM： To evaluate the safety of donors in adult living donor liver transplantation （LDLT） using the right lobe in a single liver transplantation center in China.
METHODS： We investigated retrospectively 52 living donor liver resections performed from October 2003 to July 2006. All patients were evaluated by blood tests and abdominal CT. The mean donor age was 28.2 ± 7.4 years. Residual liver volume was 42.1% ± 4.7%. Mean operative time was 420 ± 76.2 min; mean ICU stay, less than 36 h; mean hospital stay, 16.4 ± 8.6 d; and mean follow-up period, 6 mo.
RESULTS： There was no mortality. The overall complication rate was 40% （21 donors）. Major complications included biliary leak in two, and pneumonia in 2 donors. Minor complications included mild pleural effusion in 12 donors, transient ascites in 6, mild depression in 4, intra-abdominal collections in 2, and wound infections in 1 donor. Residual liver volume did not affect the complication rate. None required reoperation. Return to pre-donation activity occurred within 5-8 wk.
CONCLUSION： Right hemi-hepatectomy can be performed safely with minimal risk in cases of careful donor selection. Major complications occurred in only 7.7% of our series.     

Retrospective analysis of the causes of rejection of potential donors for living related liver transplantation

Background  A major prerequisite for living related liver transplantation is to ensure both donor safety and optimal graft quality. Therefore, excluding unsuitable donor candidates should be an important priority of the transplant team. Purpose  To analyze the criteria for exclusion of potential living related liver donors. Patients and methods  From November 2000 to March 2005, 327 potential living related donors for 136 potential recipients for liver transplantation were screened and worked up at the Liver Transplant Center, King Abdul Aziz Medical City. They were evaluated in a stepwise manner, including medical, physical, laboratory, psychosocial, and imaging assessment. Data regarding potential donors were retrospectively reviewed. Reasons for rejection of disqualified donors were analyzed. Results  Out of the 327 potential donors, 223 (68.2%) were rejected at an early stage. A total of 104 cases (31.8%) had computed tomographic (CT) volumetry and/or magnetic resonance cholangiography (MRCP). While 44 (42.3% of those who had CT volumetry and/or MRCP) had their workup completed and proved to be suitable candidates, 24 (23%) went for surgery. Causes for donor rejection were classified as donor-related factors (inadequate volume, unsafe anatomy, abnormal liver function tests, medical/psychiatric, fatty liver, etc.; n = 191) and recipient-related factors (too ill, died, received cadaveric transplant, etc.; n = 112). Conclusion  In our experience, as well as in those from other centers, a small proportion of potential donors prove to be satisfactory candidates. Therefore, strict adherence to a stepwise evaluation process is of utmost importance, so unsuitable potential donors can be disqualified, as early as possible during workup.     

心脏停搏供体肝移植中供肝选择的初步研究

目的 探讨大鼠心脏停搏供体肝移植中,如何合理地选择供肝,以提高此类供体肝移植术后的存活率。方法 实验分为３组,在供肝获取前分别经历供体心脏停搏（ＮＨＢＤ）１５、３０或４５ｍｉｎ（ＮＨＢＤ－１５、ＮＨＢＤ－３０和ＮＨＢＤ－４５组）,而后各行１８对大鼠原位肝移植。依据开腹时和冷灌洗后的表现将供肝为Ｉ、Ⅱ、Ⅲ级,并于冷灌洗的固定取供肝尾叶作病理观察。结果 ＮＨＢＤ－１５、ＮＨＢＤ－３０和ＮＨＢＤ－４５组     

