Living Donor Liver Transplantation for Acute Liver Failure: A Single Center Experience

Objective

Orthotopic liver transplantation (OLT) is the principal therapy for acute liver failure (ALF). The mortality on the waiting list for deceased donor liver transplantation (DDLT) is high, principally in countries where donation rates are low. Living donor liver transplantation (LDLT) seems an option for the treatment of ALF, although some ethical issues need to be considered. Herein we have evaluated LDLT results among patients with ALF and discussed the ethical aspects of procedures performed in emergency situations.

Patients and Methods

From March 2002 to October 2008, we performed 301 liver transplantations, including 103 from living donors. ALF was responsible for 10.6% of all transplantations; LDLT was only considered for pediatric recipients among whom 7 children displayed ALF.

Results

One patient died on postoperative day 33 due to hepatic artery thrombosis. One patient died at 2 months after transplantation due to biliary sepsis, resulting in an overall survival rate of 71%. The average time for donor discharge was 5 days. No mortality or major complications were observed.

Conclusions

The survival of children with ALF undergoing LDLT was comparable to published data. Furthermore, despite the fact that the available time to prepare the donors was limited, no serious complications were observed in the postoperative period. Thus, using living donors for children with ALF is an effective, safe alternative that can be extremely useful in countries with low donation rates.     

COMBINED LIVER-KIDNEY TRANSPLANTATION: EXPERIENCE AT A BRAZILIAN UNIVERSITY HOSPITAL

Background

Combined liver-kidney transplant is a routine procedure in many transplant centers. The increase in its number coincided with the introduction in 2002 of the MELD (Model for End-stage Liver Disease) score for allocation of livers, prioritizing patients with renal dysfunction.

Aim

To analyze the experience with combined liver-kidney transplantation in a liver transplant center in Brazil.

Method

A retrospective review was conducted. All transplants were performed using grafts from deceased donors.

Results

Sixteen combined liver-kidney transplantations were performed in the same period, which corresponds to 2.7% and 2.5% of the kidney and liver transplants, respectively. Fourteen patients were male (87.5 %) and two were female (12.5%). The average patients and donors age was 57.3±9.1 and 32.7±13.1, respectively. The MELD score mean was 23.6±3.67. The main cause of liver dysfunction were chronic hepatitis C virus (n=9). As for renal dysfunction, diabetic nephropathy (n=4) was the most frequent. There were six deaths, two of them by severe dysfunction of the liver graft and four by infectious causes. The 1, 3 and 5 years survival rate in patients undergoing liver-kidney transplantations was 68.8%, 57.3% and 57.3%, respectively.

Conclusion

The survival rates achieved in this series are considered satisfactory and show that this procedure has an acceptable morbidity and survival.     

Lobar Lung Transplantation From Deceased Donor: Monocentric Experience

Introduction

Lung transplantation is considered a therapeutic option in selected patients affected by end-stage pulmonary disease. The mortality on the waiting list is mainly attributed to the shortage of the donor pool available for transplantation. There are various strategies to overcome this shortage; one of them is lobar transplantation.

Living or Deceased Donor Kidney Transplantation: A Comparison of Results and Survival Rates Among Iranian Patients

Objective

Kidney transplantation is the selective treatment of end-stage renal disease. Although most previous studies have concluded that living kidney donation achieves better graft survival, some factors may limit this type of donation. This study investigated the survival rates of living and deceased donor kidney transplantations among Iranian patients.

Materials and Methods

The records of kidney transplantations up to year 2005 were used to compare 50 deceased (group I) with 50 living donor transplants (group II). The recipients were matched by transplantation time. We used SPSS version 15 software to analyze the data.

Results

Group I patients included 28 males and 22 females of mean age of 38 ± 13 years, while 26 males and 24 females in group II had a mean age of 34.6 ± 14 years. The rejection and graft nephrectomy rates were significantly higher among group I than group II (P = .01, P = .02). The first-year graft survival was higher in group II (P = .001). The graft survival was significantly lower in recipients who needed a biopsy or dialysis (P = .006 and P = .02, respectively) and higher among those who had a urine volume >4200 mL within the first 24 hours after transplantation (P = .003). Patient survivals were not significantly different between the groups.

Conclusion

Living donor kidney transplantations showed higher graft survival and lower acute rejection rates compared with those from deceased donors.     

Expanded criteria donor kidneys for younger recipients: acceptable outcomes

Introduction

European senior programme (ESP) is well known for acceptable outcomes using expanded criteria donor (ECD) kidneys from donors older than 65 years for recipients older than 65 years. The incidence of end-stage renal disease (ESRD) is 229/million in India with a mean age of 45 years. We performed a retrospective analysis of transplantation of ECD versus standard criteria donor (SCD) kidneys into younger recipients.

