Living Related Liver Transplantation

Living Related Liver Transplantation （LRLT）is a new strategy, which offers the option of a lifesaving procedure to patients suffering from end - stage liver disease, and the experience indicates that the results are better than cadaveric liver transplantation. It promises to decrease the waiting time for liver transplantation significantly and to reduce the number of patients dying on the waiting list. The selection of a suitable donor and the techniques of operation are of paramount importance for LRLT to minimize the risk for the recipient and the donor, and achieve better outcome for patient. 1 -year recipient survival rate of LRLT is over 90% and 5 - year recipient survival rate of LRLT is about 80%. LRLT has been becoming standard and normal operation in many western transplant centers.     

Is Liver Transplantation Without Abdominal Drainage Safe?

This observational, analytical cohort consisted of 35 consecutive liver transplant (OLT) patients with no intra-abdominal drain and a control cohort of 35 subjects operated immediately before the former who had placement of an intra-abdominal drain. We sought to assess the impact of abdominal drainage on the diagnosis and prevention of early postoperative complications: hemoperitoneum, reinterventions, biliary leaks, or percutaneous drainage. We assessed variables related to the recipient (age, indication, pretransplant ascites, body mass index, Model for End-Stage Liver Disease score and rejection), the donor (age, steatosis, ischemia time) and intra- and postoperative factors (surgery time, blood product use, and coagulopathy). The end point was defined as the need for a reintervention, paracentesis, appearance, and drainage of collections as well as lengths of hospital and intensive care unit (ICU) stays. The postoperative ICU and in-hospital stays were similar between groups (3.7 vs 3.9 days and 12 vs 14 days, respectively). Two patients in the group with drainage were reoperated due to hemoperitoneum, whereas we did not reoperate any patients in the group without drainage. No patient from either group developed a biliary fistula or required drainage of an intra-abdominal collections. The need for paracentesis was greater among the group without drainage (23% vs 5.7%; P < .04) and among those with a prior history of severe ascites. Patients with drainage displayed a greater incidence of perihepatic hematomas by ultrasound (53% vs 21%; P < .08) and required more postoperative blood products, especially platelets (P > .04) and plasma (P < .01).

Conclusion

OLT without intra-abdominal drainage is safe, not increasing morbidity. It seems likely that drainage may be responsible for intra-abdominal hematomas and greater consumption of blood products.     

Living-Donor Liver Transplantation for Budd-Chiari Syndrome: Case Series

Background

Venous reconstruction in living-donor liver transplantation for Budd-Chiari syndrome (BCS) has challenges because the grafts from living donors lack vena cava, and hepatic venous anastomosis must be performed on an already-thrombosed and/or stenosed inferior vena cava. Several techniques are described to overcome this problem, and we represent our experience with 22 patients.

Does Liver Transplantation Affect Growth Pattern in Alagille Syndrome?

Alagille syndrome (AGS) is frequently associated with growth failure, which has been attributed to concurrent congenital anomalies, cholestasis, and malabsorption and/or malnutrition. However, the underlying cause of the growth failure is not well understood. Our objective is to analyze the growth pattern in 26 patients with AGS and the possible effect that orthotopic liver transplantation (OLT) may have on this pattern. The standardized height, weight, and growth velocity of 26 pair-matched patients with AGS were compared. Thirteen patients underwent OLT. Repeated-measure ANOVA methods were used for the statistical analysis. The overall mean standardized height (z score) was –2.92 in the OLT group versus –1.88 in the non-OLT group (P = .03). The overall mean standardized weight was –1.21 in the non-OLT group and –1.67 in the OLT group (P = .23). In 15 patients, birth weight was 2.82 ± 0.4 kg, for a mean standardized weight of –0.95, and weight at diagnosis was 4.53 ± 2.12 kg, for a mean standardized weight of –1.56. Bone age was delayed in the 9 patients who underwent bone-age analysis. Growth hormone therapy administered to 2 patients did not improve growth. Patients with AGS had growth failure secondary to other factors in addition to liver disease. Growth failure beginning in the prenatal period supports a genetic basis for this feature. Growth improvement up to normal levels should not be expected as a benefit of OLT in these patients. Growth failure as a primary indication for OLT should be cautiously examined in patients with AGS.(Liver Transpl 2000;6:582-587.)     

