Vascular complications in hepatic transplantation: single-center experience in 14 years

Purpose

To evaluate the spectrum of liver transplantation-related vascular complications that occurred in a single center over the past 14 years.

Materials and methods

Vascular complications and their clinical outcomes were reviewed among 744 liver transplant recipients. All patients underwent Doppler ultrasound with findings correlated with conventional or computed tomography angiography (CTA) in 111 patients.

Results

Among 70 recipients with vascular complications (%0.9), 14/26 patients with hepatic artery thrombosis underwent thrombectomy and arterial reanastomosis; six were retransplanted and six died. Among hepatic artery stenoses, three of nine were treated with balloon angioplasty and six underwent reanastomosis. Among 20 portal vein thromboses, 16 underwent thrombectomy, two patients retransplantation and two died. Seven patients with portal vein stenosis were followed. Two of six hepatic vein stenosis were restored with balloon angioplasty and three patients with metallic stent placement; the one other died. One patient with hepatic vein thrombosis died while the other patient was retransplanted.

Conclusion

Transplantation related hepatic vascular complications diagnosed and managed in timely fashion showed a low mortality rate in our series.     

Incidence, management, and results of vascular complications after liver transplantation

Introduction

Vascular complications show an 8%-15% incidence after liver transplantation and represent an important cause of mortality. An aggressive policy is necessary for an early diagnosis and treatment.

Patients and methods

From 2001 to 2009, we performed 240 liver transplantations in 232 patients. We employed Doppler ultrasonography on days 1 and 4 as well as before hospital discharge and always try a radiological approach.

Results

The incidence of vascular complications was 7.2% (n = 18) including arterial (n = 12, 4.8%) of early thrombosis (n = 4), late thrombosis (n = 4), and stenosis (n = 4) or portal (n = 3; 1.2%) of thrombosis (n = 2) or stenosis (n = 1); or caval complications (n = 3, 1.2%). Radiologic therapy was effective in 1 patient with arterial stenosis, in the 3 patients with portal complications, and in 2 patients with caval complications. All patients with early thrombosis and 2/4 with late thrombosis required retransplantation. Surgical treatment was effective in 1 patient with late thrombosis, 3 with stenosis, and 2 with caval complications. The overall mortality rate was 16.6%; 2 patients with arterial complications and 1 with a caval complications.

Conclusion

Vascular complications, mainly artery complications, represent serious problem after liver transplantation, which often requires retransplantation. With an aggressive policy of diagnosis and treatment, we can decrease the mortality rate from these adverse events.     

Heart retransplantation for pediatric primary allograft failure

Purpose

Heart transplantation is indicated for children with end-stage heart failure or complex inoperable congenital defects. When the transplanted heart fails, retransplantation is suggested and herein we have presented the prognosis of these pediatric cases.

Materials and methods

From March 1987 to March 2011, we performed 404 heart transplantations including 45 pediatric patients, 6 (13.3%) of whom experienced graft failure requiring retransplantation. Only four of the six patients (66.7%) had a chance for retransplantation.

Results

Six of 45 pediatric heart transplant patients (13.3%) experienced graft failure requiring retransplantation. Four of them (66.7%) underwent retransplantation. Only one of the four died due to severe postoperative sepsis with acute respiratory distress. The other three patients recovered well and remain alive with no neurological sequelae; all are in New York Heart Association functional classification I at present.

Conclusion

Pediatric post-heart graft failure require expectations retransplantation, which shows a good prognosis.     

Management of early hepatic arterial thrombosis after pediatric living-donor liver transplantation

Purpose

Early hepatic arterial thrombosis after living-donor liver transplantation is a cause of graft loss and patient mortality. We analyzed early hepatic arterial thrombosis after pediatric living-donor liver transplantation.

Materials and Methods

Since September 2001, we performed 122 living-donor liver transplants on 119 children. Ten hepatic arterial thromboses developed in the early postoperative period. The 7 male and 4 female patients of overall mean age of 6.3 ± 6.1 years underwent 5 left lateral segment, 3 right lobe, and 2 left lobe transplantations.

Results

Among 10 children with hepatic arterial thrombosis, 8 diagnoses were made before any elevation of liver function tests. One child displayed fever at the time of the hepatic arterial thrombosis. The median time for diagnosis was 5 days. Hepatic arterial thrombosis was treated with interventional radiologic techniques in 9 children, with 1 undergoing surgical exploration owing to failed radiologic approaches, and a reanastomosis using a polytetrafluoroethylene graft. Successful revascularization was achieved in all children, except 1. Four children died, the remaining 6 are alive with good graft function. During the mean follow-up of 52.7 ± 18.8 months, multiple intrahepatic biliary stenoses were identified in 1 child.

