Orthotopic liver transplantation in The Netherlands 1979-1988

In 1979 the Dutch orthotopic liver transplant programme started in Groningen. Until July 1988, 73 orthotopic liver transplantations were performed in 66 adults. A survey is given of selection criteria, indications, complications and results.     

Epidemiology of infections after liver transplantation in children

One of the most important problems after solid organ transplantation including liver, remains infections. Multiple risk factors play a role among which the most important are: general patients health before transplantation, prolong operative time, graft function and type of immunosuppression. The most important problems with bacterial, fungal and viral infections was described as well as treatment and profilaxis.     

Orthotopic liver transplantation in The Netherlands. The results and impact of a medical technology assessment

In 1985 Dutch health care authorities and health insurance companies initiated a large-scale technology assessment (TA) of liver transplantation (LTx) in The Netherlands. The 10-year experience of the existing programme in the University Hospital Groningen was investigated. Topics included were patient flow, selection policies, survival, quality-of-life, costs, need, supply of donor organs and organisational aspects. Estimation of the consequences of a non-transplantation scenario allowed for the execution of a cost-effectiveness analysis. Results showed clear improvement by LTx of survival and quality-of-life, though to a lesser degree than expected. Costs of the first transplantation year amounted to Dfl 180,000 (approx US $90,000). The cost-effectiveness ratio ranged from Dfl 47,000 to Dfl 133,000 per life year gained. No overt imbalance between need and donor supply existed or was expected in the near future. The impact of this study is related to the informational value and to the contribution to the decision-process. Even at its appearance in 1988, the final report provided health policy makers with new information. Health policy concerning LTx was considerably influenced, as a rule in agreement with the study conclusions. We conclude the Dutch case study to be an example of a useful and efficient TA.     

Results of liver transplantation in children; parents' opinion

Since 1982, the liver transplantation team of the University Hospital of Groningen has been carrying out transplantations in children. This article focuses on the experiences of the parents of 19 children who have undergone transplantation. An interview and two questionnaires were used to collect the data. Data concerned children's physical and psychosocial functioning and their daily behaviour. Five older children also filled in two questionnaires. In general, parents were positive about their child's functioning. When the interviews were analysed at an individual level, several problems were reported, however. These problems did not fall within one specific domain. As a consequence, the questionnaires did not show any significant differences between these children and a matched control group of healthy children. The parents of the children aged 1-3 yr were more positive about their children's functioning than the parents of the children aged 4-12 yr. The positive results should be assessed in the light of children's functioning before transplantation: when compared with pre-transplantation problems, present problems are of little significance.     

The nature of malnutrition in children with end-stage liver disease awaiting orthotopic liver transplantation.

To evaluate malnutrition in chronic liver disease, and its relationship to nutrient deficiencies and hepatic dysfunction, 27 children with end-stage liver disease were studied. Mean protein-energy intakes were 70% of recommended daily intakes. The patients were underweight and stunted with reduced mean triceps and subscapular skinfold thicknesses and midupper arm circumference. Mean total body potassium was only 63 +/- 18% of that expected for age and sex. Deficiency of essential fatty acids (32%), and low concentrations of fat-soluble vitamins (A, 92%; E, 32%), iron (32%), zinc (42%), and selenium (13%) were common. Serum ammonia concentrations were raised in all patients, and increased methionine, tyrosine, and glutamic acid, and reduced glutamine concentrations were noted. There was no correlation between the degree of malnutrition and the degree of liver synthetic function, the degree of cholestasis, or the degree of liver injury. We suggest that potentially correctable factors in addition to liver failure (eg, inadequate absorbed intake) were important determinants of malnutrition in these patients.     

Renal transplantation in children

Despite being considered a high risk procedure, renal transplantation has been recognized for more than 20 years as the best therapeutic option for children with end-stage renal disease since it is superior than any available dialytic procedure in improving the neuropsychological development and the quality of life. Today pediatric patients have similar graft survival than adults, and 10 year-old children or less have better outcome than any other age group. These remarking results are due to the development of specialized pediatric transplant centers and research programs, improvement in the selection and preparation of donors and recipients, refinement of the surgical technique and the use of new immunossupressive drugs.     

Renal transplantation in children

Transplantation with a renal allograft is the treatment of choice for the child with end-stage renal failure. Over the past 20 years rapid advances have made it possible to transplant a kidney of adult proportions into a child aged 1 year or less. Actuarial graft survival at 5 years for first cadaveric kidneys is more than 60% in children aged less than 5 years. Long-term studies have demonstrated an improvement in linear growth and preservation of glomerular filtration rate.     

Pediatric liver transplantation

Pediatric liver transplantation has evolved over the last two decades into an effective and widely accepted therapy for infants and children. Currently, these high-risk patients achieve 85 to 90% one-year patient survival and an excellent quality of life. This paper reviews the special features of the pediatric recipient, the surgical innovations developed to be able to offer them a transplant (reduced size, live donor, split, and auxiliary partial transplantation), the most significant issues in anesthetic, immunosuppressive and postoperative care in children, as well as a global picture of the results. Additionally, the experience of the Hospital Infantil de México Federico Gómez is presented, as the largest and most successful series of pediatric liver transplantation in the country, where the first successful live donor liver transplantation and the first simultaneous liver-kidney transplantation in a child were performed.     

Nutrition in chronic liver disease and liver transplantation

Significant contributions to the field of nutrition and liver disease have been published in the last year. The most relevant includes work on the pathogenic role of energy metabolism disturbances in the development of malnutrition in cirrhosis, as well as data on the relationship between preoperative nutritional deficiencies and the outcome of liver transplantation. However, despite these contributions, large-scale multicentric trials on the therapeutic value of nutritional support and metabolic care in cirrhosis and liver transplantation are still lacking.     