The Liver Graft as Trojan Horse–Multilineage Donor-Derived Hematopoiesis After Liver Transplantation: Case Report

Hematopoietic macrochimerism, which is rarely seen after orthotopic liver transplantation (OLT), has been linked to the development of graft versus host disease (GvHD). We report on a patient with GvHD after OLT in whom full engraftment of donor-derived, multilineage hematopoiesis occurred, indicating that the liver contains pluripotent hematopoietic progenitor cells (HPC) capable to restore hematopoiesis in recipients. Although preventing graft rejection, standard immunosuppressive therapy may be under certain immunological conditions not sufficient to prevent GvHD. Age-, disease-, and treatment-related variables might be critical determinants for the development of an effective alloreactive T-cell response leading to the establishment of full hematopoietic chimerism.     

Liver Transplantation and Early Culture Growth: Risk and Impact?

ObjectiveDespite advances in immunosuppressive drugs, postoperative care, and surgical techniques, bacterial infections remain the most important cause of morbidity and mortality in liver transplant patients. The aim of this study is to evaluate the influence of culture results taken on the first day of admission to intensive care unit on mortality, graft rejection, mechanical ventilation duration, and length of intensive care unit stay. Our study has clinical importance because it is the first study evaluating the cultures obtained on the first day of intensive care unit stays in liver transplant patients.MethodsPatients' demographic data, transplant type, rates of deceased and living donors, culture results, amount of blood and blood products used intraoperatively, previous hospital admission, mortality, incidence of graft rejection, mechanical ventilation duration, and length of intensive care unit stay were recorded.ResultsMortality and graft rejection were 14.8% and 9%, respectively. The mortality was significantly higher in all 3 cultures and/or in only blood culture–positive patients. Graft rejection, mechanical ventilation duration, and length of intensive care unit stay were significantly higher in patients whose 3 cultures were all positive. Only body mass index had a significant effect on mortality, graft rejection, and positive culture results.ConclusionsLiver transplant patients' first postoperative day culture results were correlated with mortality, graft rejection, mechanical ventilation duration, and length of intensive care unit stay.     

Renal Support During Liver Transplantation: When to Consider It?

Patients undergoing orthotopic liver transplantation constitute a difficult-to-treat population. They often have multiorgan dysfunction: acute kidney injury, severe water–electrolyte and acid–base imbalances, systemic inflammatory responses, thrombocytopenia, as well as abnormalities of coagulation and fibrinolysis. All of these disorders may be further exacerbated by the surgical procedure, which is lengthy and technically complex, requiring massive blood product and other fluid infusions with a high risk to develop severe lactic acidosis, hyperkalemia, or cerebral edema. These considerations provide a rationale to institute intraoperative renal replacement therapy (ioRRT), at least for the most critically ill, namely, patients with kidney dysfunction, or those in whom one anticipates intraoperative clinical and technical problems. This article discusses the most common indications and strategies for ioRRT, examining their advantages and disadvantages as well as current experiences.     

Early Hepatic Artery Thrombosis After Pediatric Living Donor Liver Transplantation

AimHepatic artery thrombosis is one of the major complications affecting patient and graft survival after liver transplantation. In this study, we analyzed the factors affecting the development of early hepatic artery thrombosis (eHAT) and its outcomes in pediatric liver transplantation.MethodsA total of 175 pediatric patients underwent living donor liver transplantation between January 2013 and November 2018. Factors affecting eHAT and its outcomes were examined.ResultsNine patients (5.1%) developed eHAT. In multivariate analysis, intraoperative hepatic artery revision and Roux-en-Y hepaticojejunostomy biliary reconstruction type were statistically significant (all, P < .05). Thrombectomy and reanastomosis was performed in 5 patients. Two of them were successful. In total, 3 retransplantations were performed and all of those patients are still alive.ConclusionThe factors affecting eHAT are still a matter of debate. Intraoperative hepatic artery anastomosis revision and Roux-en-Y hepaticojejunostomy reconstruction were independent risk factors for development of eHAT. In the present study, the confidence interval of the variables is high, therefore exact determination of the risk factors may not be possible. Early detection and thrombectomy and reanastomosis may be the first treatment of choice to rescue the patient and graft. When it fails, retransplantation must be an alternative. The results of the present study state that at least once a day the vascular anastomosis must be examined by Doppler ultrasonography in the post-transplant first week. It must be repeated when liver enzymes increase. The patients under high risk for eHAT may be followed up closer.     

Can Patients Who Develop Cerebral Death in Fulminant Liver Failure Despite Liver Transplantation Be Previously Forseen?

