Outcomes in partial liver transplantation: deceased donor split-liver vs. live donor liver transplantation

BackgroundOrgan shortage has resulted in greater emphasis on partial liver transplantation (PLT) as an alternative to whole-organ liver transplantation.MethodsThis study was conducted to assess outcomes in PLT and to compare outcomes of deceased donor split-liver transplantation (DD-SLT) and live donor liver transplantation (LDLT) in adults transplanted in the USA using data reported to the United Network for Organ Sharing in the era of Model for End-stage Liver Disease (MELD) scores.ResultsBetween 2002 and 2009, 2272 PLTs were performed in the USA; these represented 5.3% of all liver transplants carried out in the country and included 557 (24.5%) DD-SLT and 1715 LDLT (75.5%) procedures. The most significant differences between the DD-SLT and LDLT groups related to mean MELD scores, which were lower in LDLT recipients (14.5 vs. 20.9; P < 0.001), mean recipient age, which was lower in the LDLT group (50.7 years vs. 52.8 years; P < 0.001), and mean donor age, which was lower in the DD-SLT group (23.0 years vs. 37.3 years; P < 0.001). Allograft survival was comparable between the two groups (P= 0.438), but patient survival after LDLT was better (P= 0.04). In Cox regression analysis, LDLT was associated with better allograft (hazards ratio [HR]= 0.7, 95% confidence interval [CI] 0.630–0.791; P < 0.0001) and patient (HR = 0.6, 95% CI 0.558–0.644; P < 0.0001) survival than DD-SLT.ConclusionsPartial liver transplantation represents a potentially underutilized resource in the USA. Despite the differences in donor and recipient characteristics, LDLT is associated with better allograft and patient survival than DD-SLT. A different allocation system for DD-SLT allografts that takes into consideration cold ischaemia time and recipient MELD score should be considered.     

Simplifying living donor liver transplantation

BACKGROUND:Living donor liver transplantation is a complex surgical operation.Treatment policies and operative techniques evolved in the last two decades.DATA SOURCES:Our center's experience in living donor liver transplantation was reviewed in conjunction with relevant publications in the literature.RESULTS:The surgical techniques and perioperative surgical therapeutics could be modified towards simplicity.Examples include regular inclusion of the middle hepatic vein without compromising the venous outflow...     

Efficacy and safety of moderately steatotic donor liver in transplantation

BACKGROUND:The discrepancy between available livers and requests for transplantation has forced many centers to use marginal donors in order to expand the donor pool. Many previous studies have demonstrated controversial results of the application of steatotic liver grafts.The aim of the present study was to summarize our experience and evaluate the value of steatotic liver grafts. METHODS:The clinical and follow-up data of 24 adult patients receiving moderately steatotic liver grafts (30%-60%)from May 2003...     

Asian contribution to living donor liver transplantation

Although the shortage of brain-dead donor organs is a worldwide problem, the situation is especially serious in Asia because of various cultural and social reasons, and cadaveric organ donation remains below 5 per million population per year. Living donor liver transplantation (LDLT) could provide an alternative for liver graft for patients with acute and chronic end-stage liver disease. This article introduces the important contributions to the development of LDLT by the leading Asian liver transplantation centers. The first successful adult LDLT using a left-lobe graft was reported by Makuuchi et al. from Japan in 1994. To overcome the barrier of graft-size matching for adult patients with use of a left-lobe graft, a trial of adult LDLT using a right-lobe graft with middle hepatic vein was reported with satisfactory outcome by Fan et al. from Hong Kong in 1997. Despite the impressive results of right-lobe LDLT, considerable debate persists concerning donor safety. Lee et al. from Korea initiated modified right-lobe liver grafting with interposition vein grafts to drain anterior segment and two left-lobe liver grafting to overcome graft-size insufficiency and to ensure donor safety in 1999 and 2000, respectively. In addition to technical innovations, indications for liver transplantation have been developed by Asian centers as LDLT activity has increased.     

Historical perspective of living donor liver transplantation

Living donor liver transplantation （LDLT） has gone through its formative years and established as a legitimate treatment when a deceased donor liver graft is not timely or simply not available at all. Nevertheless, LDLT is characterized by its technical complexity and ethical controversy. These are the consequences of a single organ having to serve two subjects, the donor and the recipient, instantaneously. The transplant community has a common ground on assuring donor safety while achieving predictable recipient success. With this background, a reflection of the development of LDLT may be appropriate to direct future research and patientcare efforts on this life-saving treatment alternative.     

Implications for management of Mycobacterium tuberculosis infection in adult-to-adult live donor liver transplantation.