Conclusion

Routine Doppler ultrasonography is effective for the early diagnosis of hepatic arterial thrombosis. Interventional radiologic approaches such as arterial thrombolysis and intraluminal stent placement should be the first therapeutic choices for patients with early hepatic arterial thrombosis; if radiologic methods fail, one must consider surgical exploration or retransplantation.     

Vascular complications after orthotopic liver transplantation: hepatic artery thrombosis

Introduction

Hepatic artery thrombosis (HAT) is the second main cause of liver graft failure after primary nonfunction. It is the most frequent arterial complication in orthotopic liver transplantation (OLT). The consensus for early HAT definition consists of an arterial thrombosis detected during the first month after OLT. HAT is associated with markedly increased morbidity, being the leading cause of graft loss (53%) and mortality. However, improvements in postoperative care have resulted in a marked reduction of its incidence.

Methods

We performed a review of all patients who underwent liver transplantations from January 1991 to December 2009, involving 1560 subjects who underwent 1674 OLT, excluding children. To analyze the impact of the study period on HAT, we defined 3 periods: the first between January 1991 and April 1993, the second from May 1993 to December 2003, and the last from January 2004 to December 2009.

Results

The total number of patients with HAT was 48 (2.8%) including 32 (1.9%) early HAT and 16 (0.9%) late HAT. The incidence of HAT diminished as the surgical team gained experience from 9.3% in the first period to 2.1% in the last. Most patients with early HAT presented acute fulminant hepatic failure (30%) and most were retransplantations (81%).

Discussion

In general, there are 3 modalities for HAT: revascularization, retransplantation, and observation. The choice of the treatment depended on the time of diagnosis although retransplantation was the treatment of choice for most groups. Minimizing risk factors, protocols for early detection, and good operative techniques should be the standard in all centers.     

Vascular complications after living donor liver transplantation: a Brazilian, single-center experience

Background

In living donor liver transplantation (LDLT), vascular complications are more frequently seen than in deceased donor transplantation. Early arterial, portal vein, or hepatic vein thromboses are complications that can lead to graft loss and patient death. The aim of this study was to assess the incidence, treatment, and outcome of vascular complications after LDLT in a single Brazilian center.

Methods

Between December 2001 and December 2010, we performed 130 LDLT. Sixty-four recipients were children (27 weighing <10 kg).

Results

Nine recipients had vascular complications. Hepatic artery thrombosis (HAT) occurred in 4 (3.1%), portal vein thrombosis (PVT) in 3 (2.3%), and hepatic vein thrombosis (HVT) and hepatic arterial stenosis (HAS) in 1 (0.8%) patient each. Complications were identified by Doppler and confirmed by angiography or angiotomography. Patients with HAT were listed for retransplantation. One died before retransplant. Two children were submitted to retransplantation; one is still alive, with neurologic sequelae. One adult with HAT was retransplanted with a deceased donor graft and is doing well 58 months after surgery. Two patients with PVT died as a consequence of graft malfunction. In the other case, portal vein arterialization was performed, but patient died 11 months posttransplant. HVT was detected after cardiac reanimation and was treated with an endovascular stent. This patient died 3 months after LDLT. HAS was diagnosed after liver abscess development and was successfully treated by endovascular angioplasty. No recurrence was observed after 22 months. Follow-up ranged from 9 to 117 months.

Conclusion

Pediatric patients are more prone to develop vascular complications after LDLT. Long-term survival was statistically lower for recipients with vascular complications (33.3% vs 77.7%; P = .008).     

Pediatric thoracic outlet syndrome: a disorder with serious vascular complications

Background

Thoracic outlet syndrome (TOS), caused by compression of the neurovascular structures between the clavicle and scalene muscles, typically presents with neurologic symptoms in adults. We reviewed our experience with 25 adolescents and propose a diagnostic/treatment algorithm for pediatric TOS.

Methods

From 1993 to 2005, 25 patients were treated with TOS. A retrospective chart review was performed with institutional review board approval. Demographics, clinical presentation, diagnostic studies, and treatment were evaluated.