活体肝移植治疗原发性肝癌的价值与风险评价

目的评价活体肝移植治疗原发性肝癌的价值与风险。方法自2002年1月至2006年12月，四川大学华西医院肝脏移植中心对27例原发性肝癌患者实施活体肝移植治疗，其中25例接受右半肝移植物，2例接受双供体移植物；对这27例受体及其29例供体的临床资料和随访结果进行回顾性分析。结果本组供体无死亡发生，并发症发生率为17．24％（5例），其中2例（6．90％）发生较严重的并发症，包括腹腔内出血及门静脉栓塞各l例；3例（10．34％）并发症较轻，伤口脂肪液化并感染、胸腔积液及乳糜漏各l例；所有供体目前都已完全康复，并回到以前的工作岗位。本组受体无一例发生小肝综合征，全组病例1年及3年累积生存率分别为84．01％及71．40％，与同期因各种其他非恶性疾病进行的成人活体肝移植受体1年及3年累积生存率（83．30％及75．51％）比较，两者差异无统计学意义（P〉0．05）。结论虽然活体肝移植治疗原发性肝癌对供体的风险及受体的益处尚需进一步的研究评价，但研究结果已初步表明，只要我们努力作好每一个细节，活体肝移植对供体来说是一相对安全的手术；而对肝癌患者来说则能相对满意地延长生存期，值得进一步推广运用。     

供肝脂肪变性与肝移植术后糖尿病发病风险的关系

目的探讨肝移植术后糖尿病（PTDM）发病的危险因素以及供肝脂肪变性对PTDM发病风险的影响。方法回顾性分析2001年4月至2008年12月438例接受肝移植患者的术前、术后的临床资料。采用2006年中华医学会肝脏病学分会制定的非酒精性脂肪性肝病（NAFLD）诊疗指南的组织病理评分标准判定供肝脂肪变性程度,肝功能状态判定采用Child—Pugh评分系统。根据术后空腹血糖将患者分为非PTDM组（n=298,男250例,女48例,平均年龄48岁）与PTDM组（n=140,男120例,女20例,平均年龄50岁）。对PTDM可能的危险因素,包括年龄、性别、空腹血糖、体质指数、术前肝功能、供肝脂肪变性、术后抗排异药种类、白细胞介素-2受体拮抗剂（IL-2RA）应用等进行单因素分析。在单因素分析基础上进行logistic多元回归分析。结果非PTDM组供肝脂肪变性者占34．6％（103／298）,PTDM组供肝脂肪变性者占44．3％（62／140）,2组无显著差别（X^2=3．83,P=0．05）。单因素分析提示术前空腹血糖（F=23．38,P〈0．05）、术前肝功能、IL-2RA、免疫抑制剂类型与PTDM显著相关（X^2值分别为7．69、8．30、0．02,均P〈0．05）,而供肝脂肪变性与PTDM相关性处于临界水平（X^2=3．83,P=0．05）。logistic多元回归分析提示术前空腹血糖异常（OR=1．853,P〈0．01）、供肝脂肪变性（OR=1．80,P〈0．05）可提高PTDM患病风险,而使用IL．2RA（OR=0．43,P〈0．01）可降低PTDM患病风险。结论供肝脂肪变性、术前空腹血糖异常为PTDM的危险因素,而IL-2RA应用则可降低PTDM发生风险,术前肝功能异常可能增加PTDM的发生风险,免疫抑制剂与PTDM的关系有待进一步研究。     

Problem of living liver donation in the absence of deceased liver transplantation program: Mansoura experience

We report our experience with potential donors for living donor liver transplantation (LDLT), which is the first report from an area where there is no legalized deceased donation program. This is a single center retrospective analysis of potential living donors (n = 1004) between May 2004 and December 2012. This report focuses on the analysis of causes, duration, cost, and various implications of donor exclusion (n = 792). Most of the transplant candidates (82.3%) had an experience with more than one excluded donor (median = 3). Some recipients travelled abroad for a deceased donor transplant (n = 12) and some died before finding a suitable donor (n = 14). The evaluation of an excluded donor is a time-consuming process (median = 3 d, range 1 d to 47 d). It is also a costly process with a median cost of approximately 70 USD (range 35 USD to 885 USD). From these results, living donor exclusion has negative implications on the patients and transplant program with ethical dilemmas and an economic impact. Many strategies are adopted by other centers to expand the donor pool; however, they are not all applicable in our locality. We conclude that an active legalized deceased donor transplantation program is necessary to overcome the shortage of available liver grafts in Egypt.     