BACKGROUND: Mycobacterium tuberculosis (TB) infection is a serious opportunistic infection especially in live donor liver transplantation (LDLT). Hepatotoxicity of antituberculous agents and hazardous drug interaction with immunosuppressants may render the graft more susceptible to injury. AIM OF STUDY: To review our experience of management of TB infection in liver transplant recipients including LDLT. PATIENTS AND METHODS: A total of 397 liver transplantations were performed in the University of Hong Kong Medical Centre from January 1991 to December 2004. Eight patients (2.0%) developed TB infection after transplantation (LDLT: n=6, DDLT: n=2) and their clinical courses were reviewed. RESULT: The mean time of developing TB infection after liver transplantation was 9 months (range 4-20 months). Anti-TB treatment was administered for a mean duration of 12.7 months (11-18 months). None of our patients developed antituberculous drug-induced hepatotoxicity or had unwanted drug interaction. With a mean follow-up of 65 months (range 18-102 months), one patient died due to the recurrence of hepatocellular carcinoma. CONCLUSION: High index of suspicion for TB infection should be warranted for a history of cough and fever after liver transplantation. No notable difference was observed in the natural history and management of TB infection between LDLT and DDLT. The use of antituberculous drugs is safe in liver transplant recipients provided that liver function is closely monitored and the dosage of immunosuppressants is adjusted accordingly.     

Living donor liver transplantation: Eastern experiences

BACKGROUND: The techniques of living donor liver transplantation (LDLT) developed rapidly in the 1990s to compensate for a severe deficiency in the availability of liver grafts from cadaveric donors for the treatment of patients with end-stage liver disease. This tendency was particularly prominent in East Asia, as brain-death donors have remained largely unavailable for a variety of reasons. Thanks to refinements in surgical technique and postoperative management for LDLT, the cumulative total of LDLTs in East Asian countries has exceeded 2000 and, importantly, donor mortality has yet to be encountered. Moreover, indications for LDLT have been successfully expanded from paediatric to adult cases, following the introduction of right lobe graft. The significance of LDLT under conditions of limited opportunities for cadaveric liver transplantation, as experienced in these countries, differs significantly from that seen with the numerous opportunities for cadaveric donors in Europe and the USA. This review describes not only the experiences of East Asia, but also the specific differences from Western countries, such as indications, graft size issues and ABO blood type combinations, to shed light on the future of liver transplantation.     

Retrohepatic vena cava deroofing in living donor liver transplantation for caudate hepatocellular carcinoma

The removal of tumor together with the native liver in living donor liver transplantation for hepatocellular carcinoma is challenged by a very close resection margin if the tumor abuts the inferior vena cava. This is in contrast to typical deceased donor liver transplantation where the entire retrohepatic inferior vena cava is included in total hepatectomy. Here we report a case of deroofing the retrohepatic vena cava in living donor liver transplantation for caudate hepatocellular carcinoma. In order to ensure clear resection margins, the anterior portion of the inferior vena cava was included. The right liver graft was inset into a Dacron vascular graft on the back table and the composite graft was then implanted to the recipient inferior vena cava. Using this technique, we observed the no-touch technique in tumor removal, hence minimizing the chance of positive resection margin as well as the chance of shedding of tumor cells during manipulation in operation.     

Utilization of hepatitis B core antibody-positive donor liver grafts

Background

The inclusion of hepatitis B core antibody-positive (HBcAb+) liver donors is a strategy utilized to increase organ availability. This study examined HBcAb+ transplantation practices to identify specific factors influencing outcomes.

Methods

Twenty-five HBcAb+ liver transplants were identified retrospectively among 868 adult transplants performed between 1 January 1997 and 31 December 2009. Twelve (48%) recipients had hepatitis C and five (20%) had hepatitis B. Patient and donor demographics, preoperative morbidity, transplant data and outcomes were examined. Statistical analysis was completed using Student''s t-test or the Kaplan–Meier method. A P-value of <0.05 was considered significant.

Results

There was no difference in age, body mass index or comorbidities between HBcAb+ liver recipients and control subjects. Model for End-stage Liver Disease (MELD) scores of >30 were significantly more frequent in HBcAb+ liver recipients (32% vs. 15%; P = 0.04). All patients received immunoglobulin and longterm antiviral therapy as prophylaxis against graft hepatitis B resurgence. No patients who received HBcAb+ livers developed hepatitis B infection on follow-up. Overall survival at 30 days, 1 year and 5 years in HBcAb+ liver recipients was 92%, 74% and 74%, respectively, compared with 96%, 89% and 76%, respectively, in the control group (P = not significant, log-rank test). All except one of the deaths in the HBcAb+ liver recipient group occurred within 90 days postoperatively and in patients with MELD scores >30.

Conclusions

The practice of transplanting HBcAb+ grafts incurs low risk for infection using current methods of prophylaxis. The highest mortality risk was in the early postoperative period, specifically in patients with very high MELD scores. This probably reflects the practice of using positive serology grafts in emergent situations.     