Background

The outcome of medical treatment is worse in fulminant liver failure (FLF) developing on acute or chronic ground. Recently, liver transplantations with the use of living and cadaveric donors have been performed in these diseases and good results obtained. In this study, we aimed to present the factors affecting the recovery of cerebral functions after liver transplantation in hepatic encephalopathy (HE) developing in FLF, to identify irreversible patient groups and to prevent unnecessary liver transplantation.

“State of the Art” in Liver Resection and Living Donor Liver Transplantation: A Worldwide Survey of 100 Liver Centers

Background  New strategies have been developed to expand indications for liver surgery. The objective was to evaluate the current practice worldwide regarding critical liver mass and manipulation of the liver volume. Methods  A survey was sent to 133 liver centers worldwide, which focused on (a) critical liver volume, (b) preoperative manipulation of the liver mass, and (c) use of liver biopsy and metabolic tests. Results  The overall response rate to the survey was 75%. Half of the centers performed more than 100 resections per year; 86% had an associated liver transplant program. The minimal remnant liver volume for resection was 25% (15–40%) in cases of normal liver parenchyma and 50% (25–90%) in the presence of underlying cirrhosis. The minimal remnant liver volume for living donors was 40% (30–50%), whereas the accepted graft body weight ratio was 0.8 (0.6–1.2). Portal vein occlusion to manipulate the liver volume before resection was performed in 89% of the centers. Conclusions  Limits of liver volume and the current practice of liver manipulation before resection were comparable among different centers and continents. The minimal remnant liver volume in normal liver was 25%, and more than 80% of the centers performed portal vein occlusion. S. Breitenstein and C. Apestegui contributed equally to this work. Henrik Petrowsky is the recipient of the Novartis fellowship in Hepato-Pancreato-Biliary surgery and liver transplantation at the Swiss HPB Center at the University of Zurich.     

Right Extended Split Liver Transplantation Compared With Whole Liver Transplantation: Lessons Learned at a Single Center in Latin America—Results From a Match Case-Control Study

Background

Despite the progressively increasing gap between patients waiting for liver transplant under the Model for End-stage Liver Disease MELD system and the availability of deceased donor organs, the use of right extended split liver grafts (RESLG) has not been accepted by all centers. In this study, we compared the results obtained using RESLG vs a group of matched whole liver graft (WLG) recipients at a single center in Latin America.

Does Hepatorenal Syndrome Affect the Result of Liver Transplantation? Clinical Observations

Hepatorenal syndrome (HRS) is a reversible, functional renal failure that occurs in patients with advanced hepatic failure. However, the reported rates of complete recovery of renal function and patient survivals after orthotopic liver transplantation (OLT) are variable. The aim of this study was to compare the outcomes after OLT between patients with HRS and those without HRS (no-HRS). We established exclusion criteria to select study patients who underwent OLT in a single center between January 2005 and October 2008. The exclusion criteria included the following: (1) malignancy, (2) <18 years of age, (3) other than primary OLT, (4) ABO mismatch or hemophilia, (5) no liver cirrhosis, and (6) survival >1 month after OLT. We selected 71 subjects, including 8 HRS and 63 no-HRS patients. No significant differences were observed in the estimated glomerular filtration rate (eGFR) between the 2 groups except for a lower eGFR on the day of and 1 month after OLT in the HRS group: 108.3 ± 40.5 versus 31.4 ± 14.1 mL/min and 85.4 ± 15.0 versus 57.3 ± 12.1 mL/min (P = .000 and P = .014, respectively). The renal function of 6/7 HRS patients who survived >1 year improved. The 1-year patient survival rate after OLT in HRS patients was similar to that without HRS: 95% versus 86% (P = .37). We concluded that HRS had minimal effects on patient survival and return of acceptable renal function.     

Is There Still a Need for Living-related Liver Transplantation in Children?