Analyzing predictors of graft survival in patients undergoing liver transplantation with donors aged 70 years and over

AIM To increase the number of available grafts.METHODS This is a single-center comparative analysis performed between April 1986 and May 2016. Two hundred and twelve liver transplantation(LT) were performed with donors ≥ 70 years old(study group). Then, we selected the first cases that were performed with donors 70 years old immediately after the ones that were performed with donors ≥ 70 years old(control group).RESULTS Graft and patient survivals were similar between both groups without increasing the risk of complications, especially primary non-function, vascular complications and biliary complications. We identified 5 risk factors as independent predictors of graft survival: recipient hepatitis C virus(HCV)-positivity [hazard ratio(HR) = 2.35; 95% confidence interval(CI): 1.55-3.56; P = 0.00]; recipient age(HR = 1.04; 95%CI: 1.02-1.06; P = 0.00); donor age X model for end-stage liver disease(D-MELD)(HR = 1.00; 95%CI: 1.00-1.00; P = 0.00); donor value of serum glutamic-pyruvic transaminase(HR = 1.00; 95%CI: 1.00-1.00; P = 0.00); and donor value of serum sodium(HR = 0.96; 95%CI: 0.94-0.99; P = 0.00). After combining D-MELD and recipient age we obtained a new scoring system that we called DR-MELD(donor age X recipient age X MELD). Graft survival significantly decreased in patients with a DR-MELD score ≥ 75000, especially in HCV patients(77% vs 63% at 5 years in HCV-negative patients, P = 0.00; and 61% vs 25% at 5 years in HCV-positive patients; P = 0.00). CONCLUSION A DR-MELD ≥ 75000 must be avoided in order to obtain the best results in LT with donors ≥ 70 years old.     

Comprehensive risk assessment for early neurologic complications after liver transplantation

AIM: To determine risk factors for early neurologic complications(NCs) after liver transplantation from perspective of recipient, donor, and surgeon. METHODS: In all, 295 adult recipients were enrolled consecutively between August 2001 and February 2014 from a single medical center in Taiwan. Any NC in the first 30 d post-liver transplantation, and perioperative variables from multiple perspectives were collected and analyzed. The main outcome was a 30-d NC. Generalized additive models were used to detect the non-linear effect of continuous variables on outcome, and to determine cut-off values for categorizing risk. Risk factors were identified using multiple logistic regression analysis. RESULTS: In all, 288 recipients were included, of whom 142(49.3%) experienced at least one NC, with encephalopathy being the most common 106(73%). NCs prolonged hospital stay(35.15 ± 43.80 d vs 20.88 ± 13.58 d, P 0.001). Liver recipients' age 29 or ≥ 60 years, body mass index 21.6 or 27.6 kg/m~2, Child-Pugh class C, history of preoperative hepatoencephalopathy or mental disorders, day 7 tacrolimus level 8.9 ng/m L, and postoperative intraabdominal infection were more likely associated with NCs. Novel risk factors for NCs were donor age 22 or ≥ 40 years, male-to-male gender matching, graftrecipient weight ratio 0.9%-1.9%, and sequence of transplantation between 31 and 174. CONCLUSION: NCs post- liver transplantation occurs because of factors related to recipient, donor, and surgeon. Our results provide a basis of risk stratification for surgeon to minimize neurotoxic factors during transplantation.     