Results

Seven male (28%) and 18 female (72%) patients presented between the ages of 12 to 18 years. Thirteen (52%) had vascular TOS (11 venous, 2 arterial), 11 (44%) had neurologic TOS, and 1 had both. Vascular TOS included subclavian vein thrombosis (7), venous impingement (4), and arterial impingement (2). Three patients had hypercoagulable disorders, and 6 had effort thrombosis. Venography was diagnostic in 10 cases. Neurogenic TOS was diagnosed by clinical symptoms. Five patients with subclavian vein thrombosis underwent thrombolysis, with 3 maintaining long-term patency. Of 25 patients, 24 underwent transaxillary first rib resection.

Conclusion

Vascular complications are more common in adolescents with TOS than in adults. A diagnostic/treatment algorithm includes urgent venography and thrombolysis for venous TOS and a workup for hypercoagulability. Neurogenic TOS is diagnosed clinically, whereas other studies are rarely beneficial.     

Variability of the extrahepatic arterial anatomy in 500 hepatic grafts

Purpose

To review the extrahepatic arterial anatomy in 500 consecutive liver grafts.

Materials and methods

From April 1990 to January 2005 we performed 500 liver transplantations. We received 108 deceased donor liver grafts (21.4%) from other centers. Donor arterial anatomy was recorded as described in the surgical notes of both the donor harvest and the recipient procedures. We used the modified Michels classification scheme proposed by Busuttil. We assessed incidencess of mortality, retransplantation, postreperfusion syndrome, intraoperative arrest, hemorrhagic complications, and primary malfunction, comparing with chi-squared tests.

Results

There were 376 type I (75.2%), 51 type II (10.2%), 32 type III (6.4%), 18 type IV (3.6%), 3 type V (0.6%), 2 type VI (0.4%) and 18 others (3.6%). No significant associations were found between arterial vascular anomalies of the graft and the studied variables.

Conclusion

In our experience, extrahepatic arterial anomalies of the donor graft did not influence the short-term outcomes of liver transplantation.     

New alternatives to the treatment of acute liver failure

Introduction

Acute-on-chronic liver failure (ACLF) is defined as an acute deterioration of a chronic liver disease. The most effective treatment in these patients is orthotopic liver transplantation (OLT), which is highly limited by the donor shortage. The aim of this study was to increase the usefulness of hepatocyte transplantation (HT) as a bridge or alternative to OLT.

Methods

During the last 2 years, we have performed HT in 3 patients with ACLF. The diagnosis was graft cirrhosis due to hepatitis C virus in 2 of them, who were already included on waiting lists for retransplantation, and the third, unknown alcoholic cirrhosis.

Results

After the first HT infusion, we observed an improvement in the clinical condition in all patients, hyperammonemia, and a partial correction of the degree of encephalopathy; 1 patient was retransplanted 6 days after the first HT.

Discussion

The main indications for HT are inborn errors of metabolism in children. Other indications especially in adults, are acute liver failure, ACLF in patients with end-stage-liver disease who are a waiting OLT, and acute liver failure after an hepatectomy. HT may be a new treatment to improve the clinical condition in patients awaiting OLT.     

Versatility of right gastroepiploic and gastroduodenal arteries for arterial reconstruction in adult living donor liver transplantation

Background

In cases where there is severe intimal dissection in the recipient hepatic artery (HA), or if the HA has been used already and additional operations are needed due to graft rejection or arterial occlusion, an alternative is necessary. In the present study, we have reported the feasibility of using the right gastroepiploic artery (RGEA) and gastroduodenal artery (GDA) in various situations where the HA is not a feasible option.

Methods

Among 463 patients who underwent primary adult-to-adult living donor liver transplantation from January 2002 to July 2010, eight subjects required alternative vessels. Four recipients displayed severe intimal injury associated with previous transarterial chemoembolization (TACE); two, required a salvage operation due to hepatic artery thrombosis (HAT); and two, retransplantations due to chronic rejection. The RGEA was used in five and the GDA in three patients.

Results

Postoperative Doppler ultrasonography and three-dimensional computed tomography showed patent arterial flow in all patients. However, HAT recurred in one patient who underwent a salvage operation with the RGEA; she died 2 months later. Two other patients died due to wound infection and respiratory failure within 3 months despite intact hepatic arterial flow. Four patients had no further complications during follow-up (mean = 33 months).

Conclusion

Although there was a discrepancy in the diameter of the HA and the RGEA (or GDA), there was no problem with mobilization and microanastomosis. We therefore believe that these vessels can be good alternatives when the hepatic artery is unavailable.     