Technical progress in liver transplantation

Throughout the history of liver transplantation many improvements have been made in the field of surgical technique. The technical progress improved results of liver transplantation; the split liver transplantation and living donor liver transplantation increased the number of cadaveric grafts, expanding primary the pediatric and later the adult liver graft pool. The authors present most of current methods of liver transplantation: orthotopic liver transplantation with or without preservation, of the inferior vena cava, "domino" liver transplantation, split liver transplantation, auxiliary liver transplantation and living donor liver transplantation.     

Surgical techniques in liver transplantation

Liver transplantation (LT) is probably the biggest surgical aggression that a patient can endure. It was considered only as a last option in the era of experimental LT, yet it evolved into the definitive treatment for some types of acute and chronic end stage liver disease. In terms of technique LT is the most complex of all types of transplantations. The surgical procedure in itself is well established and has changed little through time. Liver transplantation owes its improvement to better and more systematic anesthetic procedures and to perioperative care more than being due to improvement of the surgical technique. The first surgical procedure was described by Thomas Starzl in 1969. His initial work has been strengthened with the development of venous bypass, the refinement in vascular and biliary reconstruction technique and the development of the split liver. Up to date technical aspects of orthotopic liver transplantation are described in the present article.     

Organizational learning-by-doing in liver transplantation

Organizational learning-by-doing implies that production outcomes improve with experience. Prior empirical research documents the existence of organizational learning-by-doing, but provides little insight into why some firms learn while others do not. Among the 124 U.S. liver transplant centers that opened between 1987 and 2009, this paper shows evidence of organizational learning-by-doing, but only shortly after entry. Significant heterogeneity exists with learning only evident among those firms entering early in the sample period when liver transplantation was an experimental medical procedure. Firms that learn begin with lower quality outcomes before improving to the level of firms that do not learn, suggesting that early patient outcomes depend on the ability of new entrants to import best practices from existing liver transplant programs. Knowledge of best practices became increasingly available over time through the dissemination of academic research and increasingly specialized training programs, so that between 1987 and 2009, 6 month post-transplant survival rates increased from 64 to 90% and evidence of organization-level learning-by-doing disappeared. The lack of any recent evidence of organizational learning-by-doing implies that common insurer experience requirements may be reducing access to health care in non-experimental complex medical procedures without an improvement in quality.     

Advances in immunossuppression in liver transplantation

The history of immunosuppression is a long one. From the utilization of steroids and azathioptine in the 50's to the design of humanized molecules that specifically block cell surface receptors. Liver transplantation is one of the procedures that benefit the most with the development of new immunosuppressors and is also one of the reasons to create a new branch in research and clinical practice: transplant medicine. It also set the standards for research in the "immunologic tolerance" field. The cornerstone in the post-liver transplant stage is the utilization of calcineurin inhibitors combined with new anti-metabolites and monoclonal antibodies. All these settings conforms a promising field in the research of new and better immunosuppressing agents.     

肝移植患儿医院感染相关经济损失分析

目的分析肝脏移植患儿因医院感染所造成的直接经济损失,探讨造成医院感染的危险因素,采取针对性措施降低医院感染的发生,进而减少患者的经济损失。方法采用病例对照研究的方法,以某综合医院2014年1月1日-2015年12月31日期间符合研究条件的肝脏移植手术患儿222例为研究对象,将发生医院感染的58例患儿作为感染组,未发生感染的164例患儿作为对照组,分析比较两组住院费用和住院天数,分析医院感染导致的直接经济损失。结果 222例患者中58例发生医院感染,感染率为26.13%,感染部位以血液系统、手术部位和呼吸系统为主。感染组的平均医疗费用为131 605元,高于对照组,两组中位数差值为26 351元(P<0.001),增加最多的是西药费和化验费,分别增加6 276元和6 031元。感染组患儿平均住院62d,对照组患儿平均住院44d,感染组患儿较对照组患儿延长住院天数18d(P<0.001)。结论肝移植患儿术后发生医院感染会导致较大直接经济损失,应加强医院感染管理,减少医院感染的发生,降低患儿的经济负担。     

Liver transplantation in acute liver failure

Acetaminophen and idiosyncratic drug induced hepatotoxicity are the most commonly identified etiologies of acute liver failure in Western countries. Infectious complications and cerebral edema remain the leading causes of death. Moderate hypothermia and other medical interventions may improve cerebral edema in selected patients with acute liver failure. In addition, pilot studies suggest that recombinant factor VIIa infusions may allow for the safe placement of intracranial pressure monitoring devices in patients with cerebral edema and severe coagulopathy. Auxiliary liver transplantation and bioartificial liver devices offer the hope of temporary liver support for selected patients with a high likelihood of native liver regeneration. Prognostic survival models that include arterial lactate levels may improve our ability to identify acetaminophen overdose patients in urgent need of liver transplantation. The lower 1-year patient survival following liver transplantation for acute liver failure compared to chronic liver failure (60 vs 80%) is in part due to the emergent nature of surgery, concomitant vital organ failure, and the higher incidence of immunologically mediated graft dysfunction. Vaccination against hepatotrophic viruses and other public health measures designed to minimize the incidence of both intentional and non-intentional acetaminophen overdose may help reduce the future incidence of acute liver failure. In the meanwhile, it is recommended that acute liver failure patients be managed in experienced centers with ready access to liver transplantation to optimize outcomes in this rare but frequently fatal illness.