Methods

Forty-three ECD transplantations among 158 deceased donor organ transplantation (DDOT) were performed between January 2006 and December 2009. Among 43 transplantation from 30 donors, 14 were dual kidney transplantations (DKT) performed based upon biopsy evaluation. All recipients received thymoglobulin (rATG) induction followed by immunosuppression with a steroid, mycophenolate mofetil (MMF), and a calcineurin inhibitor. Statistical analysis used chi-square test and unpaired Student t test. Kaplan-Meier curves were used for survival analysis.

Results

For ECD the mean donor age was 64 ± 11 years. Cerebrovascular accidents (CVA) were the cause of death among 60% of donors, 73.13% of whom were hypertensive and 23.13% diabetic.Mean DKT donor age was 75 ± 9.17 years versus 60 ± 8.0 years for single kidney transplantation (SKT). Mean recipient age of DKT versus SKT was 44 ± 12.4 years versus 43 ± 14 years. Mean serum creatinine (SCr; mg/dL) of SKT patients was 1.64 ± 0.75 versus 1.68 ± 0.46 in DKT. Mean follow-up was 455 ± 352 days. Mean SCr of 43 ECD recipients of mean age, 43.4 ± 14.2 years was 1.61 ± 0.61 mg/dL. Among 43 recipients, 23.25% were diabetic, 41.86% displayed delayed graft function (DGF), and 23.25% experienced biopsy-proven acute rejection (BPAR). Patient survival rate was 72.09% and graft survival rate was 67.44%. For SCD transplantations (n = 115), the mean donor age was 36 ± 14 years and recipient mean age was 32.8 ± 14.07 years. Mean SCr was 1.32 ± 0.46 mg/dL with 26.95% recipients displaying DGF, whereas 20.86% had BPAR. In the SCD group the patient survival rate was 79.13% and the graft survival rate was 72.17%. Thus, although the ECD group showed poor graft function (P = .042), they had acceptable patient and graft survivals (P = .34 and P = .56, respectively).

Conclusion

Because of the organ shortage, DDOT using ECD transplants for younger recipients is a feasible option with acceptable outcomes.     

Anesthetic management in pediatric liver transplantation: a comparison of deceased or live donor liver transplantations

Purpose  

Pediatric liver transplantations (LT) are becoming increasingly more common in the treatment of a child with end-stage liver disease. The aim of this study was to evaluate the perioperative anesthetic experience of pediatric patients undergoing deceased and live donor liver transplantations.     

Pretransplant hyponatremia could be associated with a poor prognosis after liver transplantation

Introduction

Predicting the prognosis of hepatic cirrhosis is the most accurate method to achieve a fair allocation among the liver transplant waiting list thereby reducing overall mortality rates.

Aim

To study the survival rates of recipients who undergo liver transplantation in association with hyponatremia rates.

Methods

This retrospective study used a prospectively collected database. The characteristics of liver donors and recipients were: age (years), Model for End-stage Liver Disease (MELD), MELD Na score, recipient body mass index (kg/m²), warm ischemia time (minutes), cold ischemia time (minutes), intensive care unit time (days), hemocomponents transfused, recipient glycemia (mg/dL) and serum sodium (mEq/L), Child-Pugh-Turcotte classification (points), and survival time (months). We analyzed all 318 consecutive liver transplantations from February 1994 to May 2010 divided into two groups: A (Na > 130 mEq/L) and B (Na ≤ 130 mEq/L). The Kaplan-Meier method was used to evaluate survival rate and the Cox regression test to identify predictive factors.

Results

Hyponatremic patients displayed shorter survival (P = .04). The Cox regression for survival time showed that patients with low serum sodium values (group B) had: Child-Pugh scores with 1.13% plus risk of death for each point; cold ischemia time with 1.001% less risk of death for each minute; glycemia with 0.6% for each mg/dL; 0.66% use of cell-saver; plus a risk of death for each 100 mL plus 1.02% risk of death for each year of donor age.

Conclusion

Hyponatremic cirrhotic patients show more advanced stages of disease compared to normonatremic cirrhotics. They usually display metabolic or cirrhotic decompensation and comorbidities. When these symptoms were associated with the use of extended criteria donors, increased cold ischemia time, and intraoperative bleeding, we observed lower survival rates.     

Outcomes of Kidney Transplantations From the Same Deceased Donor to Two Different Recipients: A Single-Center Experience

Background

Kidney transplantation is the best treatment method for end-stage renal disease. Technically, left kidney transplantation is easier than right kidney, and the complication rates in the right are higher than the left kidney. We performed 28 kidney transplantations from 14 deceased donors between November 2010 and May 2016. Our aim was to share our outcomes and experiences about these 28 patients.

