Liver retransplantation for primary nonfunction: analysis of a 20-year single-center experience.

Initial graft function following liver transplantation is a major determinant of postoperative survival and morbidity. Primary graft nonfunction (PNF) is uncommon; however, it is one of the most serious and life-threatening conditions in the immediate postoperative period. The risk factors associated with PNF and short-term outcome have been previously reported, but there are no reports of long-term follow-up after retransplant for PNF. At our institution, 52 liver transplants had PNF (2.22%) among 2,341 orthotopic liver transplants in 2,130 patients from 1984 to 2003. PNF occurred more often in the retransplant setting. Female donors, donor age, donor days in the intensive care unit, cold ischemia time, and operating room time were significant factors for PNF. Patient as well as graft survival of retransplant for PNF was not different compared to retransplant for other causes. However, PNF for a second or third transplant did not demonstrate long-term survival, and hospital mortality was 57%. In conclusion, retransplant for PNF in the initial transplant can achieve relatively good long-term survival; however, if another transplant is needed in the setting of a second PNF, the third retransplant should probably not be done due to poor expected outcome.     

Expanded-criteria donor kidneys: a single-center clinical and short-term financial analysis--cause for concern in retransplantation

BACKGROUND: Expanded-criteria donor (ECD) kidneys are associated with a higher risk of posttransplant failure, but they remain a favorable alternative to dialysis. Now that a uniform definition of "expanded criteria" exists, it is more appropriate than ever to evaluate their utility compared with that seen with non-ECD kidneys. METHODS: The authors analyzed 202 cadaveric kidney-only recipients that underwent transplantation from January 1999 to September 2001, including 45 (22%) recipients whose donors met current ECD criteria. RESULTS: ECD and non-ECD kidney recipients had similar pretransplant characteristics except for older age and increased duration of renal failure in the ECD group. Patient, graft, and death-censored graft survival in both groups were similar in primary recipients but significantly worse in retransplant recipients of ECD kidneys. The relative risk of death-censored graft loss was 1.58 in the ECD group (P = 0.45). Overall inpatient charges (minus organ acquisition charge) for 1 year posttransplant were 76,962 US dollars (ECD) versus 71,026 US dollars (non-ECD) (P = 0.53); the same charges in retransplant recipients were 136,596 US dollars (ECD) versus 91,296 US dollars (non-ECD) (P = 0.25). ECD recipients, especially retransplant recipients, had consistently higher creatinine concentrations, although the average current value of all functioning ECD grafts remains less than 2 mg/dL. ECD recipients had a higher incidence of ureteral stricture (4.4% vs. 0%), but this never resulted in graft loss. CONCLUSIONS: Considering the widening disparity between renal allograft availability and need and the fact that ECD kidneys provide superior outcomes compared with dialysis, the authors' data encourage the continued use of ECD kidneys in primary recipients but justify caution in the retransplant setting.     

Risk factors in liver retransplantation: a single-center experience

Liver retransplantation (Re-OLT) is one of the most debated issues in medicine over the past decade. Re-OLT, currently is accepted for patients with irreversible failure of a hepatic graft caused by primary nonfunction (PNF), hyperacute/chronic rejection, or hepatic artery thrombosis (HAT); whereas it is still controversial for patients with recurrent viral disease, in particular hepatitis C virus (HCV) cirrhosis. Patient and graft survival rates are lower than those observed after primary liver transplantation (OLT). The aim of the present study was to analyze the risk factors that adversely affect survival after Re-OLT in a single center. Medical data were collected for 23 patients who underwent Re-OLT from November 2002 to December 2008 including six men and seven women of mean age of 51.3 years. The most frequent indications for Re-OLT were: PNF (69.5%; 16/23), HCV recurrence (8.6%; 2/23), or HAT (8.6%; 2/23). Mean Model for End-Stage Liver Disease (MELD) at Re-OLT was 27.7 (range = 9-40). After a mean follow-up of 37.4 ± 30 (standard deviation) months, 43% (10/23) of patients had died, including 70% within the first 2 months after Re-OLT. Sepsis represented the commonest cause of death (40%). Re-OLT was performed for PNF among 90% of succumbing patients. As regards dead patients, 4/10 were HCV⁺ whose causes of death were sepsis (n = 2), alcoholic cirrhosis (n = 2), and undetermined (n = 1). Comparing patients who died after liver Re-OLT versus alive patients, we did not find any significant difference in terms of mean MELD (28.6 vs 27; P = NS), MELD > 25 (60% vs 61.5%, P = NS), donor age > 60 years (30% vs 15.3%, P = NS), HCV⁺ (40% vs 62%, P = NS), or time interval from OLT to Re-OLT (12.2 vs 777.7 days, P = NS). Patient survivals after Re-OLT were 67% at 3 years and 50% at 5 years, which were lower than those of first transplantations, as reported by other European and International Centers. Forty percent of deaths after Re-OLT occurred among HCV⁺ recipients, but for reasons unrelated to HCV infection.     