OBJECTIVE: To assess and compare the value of split-liver transplantation (SLT) and living-related liver transplantation (LRT). SUMMARY BACKGROUND DATA: The concept of SLT results from the development of reduced-size transplantation. A further development of SLT, the in situ split technique, is derived from LRT, which itself marks the optimized outcome in terms of postoperative graft function and survival. The combination of SLT and LRT has abolished deaths on the waiting list, thus raising the question whether living donor liver transplantation is still necessary. METHODS: Outcomes and postoperative liver function of 43 primary LRT patients were compared with those of 49 primary SLT patients (14 ex situ, 35 in situ) with known graft weight performed between April 1996 and December 2000. Survival rates were analyzed using the Kaplan-Meier method. RESULTS: After a median follow-up of 35 months, actual patient survival rates were 82% in the SLT group and 88% in the LRT group. Actual graft survival rates were 76% and 81%, respectively. The incidence of primary nonfunction was 12% in the SLT group and 2.3% in the LRT group. Liver function parameters (prothrombin time, factor V, bilirubin clearance) and surgical complication rates did not differ significantly. In the SLT group, mean cold ischemic time was longer than in the LRT group. Serum values of alanine aminotransferase during the first postoperative week were significantly higher in the SLT group. In the LRT group, there were more grafts with signs of fatty degeneration than in the SLT group. CONCLUSIONS: The short- and long-term outcomes after LRT and SLT did not differ significantly. To avoid the risk for the donor in LRT, SLT represents the first-line therapy in pediatric liver transplantation in countries where cadaveric organs are available. LRT provides a solution for urgent cases in which a cadaveric graft cannot be found in time or if the choice of the optimal time point for transplantation is vital.     

Pretransplantation Tumor Necrosis Factor-α Production Predicts Acute Rejection After Liver Transplantation

Immunosuppressive therapy has many adverse effects in both the short and longer term. Tailoring immunosuppression might be possible if pretransplantation parameters predicted rejection. We investigated production of the proinflammatory cytokine, tumor necrosis factor-α (TNF-α), and the anti-inflammatory cytokine, interleukin-10 (IL-10), pretransplantation to determine whether there is a relation with acute rejection. Peripheral-blood mononuclear cells were obtained from patients with chronic liver disease on the waiting list for orthotopic liver transplantation and healthy controls. Cells (0.5 × 10⁶) were stimulated with 200 ng of lipopolysaccharide. Preincubation for 30 minutes with tacrolimus, cyclosporine, and dexamethasone at concentrations of 10 and 100 ng was also performed. TNF-α and IL-10 levels were measured by enzyme-linked immunosorbent assay. Acute rejection was defined on clinical and histological grounds. Pretransplantation in vitro production of TNF-α significantly (P < .05) increased in the group of patients with acute rejection (n = 9) compared with those who did not develop rejection (n = 12). Preincubation with dexamethasone significantly (P < .001) reduced TNF-α and IL-10 production in both patients and controls (n = 8). IL-10 production pretransplantation was not different in those who developed acute rejection (n = 9) compared with those who did not (n = 9). Preincubation with tacrolimus augmented (P < .05) the production of IL-10 in patients (n = 18), but not controls (n = 6). Pretransplantation TNF-α production is increased in patients who go on to develop acute rejection posttransplantion. (Liver Transpl 2000;6:721-727.)     

Single HCC in Cirrhotic Patients: Liver Resection or Liver Transplantation? Long-term Outcome According to an Intention-to-treat Basis

Background

Compensated cirrhotic patients with single hepatocellular carcinoma (HCC) ≤5 cm may benefit from both liver resection (LR) and liver transplantation (LT); however, the better 10-year actuarial survival of the two treatments remains unclear. We aimed to assess the long-term outcome of cirrhotic patients with single HCC ≤5 cm treated either with LR or LT on an intention-to-treat basis.

Methods

A total of 217 cirrhotic patients with single HCC ≤5 cm were evaluated at our department: 95 were treated with LR (LR group), and 122 were included on the waiting list for LT (LT group). Patients in the LR group were divided into very early HCC (tumor size ≤2 cm) and early HCC (tumor size >2 cm). Median follow-up was 5.3 (range 0.1–18) years.

Results

Tumor recurrence was 72 % in the LR group versus 16 % in the LT group (p < 0.001). 1-, 5-, and 10-year cumulative risk of recurrence was 18, 69, and 83 % in the LR group versus 4, 18, and 20 % in the LT group (p < 0.001). Ten-year actuarial survival was 33 % in the LR group versus 49 % in the LT group (p = 0.002). At HCC recurrence, 27.3 % were included on the waiting list for salvage transplantation (very early HCC group) versus 15.1 % (early HCC group) (p = 0.2). After salvage transplantation, HCC recurrence was 0 % (very early HCC group) versus 40 % (early HCC group) (p = 0.2). No significant differences were observed in 1-, 5-, and 10-year actuarial survival between the very early HCC group and the LT group (95, 55, and 50 % vs. 82, 62, and 50 %).

Conclusions

LR should be the treatment of choice for cirrhotic patients with very early HCC.