Outcomes of Expanded-Criteria Deceased Donor Kidney Transplantation in a Single Center

Background

In an effort to expand the deceased donor pool, transplant centers have accepted expanded-criteria donors as appropriate for many of the patients in the deceased donor pool. We investigated expanded-criteria deceased donor kidney transplantation and compared the outcomes of kidney transplantation according to donor types.

Methods

We retrospectively analyzed 88 kidney transplantations performed between June 2006 and December 2012. We divided the patient into 4 groups: SCDD, standard-criteria deceased donor; ECDD, expanded-criteria deceased donor; ECMO, donor under extracorporeal membrane oxygenation support; living donor.

Results

Deceased and living donor kidney transplantations were performed in 52 (59.1%) and 36 (40.9%) cases, respectively. Among deceased donors, 31 (35.2%) were standard-criteria donors and 14 cases (15.9%) were expanded-criteria donors. Seven (8.0%) donors were under extracorporeal membrane oxygenation support. Mean follow-up was 26.1 ± 20 months. Average number of HLA mismatches among the donor types was 3.39, 3.07, 3.0, and 2.94 in SCDD, ECDD, ECMO, and living donor groups, respectively (P = .708). Delayed graft function occurred in 2 (6.9%), 3 (21.4%), 3 (42.9%), and 3 (8.3%) patients in the SCDD, ECDD, ECMO, and living donor groups, respectively (P = .043). Episodes of acute rejection within a year occurred in 14 (45.2%), 2 (14.3%), 1 (14.3%), and 6 (16.7%) patients in the SCDD, ECDD, ECMO, and living donor groups, respectively (P = .029). Renal functions after kidney transplantation at 3 months, 6 months, 9 months, and 1 year were not significantly different according to donor types. Graft survival was not different among the different donor types (87.1%, 92.8%, 85.7%, 91.7% in SCDD, ECDD, ECMO, and living donor groups, respectively; P = .67). Patient survival was not different among the different donor types (87.1%, 92.9%, 100%, 97.2% in SCDD, ECDD, ECMO, and living donor group, respectively; P = .36).

Conclusion

The use of expanded-criteria deceased donor had no impact on graft or patient survival after kidney transplantation.     

Comparision of Ureteral Stent Colonization Between Deceased and Live Donor Renal Transplant Recipients

Background

The use of a ureteral stent can cause a urinary tract infection (UTI), although it reduces urologic complications. UTIs are associated with a higher rate of ureteral stent colonization (USC). The aim of this study was to compare USC in living and deceased donor renal transplant recipients.

Living-donor hepatectomy

Background

Organ transplantation from deceased donors is still far below the need. Because of this deficiency, liver transplantations are performed mostly from live donors in many transplant centers in our country. Living-donor liver transplantation (LDLT) has evolved dramatically over the past decade. The aim of this study was to present our clinical experience with living-donor hepatectomy.

Methods

We retrospectively analyzed all patients who underwent donor hepatectomy between March 2000 and September 2010. We reviewed demographic data, operation type, operation and cold ischemia times, duration of hospital stay, and postoperative complications.

Results

During the study period, 140 living donors underwent operations for liver transplantation. We performed 108 right hepatectomies, 17 left hepatectomies, and 15 left lateral hepatectomies. The mean age of the donors was 30.8 years. There was no operative or postoperative mortality. Overall morbidity rate was 13.57% (n = 19). Nine patients had biliary leakages, 4 biliomas; 2 urinary tract infections, and 1 each inferior vena caval injury, pneumonia, portal vein thrombosis, and acute tubular necrosis. Reoperation was not required in any of these patients.

Conclusions

Living-donor liver transplantation is a valuable alternative for patients awaiting a cadaver organ. Live-donor hepatectomy can be performed with low morbidity. The greatest disadvantage of this procedure is the risk of the surgical operation for the individual who will experience no medical benefit from this procedure.     

Impact of Slow and Delayed Graft Function on Kidney Graft Survival Between Various Subgroups Among Renal Transplant Patients

Objective

Renal allografts with excellent graft function show good long-term outcomes, while grafts with delayed function have been associated with poor long-term survivals, although few reports have analyzed outcomes among these groups. We compared first-week postoperative graft function among renal transplant patients to analyze the impact of slow graft function (SGF) and delayed graft function (DGF) on graft survival.