Cardiac retransplantation: a 15-year single-center clinical experience

BACKGROUND: Cardiac retransplantation is a controversial therapy because of the shortage of donor hearts. We retrospectively reviewed the short-term and long-term outcomes after cardiac retransplantation. METHODS AND RESULTS: Twenty-eight cases (18 males, 7 females; mean age, 50.3 +/- 13.5 years) underwent cardiac retransplantation: 25 first retransplantations and 3 second retransplantations. The indications for retransplantation were primary graft failure (PGF) in 11 patients (39.3%), intractable acute cardiac rejection (IACR) in 4 patients (14.3%), and coronary allograft vasculopathy (CAV) in 13 patients (46.4%). The patients had been supported as follows: prolonged cardiopulmonary bypass (CPB; n = 3), intra-aortic balloon pumping (IABP; n = 1), intravenous inotropic support (n = 7), extracorporeal membranoxygenator (ECMO; n = 3), ventricular assist device (VAD; n = 4), and no inotropic support (n = 10). There were 8 deaths within 30 days after retransplantation (28.6%). The overall 1-, 5-, 10-, and 15-year survival rates were 46.4%, 40.6%, 32.5%, and 32.5%, respectively. Acute cardiac rejection was the most common cause of death (43.8%). Thirty-day and 1-year survival rates of IACR, PGF, and CAV were 50.0%/0%, 63.6%/45.5%, and 84.6%/68.4%, respectively. CONCLUSIONS: Long-term survival after retransplantation was acceptable for patients with CAV and PGF; however, we must select patients for retransplantation carefully if the indication is IACR, because of the poor outcome.     

Long-term survival after cardiac retransplantation: a twenty-year single-center experience

OBJECTIVE: To identify risk factors for survival after cardiac retransplantation and compare the survival after retransplantation with that after primary cardiac transplantation. METHODS: A retrospective analysis of 952 patients undergoing cardiac transplantation for the treatment of end-stage heart disease at a single center between 1977 and October 1997. Of these, 43 patients (4.5%) underwent cardiac retransplantation for cardiac failure resulting from transplant-related coronary artery disease, rejection, and early graft failure. RESULTS: No significant difference in actuarial patient survival was found by Kaplan-Meier analysis at 1, 2, and 5 years between patients undergoing primary transplantation and those undergoing retransplantation 76%, 71%, and 60% versus 66%, 66%, and 51%, respectively (P =.2). Multivariable analysis identified a shorter interval between transplants and an initial diagnosis of ischemic cardiomyopathy as significant risk factors for death after retransplantation (P =.04 and.03, respectively). Since 1993, when our criteria for patient selection for retransplantation were revised on the basis of earlier experience to exclude patients with allograft dysfunction as a result of primary graft failure and those with intractable acute rejection occurring less than 6 months after transplantation, the survival has been significantly better (<1993 = 45%, 45%, and 33% versus >/=1993 = 94%, 94%, and 94% at 1, 2, and 4 years, respectively, P =.003). CONCLUSION: The long-term outcome of cardiac retransplantation is comparable with that of primary transplantation, especially in patients with transplant-related coronary artery disease. Patient characteristics and other preoperative variables should assist in the rational application of retransplantation to ensure optimal use of donor organs.     