Cholangitis as a late complication in long-term survivors after surgery for biliary atresia

Background/purpose

A retrospective review was performed to assess the utility of diagnostic imaging (DI), efficacy of treatment, and outcome of late cholangitis in long-term survivors after surgery for biliary atresia.

Methods

Sixty-one patients surviving without liver transplantation (LTx) for more than 20 years were divided into 2 groups depending on whether cholangitis developed after age 20. Clinical factors including the type of obstruction, the age at the initial operation, and the early complication with cholangitis were compared between the 2 groups. DI such as computed tomography scan and magnetic resonance imaging, clinical courses after treatment of cholangitis, and current status of the patients were also evaluated.

Results

Thirteen patients had cholangitis after age 20. There was no statistical difference in the clinical factors studied between the 2 groups. Abnormal DI findings including dilatation of intrahepatic bile ducts and hepatic fibrosis were seen in 10 patients with late cholangitis. One patient died, and 2 ultimately underwent LTx. The remaining 10 patients including 4 with normal or near-normal liver function have survived without LTx.

Conclusions

Although the majority of the patients had potential predisposing factors for cholangitis such as dilatation of intrahepatic bile ducts, a few patients unexpectedly had cholangitis without such abnormal findings after an excellent, long-term postoperative course.     

Surgical treatment of biliary tract complications after liver transplantation

Objective

Biliary strictures are the most common biliary tract complication after liver transplantation. There are scarce data on the results of hepaticojejunostomy (HJ) in the management of biliary complications after orthotopic liver transplantation (OLT). Thus, the role of surgery in this setting remains to be established. The aim of this study was to evaluate the results of surgical treatment of patients with biliary complications at our institution.

Patients and Methods

We reviewed 1000 consecutive liver transplantations performed at our institution from 1984 to 2007. We used a prospectively recorded database to identify patients who underwent HJ to treat any biliary tract complication.

Results

Overall, 62 patients (6.2%) underwent HJ, 40 for an anastomotic and 7 for a non-anastomotic stricture as well as 15 for biliary leaks. Postoperative morbidity was 16%, and postoperative mortality 1.6%. There were 7 cases of anastomotic stenosis (11.3%). Four patients (5%) required retransplantation.

Conclusions

HJ is a safe procedure to manage biliary complications after OLT. It may be the first treatment choice especially for cases with anastomotic strictures.     

Biliary complications after orthotopic liver transplantation from donors after cardiac death: broad spectrum of disease

Background

Donation-after-death liver transplantation (DCD-LT) carries higher complication rates compared with donation-after-brain death liver transplantation (DBD-LT). In this report we describe our experience with biliary complications in DCD-LT with emphasis on anatomical patterns and outcomes.

Materials and Methods

We performed retrospective review of patients' medical records from August 2004 to December 2008, during which time total of 26 DCD-LTs were performed. Mean follow-up was 29 months (range 3 to 51 months).

Results

Biliary complications occurred in 12 patients (46%), of whom 9 were related to DCD (35%). Four patients had more than 1 biliary complication, and 4 had concomitant arterial problems (stricture/thrombosis). Treatment of complications included: ERCP (n = 5, 3 resolved), conversion to roux (n = 5, 2 resolved), revision of roux (n = 1), percutaneous transhepatic cholangiography (n = 1), artery revision (n = 3). Three patients with casts had operative extraction of casts depicting a mummified biliary tree; histology showed casts and fibrosis and anastomotic suture material. Six patients underwent retransplantation (23%). Among retransplanted patients, 2 deaths occurred (7.7%).

Conclusion

Our experience with DCD-LT reveals a high prevalence of biliary complications with a new and wide spectrum of clinicopathologic findings. Better strategies for prevention of these unique biliary complications are needed to better justify the added risks and costs for performance of DCD-LT.     

Descending thoracic aortic rupture: role of endovascular stent-grafting

Background

The mortality of patients with descending thoracic aortic rupture who are treated by conventional surgery is high. Our current strategy for the management of descending thoracic aortic rupture is to treat seriously ill patients with endovascular stent-grafting using handmade grafts, and to treat other patients with traditional open repair. The aim of this study was to assess the early results of our strategy.

Methods

Twenty-nine consecutive patients with descending thoracic aortic rupture were referred to Sapporo Medical University Hospital from June 2001 to January 2004. Eighteen of these 29 patients were selected for endovascular stent-grafting because of polytrauma (n = 7), comorbidities (n = 6), advanced age (n = 2), past history of left thoracotomy (n = 2), and patient's preference (n = 1). The remaining 11 patients underwent traditional graft replacement of the diseased aorta. Their outcomes and follow-up data were collected and analyzed retrospectively.

