Domino liver transplantation from a living related donor

BACKGROUND: Although domino liver transplantations (OLT) from cadaveric donors have been performed in about 50 cases since 1995, only one case in the Japanese literature has been reported on a domino OLT from a living related donor. The difficulties of the later surgery lie in the small size of the graft volume and the short length of the vascular cuffs in the graft. METHODS: The left lobe graft was procured from a 43-year-old younger brother of a familial amyloidotic polyneuropathy (FAP) patient. Next, the left lobe graft (510 g, 44% of the estimated standard liver volume of the FAP patient) was implanted into the 48-year-old female FAP patient. At surgery for the FAP patient, a sufficient length of the vascular cuffs was secured by an extended left lobe resection, although the right lobe graft was able to maintain sufficient vascular cuffs. The right lobe graft (720 g, 54% of the recipient's estimated standard liver volume) was then implanted in the 43-year-old male patient with liver cirrhosis and hepatocellular carcinoma (stage IV-A). RESULTS: The two recipients were discharged from the hospital 1 month after OLT. At 7 months after OLT, they are both doing well and the domino recipient is free of any tumor recurrence. CONCLUSION: A domino OLT from the living related donor can therefore be done safely when careful attention is paid to the graft volume and the length of the vascular cuffs for anastomosis.     

活体肝移植供体术后早期肝功能恢复的研究

目的 探讨不同移植肝类型的活体肝移植供体术后早期肝功能的变化规律和并发症发生率.方法 对四川大学华西医院2002年1月至2009年5月154例活体肝移植供体的资料进行前瞻性的收集和登记,依据移植肝类型分为右叶肝供体组141例(R组)和左叶肝供体组13例(L组),对其术后肝功能指标和并发症进行比较分析.结果 R组实际切取的供肝重量大于L组(t=11.418,P＜0.05),R组残余肝重量小于L组(t=-5.040,P＜0.05)、残余肝重量/标准肝重量(%)小于L组(t=-10.841,P＜0.05).除R组TB峰值出现在术后第3天外,L组的TB和两组中的ALT、AST、INR的峰值均出现在术后第1天,此后这些指标均向正常参考值方向下降.术后第1、3、7天R组的TB高于L组(分别t1=5.285,t3=3.747,t7=2.729,均P＜0.05).术后第1、3、7天R组的INR高于L组(分别t1=5.260,t3=5.035,t7=2.267,均P＜0.05).本组活体肝移植无供体死亡,供体总的并发症发生为53/154(34.42%),R组52/141(36.88%),L组1/13(7.69%),2组比较差异无统计学意义(x2=3.292,P＞0.05).结论 右叶肝供体组(大体积供肝组)与左叶肝供体组相比,供体术后早期肝功能损害更大;供体总体安全性较好,但仍面临着一定的并发症风险.

Abstract：

Objective To investigate the liver function injury and the rate of complications in living liver transplantation donors in different graft type transplantation.Methods Postoperative data of 154 living liver donors satisfying our inclusion criteria were prospectively collected and registered from Jan 2002 to May 2009 in our hospital.We divided the donors into two groups (right-lobe graft, R group and left-lobe graft, L group), and made comparison on the liver function and complications.Results Remnant liver weight in R group were smaller than those in L group (t = 11.418, P ＜ 0.05).the ratio of remnant liver weight to standard liver weight in R group were smaller than those in L group (t = - 5.040, P ＜ 0.05 ) .Peaks of ALT, AST and INR in both groups appeared on the first day after operation, while the peak of TB in R group appeared on the third day after operation.All the index values returned to a normal baseline after reaching its peak.Mean values of TB in R group were higher than those in L group on the 1st, 3rd, 7th day after operation (seperately t1 = 5.285, t3 = 3.747, t7 = 2.729, all P ＜ 0.05).Mean values of INR in R group were higher than those in L group on the 1st, 3rd, 7th day after operation (seperately t1 = 5.260, t3 = 5.035, t7 = 2.267, all P ＜ 0.05).The level of TB in both groups returned to normal range on the 7th postoperative day, while the level of ALT and AST remained twice the upper limits of the normal.There were no deaths; Complications occurred in 53 of 154 donors (34.42% ) , 52/141 (36.88% ) in R group and 1/13 (7.69% ) in L group (x2 = 3.292, P ＞ 0.05).Conclusions Ramnant liver function of R group during early postoperative period was poorer than that of the L group.Donors were safe, though suffering from comparatively high complication rate.     