再次肝脏移植

目前肝脏移植已成为临床常规治疗方法,挽救了大量终末期肝病病人的生命.但是仍然有部分病人在肝移植手术之后,由于各种原因造成急性或慢性移植肝失功,需要进行再次肝脏移植(liver retransplantation).     

再次肝移植单中心16例分析

目的 研究再次肝移植术的手术适应证、临床效果和预后.方法 回顾性分析2004年4月至2013年4月我中心进行的612例肝移植临床资料.结果 共有16例再次肝移植,再次肝移植率2.61％(16/612).两次移植间隔时间(即首次移植物存活时间)为(16.2±18.3)个月(10 d至64个月,中位时间9.5个月).再次肝移植后总体病死率50％(8/16),围手术期病死率18.75％(3/16);再次移植物存活时间为(37.4±34.3)个月(3d至94个月,中位时间39.5个月);受者平均生存时间(53.6±33.9)个月(10 d至94个月,中位时间57个月),5年总体生存率48.3％.结论 对于肝移植术后常规方法难以治疗的严重并发症,再次肝移植是合理、必要和可行的救治手段.再次肝移植在首次移植6个月后进行,有利于降低再次肝移植的围手术期病死率.     

Liver retransplantation: a model for determining long-term survival

BACKGROUND: Because of the worse results from retransplantation in relation to the initial liver transplantation, there is a need to refine the indication for retransplantation, such that fair distribution of this benefit is obtained. METHODS: This was a study of 139 patients who underwent liver retransplantation. Thirty variables were studied: 18 relating to the recipient and 12 to the donor. All the independent variables were initially compared with the length of survival using univariate analyses. Variables presenting significance were compared with the dependent variable of length of survival, to determine which factors were related to longer survival among patients, when evaluated together. RESULTS: A multivariate model for determining long-term survival among patients with retransplants was built up using the following variables: recipient's age, creatinine, urgency of retransplantation and early failure of the first graft. Through this multivariate model it was possible to determine a score that was categorized according to tertile distributions (below the 33rd percentile, score <24; 33rd to 66th percentile, 24 < or = score < or = 32; above the 66th percentile, score > 32). One-year, 3-year, and 5-year patient survival rates following retransplantation were respectively 85%, 82%, and 77% for scores <24; 69%, 66%, and 61% for scores between 24 and 32; and 21%, 19%, and 16% for scores >32 (P < 0.0001). CONCLUSION: The variables of recipient's age, creatinine, urgency of retransplantation, and early failure of the initial transplantation were factors that were independently related to the long-term survival of patients with liver retransplants.     

再次肝移植的原因与手术时机的选择

目的 探讨再次肝移值的原因与手术时机的选择。方法 本移植中心1999年7月至2004年12月共实施的164例肝移植中，再次肝移植6例，其中因缺血再灌注损伤致肝内胆管多发狭窄3例，肝动脉狭窄和血栓1例，乙肝复发1例，肝静脉流出道梗阻1例。再移植率为3．65％，再次肝移植均采用改良背驮式肝移植技术。结果 6例再次肝移植术后临床症状改善4例，无明显改善2例。术后腹腔出血2例，胆漏1例，腹腔细菌感染1例，霉菌感染2例，术后4月内死于细菌和霉菌感染2例，保守治疗治愈4例。结论 供肝缺血再灌注损伤致肝内胆管狭窄或消失是国内再次肝移植的主要原因，对于各种治疗均无法改善移植肝肝功能，肝功能进行性恶化，应该尽早行再次肝移植。     