Results

The in-hospital mortality rate was 14% (4/29). The mortality rate for surgical patients and stent-grafting patients was 9% (1/11) and 17% (3/18), respectively. The survival rate of patients at 2 years was 63% ± 10%. In the follow-up period, 2 of the 18 patients who underwent endovascular stent-grafting required open repair, and 1 patient underwent a redo endovascular stent-grafting procedure because of stent failure. One of these 3 patients died of an intraoperative retrograde type A aortic dissection.

Conclusions

The early results of endovascular stent-grafting for the treatment of high-risk patients with descending thoracic aortic rupture are promising. Early results of open repair can also be improved by the selection of stabilized patients. However, the requirement of reintervention indicates that detailed follow-up examinations in patients who have undergone endovascular stent-grafting with handmade stent-grafts should be performed.     

Hepatic artery reconstruction in living donor liver transplantation: running suture under surgical loupes by cardiovascular surgeons in 180 recipients

Objectives

The aim of our study was to retrospectively investigate the outcomes of hepatic artery (HA) reconstruction by cardiovascular surgeons in adult-to-adult living donor liver transplantation (A-A LDLT).

Methods

From April 2007 to April 2011, 187 recipients underwent A-A LDLT. After excluding seven ABO-incompatible transplant recipients, we reviewed the courses of 180 patients including 125 men and 55 women of mean age 52.5 ± 9.2 years (range = 23-71). One hundred seventy-seven patients received right-lobe grafts with inclusion of middle hepatic vein (MHV); two, right-lobe grafts without MHV; and one, left-lobe graft. A continuous, single-stitch, running suture with the parachute technique was used for HA reconstruction. The anastomosis was performed by cardiovascular surgeons employing surgical loupes with 4.5× magnification.

Results

The mean time for an arterial reconstruction was 10.7 ± 4.0 minutes (median = 10, range = 4-30). Hepatic arterial thrombosis (HAT) was encountered in 3 (1.66%) patients. One HAT that developed on postoperative day 1 was successfully rescued by the intra-arterial infusion of urokinase. Another patient required reoperation due to a redundant kinked HA. A third HAT patient underwent successful retransplantation with a cadaveric graft on postoperative day 6. In our series, no delayed HAT was detected and no recipient deaths were related to HAT.

Conclusion

HA reconstruction with a running suture under surgical loupes is a feasible technique in A-A LDLT. A speedy reconstruction can be performed by an experienced cardiovascular surgeon with a low incidence of HAT.     

Traumatic pseudoaneurysms of the liver and spleen in children: is routine screening warranted?

Background

Although blunt injury to the spleen and liver can lead to pseudoaneurysm formation, current surgical guidelines do not recommend follow-up imaging. Controversy exists regarding the clinical implications of these traumatic pseudoaneurysms as well as their management.

Methods

Retrospective review of children treated nonoperatively for isolated blunt liver and spleen trauma between 1991 and 2008 was undertaken. Patient demographics, grade of injury, and follow-up Doppler ultrasound results were obtained.

Results

Three hundred sixty-two children were identified. One hundred eighty-six of them had splenic injuries, and 10 (5.4%) developed pseudoaneurysms. They were associated with grade III (3/39 [8%]) and grade IV (7/41 [17%]) injuries. In 7 patients, the pseudoaneurysm thrombosed spontaneously. Angiographic embolization was required in 2 children, and one underwent emergency splenectomy for delayed hemorrhage. Of the 176 patients who had liver injuries, 3 (1.7%) developed pseudoaneurysms. All 3 were associated with grade IV injuries (3/11 [27%]). One child underwent early embolization, while 2 developed delayed hemorrhage requiring emergent treatment.

Conclusions

Pseudoaneurysm development after blunt abdominal trauma is associated with high-grade splenic and liver injuries. Routine screening of this group of patients before discharge from hospital may be warranted because of the potential risk of life-threatening hemorrhage.     

Preoperative performance status predicts outcome following heated intraperitoneal chemotherapy

Background

Peritoneal carcinomatosis has a typical natural history of bowel obstruction and death. Significant evidence suggests that cytoreduction with heated intraperitoneal chemotherapy (HIPEC) improves long-term survival for these tumors.

Methods

A retrospective case series of patients who underwent initial HIPEC treatment was performed at 2 moderate-volume centers. Clinicopathologic data were reviewed and univariate analyses performed to determine predictors of periprocedural complications.