Domino liver transplantation

Orthotopic liver transplantation is today an established treatment for end stage liver diseases. However, the ongoing shortage of suitable livers together with progressively longer waiting lists prevents many patients from being transplanted, and many patients die while being on the waiting list. Using livers from living donors is one way to increase the supply of liver grafts. Another group of potential living liver donors are some selected liver recipients, whose native explanted liver in turn can be considered for transplantation into another patient. This unorthodox procedure have been named domino liver transplantation (DLT). The domino approach can be considered in patients with some genetic or biochemical disorders that today are treated by liver transplantation. The underlying rationale is that such livers ultimately cause severe systemic disease but are otherwise normal. In this review we present the current world status of DLT as well as updated results from the Domino Liver World Transplant Register (DLTR) and our own experience at the Karolinska University Hospital Huddinge with the DLT procedure.     

活体肝移植供体的安全性

早期活体肝移植主要应用于儿童受体，供肝切取量较小，并发症发生率低，供体安全性很快得到确认。此后，有学者总结了活体肝移植的经验，建立了开展活体肝移植的三条基本原则，即波士顿标准：（1）对于受者具有显著的成功率；（2）对于供者低风险；（3）供者的知情同意。迄今为止，波士顿标准仍然是指导活体肝脏移植开展的基本原则，促使活体肝移植在充分保障供体安全的前提下，逐步应用于成人终末期肝病的治疗。[第一段]     

Nonalcoholic steatohepatitis in donors for living donor liver transplantation

BACKGROUND: In 2003, we encountered the first donor death for living donor liver transplantation in Japan, which was related to nonalcoholic steatohepatitis (NASH). The aim of this study was to retrospectively investigate the prevalence of NASH among a living donor liver transplantation donor population and to analyze the postoperative course for both donors and recipients of NASH grafts to minimize risk for donors. METHODS: The study population comprised 263 donors who donated the right lobe of the liver between February 1998 and April 2003. Their zero-hour biopsy specimens were screened retrospectively. Regarding severe steatosis or NASH, long-term follow-up results for laboratory data from donors were investigated along with changes in graft histologic findings in recipients. RESULTS: NASH was diagnosed histopathologically in three cases (1.1%). Pathologic examination showed that a donor who died in 2003 had the most severe NASH among the three cases. The remaining two NASH donors had uneventful postoperative courses without complications. All grafts showed improvement with respect to the steatosis and histologic findings of NASH. CONCLUSIONS: Donor safety is a top priority in living donor liver transplantation. To exclude patients with NASH from potential donor lists, careful evaluation, including selective preoperative liver biopsy, should be carried out.     

活体肝部分移植的进展

活体肝部分移植的进展管文贤李开宗３２年前，Ｓｔａｒｚｌ成功地开展临床首例肝移植以来，目前肝移植术已成为晚期肝病患者有效的治疗手段。近年在北美、欧州上百个移植中心，以每年约５０００例的业绩，使肝移植术得到不断发展和完善，现总例数已突破３００００例〔１～...     

成人右半肝活体肝移植供者的处理

目的 探讨成人右半肝活体肝移植供者处理的技术问题.方法 对我院2007年4月至2009年2月完成的19例成人右半肝活体肝移植供者资料进行回顾性分析.结果 19例右半肝移植物中带肝中静脉者4例,不带肝中静脉者15例;供肝重量为585～920 g,平均(727.32±117.01)g,与受者标准肝体积比为43%～67%(53.69%±1.77%),与受者重量比为0.82%～1.46%(1.10%±0.04%),供者残肝百分比为32%～55%(47%±2%),供者术中失血量400～1000 ml,平均(660±39.11)ml,输自体血0～735 ml,平均(216.37±62.28)ml,输新鲜冰冻血浆600～2000 ml,平均(789.47±75.66)ml,手术时间480～930min,平均(695.53±26.57)min.供者术后无死亡,发生并发症23例次,按照Clavien分级,Ⅰ级为15例次,Ⅱ级为8例次,经对症处理后均痊愈.住院时间13～58 d,平均(25.42±2.67)d.随访时间6～28月,全部供者均恢复正常工作生活.受者术后1年存活率为78.95%.结论 仔细术前评估,精细手术操作,合理地分配并保证移植物和残肝的功能性体积,术后密切监护、妥善处理并发症是供受者安全的重要保证.     