Pediatric liver retransplantation: indications and outcome

INTRODUCTION: Liver transplantation is the only treatment for end-stage liver disease. Not all patients have a favorable outcome. Graft failure secondary to primary nonfunction, vascular complications, or chronic rejection among other problems may lead to retransplantation. Retransplantation represents 8% to 29% of liver transplantations in the pediatric population. The aim of this study was to present our experience with retransplanted children by analyzing the indications and the results. METHODS: All patients were prospectively included in our database, including 125 children. We included the indications for retransplantation, complications, and mortality. Kaplan-Meier curves were used for survival analysis. RESULTS: Since 1994, 125 patients were transplanted and 25 were retransplanted (20%), including 5 who received a third graft. Primary nonfunction represented 30% of the indications for retransplantation and hepatic artery thrombosis, 20%. Six of 25 patients who received a first retransplantation and 2 of 5 who received a second retransplantation died. The most frequent cause of death was multiorgans failure. The survivals at 1 and 5 years were 82% and 76% for children receiving a first retransplantation, and 60% at 1 and 5 years for those who received a second retransplantation. CONCLUSIONS: Organ failure after liver transplantation was a common event in pediatric transplantation. Survival was similar between patients transplanted once and those who received one retransplantation. Survival decreased among patients who received a third graft but was maintained at 60%, which is better than most published results for first retransplanted patients. Retransplantation is a valid option with good results for selected pediatric cases.     

Liver retransplantation in superobese patients: a single center experience

A retrospective review of patients who had body mass indeces greater than 40 kg/m² who underwent liver retransplantation (LR) from February 1998 to December 2008 at our institution. There were 73 patients who had body mass indeces greater than 40 kg/m² and had orthotopic liver transplantation. Six of 73 patients required retransplantation. Median time between orthotopic liver transplantation and LR was 131 days (range, 2 to 2812 days). Indications for LR were ischemic cholangiopathy, hepatic necrosis, recurrent hepatitis C, and primary non-function. Four patients are still alive with median survival of 37 months after LR. Two patients had perioperative death.     

肝移植治疗肝豆状核变性的单中心疗效分析

目的探讨肝移植治疗肝豆状核变性的疗效。方法 回顾性分析2003年9月至2009年7月接受肝移植手术治疗的5例肝豆状核变性患者的临床资料。结果 采用附加腔静脉整形的改良背驮式肝移植3例,成人间活体部分肝移植2例。围手术期死亡1例,死于肺部真菌感染和多器官功能衰竭,另4例患者恢复良好且存活,其中生存时间≥1年4例,≥3年3例。3例伴有神经精神功能障碍的患者中,除1例死亡外,另2例症状得到不同程度的改善。存活的4例术后1个月肝功能较术前明显改善,血清铜蓝蛋白水平明显升高。结论 全肝移植或活体部分肝移植术能改善肝豆状核变性患者的铜代谢和神经精神症状,提高患者的生活质量和存活率。     

再次肝移植80例临床报告

目的总结再次肝移植的临床经验。方法回顾性分析我中心自1999年1月至2005年7月实施的80例再次肝脏移植的原因、与首次肝移植的时间间隔、选择的术式、1年存活率、围手术期死亡率及死亡的主要病因。结果再次肝移植的主要原因是胆道并发症,占45．0％;距首次移植术后超过1个月再次移植围手术期死亡率（19．6％）明显低于首次移植术后8～30d行再次移植患者（70．0％）;围手术期死亡的主要原因是感染（54．5％）和多脏衰（18．2％）。结论选择合适的手术适应证及手术时间,根据术中情况决定具体术式,制定合理的免疫抑制方案及有效的抗感染治疗是提高再次移植生存率的关键。     

Simultaneous pancreas-kidney transplant: a single-center long-term outcome

BACKGROUND: In patients with type 1 diabetes mellitus and end-stage renal disease, simultaneous pancreas-kidney transplantation is associated with increased survival when compared with solitary deceased kidney transplant or dialysis. We consider that the analysis of our long-term program (based in a single center) of simultaneous pancreas-kidney transplantation would provide valuable information for this therapeutic approach regarding patient and organ survival. METHODS: The outcome of 57 consecutive pancreas-kidney transplants patients was analyzed. The analysis included characteristics of the donor and recipient and survival rates of patients and both grafts. We also analyzed age and modality of renal replacement treatment as possible mortality risk factors. RESULTS: Ten-year patient, kidney and pancreas graft survival rates were 75.8%, 57.2% and 42.7%, respectively. Censoring for patient death, the results for 10-year kidney and pancreas survival were 78.5% and 58%, respectively. CONCLUSION: Our results add evidence to support the notion that the double and simultaneous pancreas-kidney transplantation is in fact the treatment of choice in selected patients with end-stage renal failure due to type 1 diabetes mellitus.