Donor safety and remnant liver volume in living donor liver transplantation

AIM:To evaluate the relationship between donor safety and remnant liver volume in right lobe living donor liver transplantation(LDLT).METHODS:From July 2001 to January 2009,our liver transplant centers carried out 197 LDLTs.The clinical data from 151 cases of adult right lobe living donors(not including the middle hepatic vein) were analyzed.The conditions of the three groups of donors were well matched in terms of the studied parameters.The donors' preoperative data,intraoperative and postoperative data were calculated for the three groups:Group 1 remnant liver volume(RLV) 35%,group 2 RLV 36%-40%,and group 3 RLV 40%.Comparisons included the different remnant liver volumes on postoperative liver function recovery and the impact of systemic conditions.Correlations between remnant liver volume and post-operative complications were also analyzed.RESULTS:The donors' anthroposomatology data,op-eration time,and preoperative donor blood test indicators were calculated for the three groups.No significant differences were observed between the donors' gender,age,height,weight,and operation time.According to the Chengdu standard liver volume formula,the total liver volume of group 1 was 1072.88 ± 131.06 mL,group 2 was 1043.84 ± 97.11 mL,and group 3 was 1065.33 ± 136.02 mL.The three groups showed no statistically significant differences.When the volume of the remnant liver was less than 35% of the total liver volume,the volume of the remnant had a significant effect on the recovery of liver function and intensive care unit time.In addition,the occurrence of complications was closely related to the remnant liver volume.When the volume of the remnant liver was more than 35% of the total liver volume,the remnant volume change had no significant effect on donor recovery.CONCLUSION:To ensure donor safety,the remnant liver volume should be greater than the standard liver volume(35%) in right lobe living donor liver transplantation.     

Rapid donor liver procurement with only aortic perfusion

ATM:to describe a rapid technique for procurement ofdonor liver with aortic perfusion only(APO).METHODS:Only the aorta is cannulated and perfused withchilied preservation solution.RESULTS:The quality of donor liver can ensure the graftedliver functions.CONCLUSION:The method of APO can simplify the operativeprocedure,compared with the dual cannulation.It also canminimize the danger of injuring vascular structures andinvolve less dissection.     

对肝功能衰竭的猪行异位部分肝移植的效果评价

目的 探讨在猪急性缺血性肝功能衰竭时行辅助性异位部分肝移植的作用。 方法在缩窄门静脉8 5％以上的同时,对结扎及不结扎肝动脉的家猪体内配对开展辅助性异位部分肝移植,监测受体存活情况、肝功能、肝脏血流情况、病理及供肝胆汁分泌情况。 结果 在缩窄门静脉85％以上并结扎肝动脉的受体肝脏体积缩小,病理提示大片肝细胞坏死,在缩窄门静脉85％以上而未结扎肝动脉的受体肝脏色泽正常,病理肝细胞无明显异常;植入肝体积增大,病理提示肝细胞存活良好并有分裂增生。 结论 受体肝动脉结扎、门静脉缩窄可以造成急性肝功能衰竭模型;辅助性异位部分肝移植能纠正肝功能衰竭;保留受体肝脏动脉血供、减少门静脉血供对受体肝脏功能无严重影响。     

Portal vein arterialization technique for liver transplantation patients

Liver transplantations were performed on two patients with hepatic failure caused by liver cirrhosis. Hard obsolete thrombi and portal venous sclerosis were observed in the major portal veins of both patients. The arteria colica media of one recipient and the portal vein of the donor were anastomosed end-to-end. The hepatic artery of the first donor was anastomosed end-to end with the gastroduodenal artery of the first recipient; meanwhile, the portal vein of the second donor was simultaneously anastomosed end- to-end with the common hepatic artery of the second recipient. The blood flow of the portal vein, the perfusion of the donor liver and liver function were satisfactory after surgery. Portal vein arterialization might be an effective treatment for patients whose portal vein reconstruction was difficult.     

Cadaveric liver transplantation for non-acetaminophen fulminant hepatic failure： A 20-year experience

AIM: To investigate the long-term results of liver transplantation (LT) for non-acetaminophen fulminant hepatic failure (FHF). METHODS: Over a 20-year period, 29 FHF patients underwent cadaveric whole LT. Most frequent causes of FHF were hepatitis B virus and drug-related (not acetaminophen) liver failure. All surviving patients were regularly controlled at the out-patient clinic and none was lost to follow-up. Mean follow-up was 101 mo. RESULTS: One month, one-, five- and ten-year patient survival was 79%, 72%, 68% and 68%, respectively. One month, one-, five- and ten-year graft survival was 69%, 65%, 51% and 38%, respectively. Six patients needed early (< 2 mo) retransplantation, four for primary non-function, one for early acute refractory rejection because of ABO blood group incompatibility, and one for a malignant tumor found in the donor. Two patients with hepatitis B FHF developed cerebral lesions peri-transplantion: One developed irreversible and extensive brain damage leading to death, and one suffered from deep deficits leading to continuous medical care in a specialized institution. CONCLUSION: Long-term outcome of patients transplanted for non-acetaminophen FHF may be excellent. As the quality of life of these patients is also particularly good, LT for FHF is clearly justified, despite lower graft survival compared with LT for other liver diseases.     