Partial liver transplantation from living related donors.

Living related liver transplantation was performed in five cases between June 1989 and July 1991 at Shinshu University Hospital. All of the donors were fathers of the patients and blood type was identical in each case. All of them were discharged from the hospital 2 weeks after hepatectomy without any complications. They started to work 2 months after surgery. Four recipients are surviving but one died. Three are enjoying daily life 17 months after LT in case 1, 5 months after LT in case 4, and 4 months after LT in case 5. Case 2 is still in the hospital 14 months after LT. Advantages of LRLT we noted were (1) cases can be performed totally electively and allow full preparation for the family and the transplant team, (2) primary graft nonfunction has not been observed to date, and (3) 38 patients received the chance of liver transplantation in their own country, which under current legislation would not otherwise have been possible. Disadvantages of LRLT were (1) partial hepatectomy was performed in healthy persons, and (2) retransplantation is difficult.     

活体供者供肝术后早期并发症分析

目的 探讨活体肝移植供者术后早期并发症的发生情况.方法 对2002年1月至2009年8月间170例活体肝移植供者的临床资料进行回顾性分析,依据供肝类型分为右半供肝组和左半供肝组,采用Clavien分类系统对术后早期发生的并发症进行分析.结果 两组间供者年龄、身高体重指数、手术时间等差异均无统计学意义(P＞0.05).与左半供肝组比较,右半供肝组实际切取的供肝重量较大(P＜0.05),残余肝重量较小(P＜0.05),残余肝重量与标准肝重量之比较小(P＜0.05),且住院时间较长(P＜0.05).住院期间,共有55例供者发生并发症62例次,总的并发症发生率为32.35％(55/170),其中右半供肝组并发症发生率为34.39％(54/157),左半供肝组并发症发生率为7.69％(1/13),两组比较,差异无统计学意义(x2=2.787,P＞0.05).62例次并发症中,Ⅰ级39例次,Ⅱ级5例次,Ⅲ级16例次占,Ⅳa级2例次,无Ⅳb和Ⅴ级(死亡)并发症.所有并发症经积极治疗后得以痊愈,所有供者均健康存活.结论 活体肝移植供者总体安全性较好,但仍面临着发生严重并发症的风险.术前应严格对供者进行选择和评估,术中手术操作应严密精细,重视供者术后管理,避免供者术后发生并发症.     

Psychosocial data of potential living donors before living donor liver transplantation

In view of the scarcity of organ resources for transplantation, donation by living donors is assuming greater significance now that the technical-surgical problems involved have been solved. In the period between December 1999 and December 2000, 47 potential living liver donors were evaluated and a total of 27 hepatic lobes were transplanted at the Virchow-Klinikum of the Charité Hospital in Berlin. The close personal relationships between recipients and donors gives reason to anticipate high levels of psychosocial pressure during the pre-operative evaluation process; this process consists in part in looking into donor motivation, ambivalence and anxiety. The pre-operative psychometric evaluation of 40 potential living donors indicated that most of the potential donors see themselves as 'super-healthy' and tend to adapt to social expectations, while on the other hand those seven potential living donors not accepted for psychosocial reasons were marked by heightened values for anxious depression and pessimism. The results indicate in most cases a great willingness to donate and on the other hand a high level of obvious psychological pressure for a low number of potential donors. For the latter, both the clinical evaluation interview and the psychometric diagnostics used revealed clear-cut feelings of anxiety and ambivalence towards transplantation.     