Living donor liver transplantation: issues regarding left liver grafts

BackgroundThe necessity of widening the indications for living donor liver transplantation (LDLT) has been emphasised. Clarification of the advantages and limitations of using a left liver graft for LDLT in adults is essential for donor safety.MethodsBetween June 1990 and November 2002, 185 patients underwent LDLT at Shinshu University Hospital, Japan. In 97 of these, the graft comprised the left liver with or without the left portion of the caudate lobe. The peri-hepatectomy profiles of the donors, significance of left liver grafts, postoperative courses of the donors and recipients, and survival of the recipients were investigated.ResultsAll the donors recovered well and returned to a normal lifestyle. None required banked-blood transfusion or repeat surgery, and postoperative liver function tests had satisfactory results. The cold ischaemic time for the graft was 127±54 minutes. The graft volumes (GVs) ranged from 230 to 625 ml, and GV/standard liver volume (SV) ratios varied from 22% to 65%, at the time of transplantation. Although 85% of the liver grafts had GV/SV ratios <50%, no patient developed immediate postoperative liver failure. Patient survival rates were 89%, 84% and 84% at 1, 3 and 5 years, respectively.DiscussionAlthough LDLT using a left liver graft imposes potential postoperative complications (a small liver is more vulnerable to injury, and recipients of small grafts are at higher risk of complications during recovery), such grafts have yielded acceptable results in adult LDLT, with minimal burden to the donors.     

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.     

Late-onset acute rejection after living donor liver transplantation

INTRODUCTION Standard regimens for immunosuppressive therapy after liver transplantation include calcineurin inhibitors and steroids, which result in a reduced incidence of acute rejection and improved recipient survival[1]. The long- term complications o…     

Clostridium difficile-associated diarrhea after living donor liver transplantation

AIM： To assess the incidence and analyze the risk factors for Clostridium difficile-associated diarrhea （CDAD）after living donor liver transplantation （LDLT） in adult.
METHODS： The micobiological data and medical records of 242 adult recipients that underwent LDLT at the Tokyo University Hospital were analyzed retrospectively. The independent risk factors for postoperative CDAD were identified.
RESULTS： Postoperative CDAD occurred in 11 （5%）patients. Median onset of CDAD was postoperative d 19（range, 5-54）. In the multivariate analyses, male gender （odds ratio, 4.56） and serum creatinine （≥ 1.5 mg/dL,odds ratio, 16.0） independently predicted postoperative CDAD.
CONCLUSION： CDAD should be considered in the differential diagnosis of patients with postoperative diarrhea after LDLT.     

PNPLA3 as a liver steatosis risk factor following living‐donor liver transplantation for hepatitis C

Aim

Liver steatosis frequently occurs following liver transplantation (LT) and can affect patient outcome. Here, we aimed to clarify the steatosis and steatohepatitis risk factors that apply after living‐donor LT for chronic hepatitis C.

Methods

We retrospectively examined 43 transplant recipients and donors, and tested for single nucleotide polymorphisms in the PNPLA3 gene. Liver biopsies taken 1 year after transplantation and yearly thereafter, or when abnormal liver enzyme levels were detected, were examined by histopathology.

Results

Liver steatosis (>5% steatotic hepatocytes) was evident in 13 of 43 cases (30%), and steatohepatitis in 3 (7.0%). The average time to steatosis after LT was 2.74 ± 1.55 years. The PNPLA3 rs738409 GG genotype, a steatosis risk factor, was identified in 13 recipients and 10 donors. Steatosis prevalence did not differ according to recipient genotype. However, this condition was significantly more common among patients who received tissue from donors carrying the rs738409 GG genotype compared to those with grafts from donors of the CC or CG genotype (60, 7, and 26%, respectively; P < 0.05). All 3 steatohepatitis cases were associated with the GG donor genotype.

Conclusion

The PNPLA3 rs738409 GG donor genotype affects liver steatosis and steatohepatitis risk following living‐donor LT.     

Assessment of liver stiffness in patients after living donor liver transplantation by transient elastography

Objective. Recurrence of hepatitis and progression of fibrosis are major problems in liver transplantation (LT) for patients with hepatitis C. Liver stiffness measurement (LSM) by transient elastography correlates well with histologic liver fibrosis stages in chronic liver diseases. The aim of this study was to evaluate the usefulness of transient elastography for the assessment of fibrosis in patients after living donor LT. Material and methods. Seventy-nine patients who visited our institution, and in whom LSM was successfully evaluated, were enrolled in the study. The patients were divided into three groups according to positivity for hepatitis C antibody and hepatitis B surface antigen as the hepatitis C virus (HCV) group (n=37), the hepatitis B virus (HBV) group (n=10), and the NBNC (negative for both hepatitis B and C) group (n=32). The correlation between LSM and histologic fibrosis stage was assessed in 36 patients. LSM was also compared with regard to the effect of interferon therapy in HCV patients. Results. The median value for liver stiffness was 6.8 kPa and the median time from LT was 3.1 years. In patients who underwent liver biopsy, stiffness was significantly correlated with the stages of fibrosis (p<0.001, rho = 0.848). In patients who received interferon therapy after LT, the LSM decreased over time in those with a sustained virological response, whereas LSM increased in patients without a response. Conclusion. Transient elastography may be an appropriate non-invasive procedure to sequentially assess the progression of liver fibrosis in patients after LT.