Pushing the frontiers of living donor right hepatectomy

Living donor right hepatectomy(LDRH)is currently the most common donor surgery in adult-to-adult living donor liver transplantation although the morbidity and mortality reported in living donors still contradicts the Hippocratic tenet of"do no harm".Achieving low complication rates in LDRH remains a matter of major concern.Living donor surgery is performed worldwide as an established solution to the donor shortage.The aim of this study was to assess the current status of LDRH and comment on the future of the procedure;assessment was made from the stand point of optimizing the donor selection criteria and reducing morbidity based on both the authors’8-year institutional experience and a literature review.New possibilities have been explored regarding selection criteria.The safety of living donors with unfavorable conditions,such as low remnant liver volume,fatty change,or old age,should also be considered.Abdominal incisions have become shorter,even without laparoscopic assistance;upper midline laparotomy is the primary incision used in more than 400 consecutive LDRHs in the authors’institution.Various surgical techniques based on preoperative imaging technology of vascular and biliary anomalies have decreased the anatomicalbarriers in LDRH.Operative time has been reduced,with low blood loss.Laparoscopic or robotic LDRH has been tried in only a few selected donors.The LDRHspecific,long-term outcomes remain to be addressed.The follow-up duration of these studies should be long enough to address possible late complications.Donor safety,which is the highest priority,is ensured by three factors:preoperative selection,intraoperative surgical technique,and postoperative management.These three focus areas should be continuously refined,with the ultimate goal of zero morbidity.     

T cell receptor repertoires within liver allografts are different to those in the peripheral blood

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乙型肝炎相关性肝脏疾病肝移植术后乙肝病毒复发的预防

目的通过乙型肝炎相关性肝脏疾病患者在拉米夫定联合乙型肝炎高效免疫球蛋白（HBIG）治疗下供肝植入前后受体乙型肝炎标志物变化，HBV基因序列变化检测，探讨其预防受体HBV再感染的效果。方法采用MEIA法、PCR-微流芯片法，基因测序法检测21例受体手术前后血清HBV—M、HBV—DNA定量、HBV—YMDD、HBVS基因α决定簇变异，同时采用ELISA法检测供体血清HBV—M。结果术前21例受体HBsAg、HBeAg／HBeAb、HBcAb阳性，16例HBV-DNA阳性，1例HBV．DNA阴性，4例HBV．DNA未测，术后19例患者HBV-M变成HBsAb或HBsAb、HBcAb阳性，1例为HBsAg、HBeAg、HBcAb阳性，1例为HBsAg、HBeAb、HBcAb阳性，其中19例HBV-DNA阴性，2例HBV-DNA阳性，无一例术前、后出现HBV．YMDD、HBVS基因α决定簇变异，供肝HBV-M均阴性。结论拉米夫定联合HBIG预防肝移植术后乙肝复发疗效确切，乙肝低或无复发可能与供体HBV-M阴性及受体无HBVS基因d决定簇变异有关，术前受体HBV-DNA结果与术后乙肝复发相关性未显示。     

肝病患者血浆输注的现状

肝脏疾病的患者往往会伴随不同程度的凝血功能障碍和出血。成分血液中的血浆中含有大量的各种凝血因子,故血浆在肝病患者的治疗过程中起着不可替代的作用。为了解血浆在肝病中应用动态,为血浆在肝病中的临床应用提供参考,本文就国内外血浆在肝病中的应用作一概述。