Analysis of postsurgical complications in 75 living liver transplantation donors

Seventy-five living donor liver hepatectomies were performed at our transplantation center between April 1990 and December 2004. We collected the data from patient charts, files, and the Baskent University Liver Registry. There were 39 male and 36 female donors (mean age, 35.1 +/- 9.3 years). We have performed 29 (38.6%) left hepatic lobectomies, 18 (24%) left lateral segmentectomies, 26 (34.6%) right lobectomies, and two (2.6%) donors had simultaneous living donor nephrectomy plus left lobe hepatectomy. The mean remnant liver volume was 598 +/- 168 cm(3) (range, 410-915 cm(3)). The mean percentage of remnant liver for the donor was 55.2%. Mean postoperative hospital stay was 10 +/- 4.4 days. After surgery, there was no mortality or reoperation. We saw 15 (20%) postsurgical complications in 14 donors. Intra-abdominal collection was seen in five (6.6%) patients. Biliary leak was seen in four patients. Portal vein thrombosis was seen in one patient, and a pulmonary embolus developed in one liver donor. Patient safety must be the primary focus in living-donor liver transplantation. These donors face significant risks, including substantial morbidity and death. More experience, improved surgical techniques, and meticulous donor evaluation will help minimize morbidity and mortality for both living liver donors and recipients.     

Assessment of potential donors for living related liver transplantation

BACKGROUND: Living related liver transplantation has been developed as an important potential source of organs for treatment of children with acute and chronic liver disease. A single UK centre performing living related liver transplantation was established in 1993. METHODS: Parents who were potential donors for their children for living related liver transplantation were assessed for suitability according to a protocol based on one developed and published by the University of Chicago Transplant Group. Records kept by the transplant coordinators were retrieved and data were extracted. RESULTS: Of 64 potential donors for 32 potential recipients ten were excluded at a preliminary stage. Fourteen ultimately became donors. Of 54 parents who began evaluation 23 were finally considered to be suitable. There were 19 non-disease-related reasons for unsuitability: blood group mismatch (eight cases), size discrepancy (six), pregnancy (two), oral contraceptive medication (one), vascular anatomy variant (one) and age (one). Sixteen were unsuitable because disease was found, namely fatty liver (four), thyroid disease (two), hepatitis B positivity (two), cardiac murmur (one), anaemia (one), glucose-6-phosphate dehydrogenase deficiency (one), diabetes mellitus (one) and psychological problems (one), and three parents were affected by the same disorder as the child (Alagille syndrome, one; mitochondrial disorder, one; recurrent cholestasis, one). Three parents were rejected for more than one reason. Both parents were unsuitable for donation in 21 per cent of cases. CONCLUSION: Parents approach living related liver transplantation with enthusiasm. They should be advised of the high chance of unsuitability, including the finding of significant pathology. The limitation of living related liver transplantation as the major source of organs for children is recognized.     

Simultaneous liver and kidney transplantation from different living donors

Objectives

To present our experience with simultaneous living donor liver and kidney (SLK) transplantation from two different living donors.

Patients and methods

We performed five SLK transplantations from two different living donors from November 2006 to December 2010. Four patients were males and one, female. Their age range was 47 to 66 years (mean, 55 years). The primary liver diseases included hepatitis B virus (n = 2), alcoholic liver cirrhosis (n = 2), cryptogenic liver disease (n = 1), and hepatitis C virus with hepatocellular carcinoma (n = 1). All five patients had chronic renal failure: four were on hemodialysis (H/D) and one on chronic ambulatory peritoneal dialysis for 1 to 20 years. Liver implantation was performed first, followed by kidney transplantation. The liver and kidney teams worked closely to shorten the ischemia time.

Results

All surgical procedures were performed uneventfully and all recipients and donors survived the operations. Good liver graft function was noted in all five patients. The patient with both anti-T- and anti-B-cell positive crossmatch tests developed hyperacute rejection of the kidney graft requiring its immediate removal. This patient was maintained on regular H/D afterward. The other four patients displayed good renal function. No evidence of severe acute rejection was noted during the follow-up period (range, 9-55 months) among patients treated with tacrolimus-based immunosuppression.

Conclusion

We suggest that SLK transplantation be performed with organs from two different instead of a single live donor.     

Portal vein reconstruction in pediatric liver transplantation from living donors.