Results

Twenty-eight patients underwent HIPEC procedures. The most common pathologies were colonic adenocarcinoma and pseudomyxoma peritonei. The median preoperative peritoneal cancer index was 9.5. Thirteen patients had 34 complications, with no postoperative deaths. Pleural effusion and wound infection were the most common complications. Preoperative performance status and the extent of disease were predictive of complications.

Conclusions

Cytoreduction and HIPEC can be done at moderate-volume centers with morbidity and mortality rates comparable with published results from large-volume centers. Preoperative performance status and the extent of disease predict postoperative complications.     

The evaluation of CEEA 34 for stapled hemorrhoidectomy: results of a prospective clinical trial and patient satisfaction

Introduction

Stapled hemorrhoidectomy (SH) has routinely been performed using Procedure for Prolapse and Hemorrhoids Proximate Hemorrhoidal Circular Staplers (Ethicon Endo-surgery, Cincinnati, OH). Premium Plus CEEA 34 (Tyco Healthcare, New Haven, CT) has been recently introduced for SH. This study aims to review the effectiveness of CEEA 34 for SH.

Methods

From April to June 2007, the SH procedure was performed or supervised by 5 experienced consultant surgeons. A quality of life telephone survey was performed within 4 to 6 weeks postoperatively.

Results

Two hundred thirteen patients (52% men and 48% women) with a median age of 46 years (range 26-78 years) underwent SH during the trial period. Median duration of surgery was 10 minutes (range 5-35 minutes). Ninety-seven percent underwent SH for third- and fourth-degree piles. Ten patients (4.7%) had bleeding postoperatively in the first week that ceased with adrenaline injection or pack, and 2 required transfusions. Eighty-three percent participated in the quality of life survey, and 92% of these patients expressed satisfaction with the outcome of the procedure.

Conclusion

CEEA 34 for SH is safe and effective with few postoperative complications and high patient satisfaction.     

Chronic hepatic artery occlusion with collateral formation: imaging findings and outcomes

Objective

The imaging findings, clinical presentation, and outcome in post liver transplantation patients with hepatic arterial collaterals are reviewed.

Materials and Methods

Adult post orthotopic liver transplantation patients who underwent an angiography at our institution for suspected hepatic arterial abnormality during an approximately 10-year period were included in our study. A retrospective review of all cases that had hepatic arterial collaterals detected on angiography was then performed. Angiographic findings were correlated with the findings on ultrasound and other imaging studies. Liver function at the time of angiography was recorded. Clinical outcomes were reviewed.

Results

Of the 129 angiographies performed in the approximately 10-year period, 24 (19.4%) were found to have collaterals on angiography. Maximum size of the collaterals seen on angiography was 3 mm. Twenty patients (83%) with collaterals are currently alive. Twelve patients (50%) had a normal outcome and did not develop any complications on follow-up; however, the rest developed complications. Eleven patients (41.7%) had complication related to the liver ischemia and 2 patients (8.3%) developed malignancy (posttransplant lymphoproliferative disease).

Conclusion

Collaterals seen in patients with chronic hepatic artery occlusion are usually small in caliber and their significance is unclear. Recognition and understanding of this phenomenon is important as this subset of patients may not need urgent surgical re-exploration/vascular intervention.     

Causes of sirolimus discontinuation in 97 liver transplant recipients

Introduction

Sirolimus is a potent immunosuppressant with a mechanism of action different from calcineurin inhibitors (CNIs). It has increasing importance for liver transplant (OLT) patients, in particular if when there is decreased renal function. We evaluated the efficacy and the causes for discontinuation of sirolimus-based immunosuppression among OLT recipients.

Objective

We retrospectively analyzed 97 liver transplanted patients who were prescribed sirolimus as the principal immunosuppressant. Of these, 61 patients discontinued treatment. Herein we have reported the causes, the timing, and the effects of sirolimus discontinuation.

Results

The overall patient survival at 3 years follow-up was 89%. Hepatotoxicity and blood disorders were the most frequent, severe reported side effects. Acute cellular rejection episodes appeared in seven patients and was relieved in 1 to 2 weeks after the sirolimus administration. In 10 patients, the cholestasis associated with chronic rejection was sharply reduced after the introduction of sirolimus. No increase in vascular thrombosis and/or poor wound healing were reported.

Conclusion

Sirolimus given alone or in combination with CNIs appears to be an effective primary immunosuppressant regimen for OLT patients. However, in the late postoperative period (>3 months) the drug is associated with a relatively high rate of side effects.