OBJECTIVE: The authors analyze the surgical pattern and the underlying rationale for the use of different types of portal vein reconstruction in 110 pediatric patients who underwent partial liver transplantation from living parental donors. SUMMARY BACKGROUND DATA: In partial liver transplantation, standard end-to-end portal vein anastomosis is often difficult because of either size mismatch between the graft and the recipient portal vein or impaired vein quality of the recipient. Alternative surgical anastomosis techniques are necessary. METHODS: In 110 patients age 3 months to 17 years, four different types of portal vein reconstruction were performed. The portal vein of the liver graft was anastomosed end to end (type I); to the branch patch of the left and right portal vein of the recipient (type II); to the confluence of the recipient superior mesenteric vein and the splenic vein (type III); and to a vein graft interposed between the confluence and the liver graft (type IV). Reconstruction patterns were evaluated by their frequency of use among different age groups of recipients, postoperative portal vein blood flow, and postoperative complication rate. RESULTS: The portal vein of the liver graft was anastomosed by reconstruction type I in 32%, II in 24%, III in 14%, and IV 29% of the cases. In children <1 year of age, type I could be performed in only 17% of the cases, whereas 37% received type IV reconstruction. Postoperative Doppler ultrasound (mL/min/100 g liver) showed significantly (p < 0.05) lower portal blood flow after type II (76.6 +/- 8.4) versus type I (110 +/- 14.3), type III (88 +/- 18), and type IV (105 +/- 19.5). Portal vein thrombosis occurred in two cases after type II and in one case after type IV anastomosis. Portal stenosis was encountered in one case after type I reconstruction. Pathologic changes of the recipient native portal vein were found in 27 of 35 investigated cases. CONCLUSION: In living related partial liver transplantation, portal vein anastomosis to the confluence with or without the use of vein grafts is the optimal alternative to end-to-end reconstruction, especially in small children.     

Vascular complications after pediatric liver transplantation from the living donors

Early arterial or portal vein thrombosis is a complications that can lead to graft loss and patient death or need of immediate retransplantation. The aim of the study was to assess the incidence, causes, treatment, and outcome of vascular thrombosis after living related donor liver transplantation (LRdLTx). Between 1999 and 2004 71 LRdLTx were performed in children aged from 6 months to 10 years. Vascular thrombosis was found in 12 recipients. Hepatic artery thrombosis (HAT) occurred in 4 (5.6%), portal vein thrombosis (PVT) in 8 (11.2%) cases. HAT occurred 5 to 8 days, PVT 1 to 22 days after LTx. Diagnosis of vascular thrombosis was confirmed by routine Doppler ultrasound examination. Thrombectomy was successful in one patient with HAT and in three patients with PVT. Venous conduit was performed in one patient with PVT after second thrombosis. Two children developed biliary strictures as a late complication of HAT and required additional surgical interventions. Two children with PVT developed portal hypertension with esophageal bleeding, which required surgical intervention; one another underwent endoscopic variceal ligation for grade III varices. Follow-up ranged from 7 to 60 months. One patient died as a result of HAT after retransplantation due to multiple intrahepatic abscesses 2 months after first transplant. Any risk factors of vascular thrombosis that can be controlled should be avoided after transplantation. Routine posttransplant Doppler examination should be performed at least twice a day within 7 to 14 posttransplant days. Immediate thrombectomy should be always carried out to avoid late complications and even mortality.     

Comparative study between living and cadaveric donors in pediatric liver transplantation

We examined whether the results in living-related hepatic transplantation (LRLT) are better than those from a cadaveric donor (CDLT). MATERIAL AND METHODS: The last 27 consecutive LRLT, performed from 1998 to 2005, were compared with 27 CDLT matched for age, weight, date, and diagnosis. Grafts in LRLT group were left lateral segment (n = 22), left lobe (n = 3), and right lobe (n = 2). In the CDLT group, the grafts were split in situ (n = 10), hepatic reduction (n = 9) and whole liver (n = 8). We analyzed the actuarial survivals (grafts and children), retransplantation, primary nonfunction, initial graft malfunction (liver enzymes >2000 U/L), surgical complications, rejection, and resource consumption. RESULTS: Patient survivals at 6 months, 1 year, and 5 years were 100%, 96%, and 96% in LRLT and 100%, 100%, and 100% in CDLT (P = NS). Graft survivals were 93%, 89%, and 89% versus 96%, 96%, and 96%, respectively (P = NS). Complications were biliary complications (LRLT, 25% vs CDLT, 3%; P = .021); portal vein thrombosis (LRLT, 7% vs CDLT, 3%; NS), and hepatic artery thrombosis (LRLT, 0% vs CDLT, 3%; NS). The overall incidence of acute rejection was slightly higher (NS) in LRLT (LRLT, 18% vs CDLT, 11%; NS). Liver enzyme levels were higher in the CDLT group, but initial malfunction rate was not statistically different. Regarding resource consumption: blood product needs were higher in LRLT (P < .05) and hospital stay and ICU stay were longer, although not significantly, among LRLT. CONCLUSIONS: The results in LRLT among children are similar to those obtained in CDLT. We found a trend towards less initial graft malfunction in LRLT. Blood product needs were higher in LRLT. Hospital and ICU stay were longer, but not significantly different in LRLT. The benefits of LRLT are saving a scarce resource: a cadaveric donor liver graft.     

活体肝移植供者生活质量调查研究

目的调查活体肝移植供者的生活质量,了解影响该人群生活质量的因素。方法应用调查研究设计,采用中文版SF-36生活质量量表调查活体肝移植供者的生活质量。结果 18例供者躯体相关生活质量分为84.78±13.21,心理相关生活质量分为80.71±14.65,总分为165.49±22.63。在＂总体健康＂、＂活力＂维度上的得分中青年组高于中年组（P〈0.05）,在＂躯体疼痛＂维度上的得分男性组高于女性组（P〈0.05）。结论活体肝移植供者的生活质量与正常人群接近。供者年龄是影响术后生活质量的因素。     

婴幼儿患者亲体肝移植术的麻醉管理

目的总结婴幼儿亲体肝移植术的麻醉管理特点。方法 60例接受肝移植术的终末期肝病患儿,男32例,女28例,年龄6~30个月。麻醉诱导均采用静脉注射阿托品0.01mg/kg、甲基强的松龙1mg/kg、咪达唑仑0.05~0.1mg/kg、芬太尼2~5μg/kg、丙泊酚2~3mg/kg和罗库溴铵0.6~1.0mg/kg进行快速诱导;无外周静脉通路的患儿可先肌肉注射氯胺酮5~8mg/kg和阿托品0.02mg/kg后开放外周静脉通路。采用持续吸入2%~3%七氟醚、持续静脉输注瑞芬太尼0.1~0.2μg·kg-1·min-1和顺苯磺酸阿曲库铵1~2μg·kg-1·min-1维持麻醉。记录患儿肝血管阻断前即刻、阻断后即刻、无肝期30min、再灌注后即刻、新肝期1h和术毕的呼吸功能、血流动力学、凝血功能、体温、尿量、血糖(Glu)、血乳酸(Lac)和血电解质等。结果 60例患儿均未发生麻醉相关并发症并能顺利拔管。患儿预充氧后缺氧安全时限明显降低,易发生气道痉挛,经鼻插管更易出现插管失败和面罩通气困难。与阻断前即刻比较,阻断后即刻患儿HR明显增快、CVP明显降低(P0.01),但MAP差异无统计学意义;再灌注后即刻患儿MAP明显下降、HR明显减慢,伴有CVP的明显增高(P0.05或P0.01);新肝期患儿HR明显减慢(P0.01);无肝期30min至术毕患儿体温均明显降低(P0.01);无肝期至术毕激活凝血时间(SonACT)明显延长,纤维蛋白凝集速率(CR)水平和血小板功能(PF)水平逐渐减低(P0.05或P0.01),Na+水平逐渐升高(P0.01),K+水平明显降低(P0.01),再灌注后即刻至新肝期1h时Glu和Lac水平明显升高(P0.05或P0.01)。结论婴幼儿亲体肝移植术的麻醉管理有其特殊性,其中气道和呼吸系统的评估与管理最为关键,无肝期应积极采取措施预防再灌注后综合征的发生,新肝期应维持适宜的凝血功能以避免肝动脉血栓的发生,还应及时纠正电解质、酸碱和体温的失衡。