Materials and Methods

Renal transplantations were performed from 362 unrelated, 46 related, and 163 deceased donors. Kidney transplant patients were divided into 3 groups according to their initial graft function. First-week dialyzed patients formed the DGF group. Nondialyzed patients were divided into a SGF or an excellent graft function (EGF) cohort according to whether the serum creatinine at day 7 was higher vs lower than 2.5 mg/dL, respectively.

Results

Of the 570 renal transplant recipients, DGF was observed in 39 patients (6.8%), SGF in 64 (11.2%), and EGF in 467 (81.8%). There was no significant difference in SGF vs DGF between patients who received kidneys from unrelated vs related living or deceased donors. Graft survival was worse among the DGF than the SGF or EGF patients, with no significant difference between the last 2 groups. The 6-month graft survivals were 74%, 93%, and 96%; the 3-year graft survivals were 70%, 88%, and 90%, respectively (P < .001).

Conclusions

We observed a similar impact of EGF and SGF on kidney graft survival. Kidney transplant recipients who developed DGF showed worse graft survival than those with EGF or SGF.     

Transplantation with hyper-reduced liver grafts in children under 10 kg of weight

Background

We had previously described a left lateral segment hyper-reduction technique capable of sizing the graft according to the volume of the abdominal cavity of the recipient.

Aim

The purpose of our study was to evaluate our 14-year live-donor liver transplantation experience with in situ graft hyper-reduction in children under 10 kg of weight.

Patients and methods

Between January 1997 and May 2011, we performed 881 liver transplants. Two hundred and seventy-seven (n?=?277) involved pediatric recipients, of which 102 (37 %) were from live donors. Thirty-five (n?=?35) patients under 10 kg of weight underwent hyper-reduced living donor liver transplants. There were 21 females (60 %) and 14 males (40 %), with a median age of 12 months (range 3–23) and a median weight of 7.7 kg (range 5.6–10).

Results

Median operative time was 350 min (range 180–510). Median cold ischemia time was 180 min (range 60–300). Twenty-six (n?=?26) patients required intraoperative transfusion of blood products. There were 49 postoperative complications involving 26 patients (74 % morbidity rate). One-, 3-, and 5-year survival rates were 87, 79, and 74 %, respectively. Twenty-eight patients are currently alive.

Conclusions

Hyper-reduced grafts provide an alternative approach for low-weight pediatric recipients. The relatively high immediate postoperative morbidity could be related to the complexity of these patients.     

A Kidney Transplant Center's Initial Experiences in Eastern Turkey

Objectives

Kidney transplantation is the best treatment method associated with improved quality of life and better survival for patients with end-stage renal disease. We started performing kidney transplantations in November 2010. We have performed 19 kidney transplantations so far. Fourteen of these were from living donors and five from deceased donors. Here, we present our initial experiences with 14 kidney transplant recipients from living donor kidney transplantations.

Materials and methods

All recipients and their donors underwent detailed clinical history and examination. Recipients and their donors were followed in the transplant clinic during hospitalization.

Results

The male-to-female ratio was 11:3 in recipients. The mean age of recipients was 27.8 years (range 4-58 years). The number of the related, emotionally related, and unrelated transplantations were 9, 3, 2, respectively. The mean warm ischemic time was 95.7 seconds (range 52-168 seconds). Urine output started immediately after vascular anastomosis in all. The mean time of discharge from hospital was postoperative day 8 (range 4-18 days). The mean flow up was 125 days (range 18-210 days). Graft survival was 100% in this period, but one patient died from sepsis after 56 days. No kidney was lost from rejection, technical causes, infection, or recurrent disease.

Conclusion

If transplant centers are as equipped and experienced as ours, kidney transplant programs should be started immediately so that they can reduce the number of the patients in waiting list for kidney transplantation.     

Pancreata From Pediatric Donors Restore Insulin Independence in Adult Insulin-Dependent Diabetes Mellitus Recipients

Context

The use of pediatric donors can increase the number of donors available for pancreas transplantation.

Aim

The aim of this study was to verify if pancreas transplantation from pediatric donors is as effective as transplantation from adult donors to restore metabolic control in type 1 diabetic patients.

Materials and Methods

From 2000 to April 2009 we performed 17 pancreas transplantations from pediatric donors: 9 simultaneous kidney-pancreas (SPK), 6 pancreas transplantation alone (PTA), and 2 pancreas after kidney (PAK). All subjects received whole organs with enteric diversion of exocrine secretions; 11 underwent systemic and 6 underwent portal venous graft drainage. The immunosuppressive therapy was as follows: prednisone, mycophenolate mofetil, anti-thymocyte globulin (ATG), and cyclosporine or tacrolimus. The pediatric donor population had a mean age of 15.3 years (range, 12-17), a mean weight of 60.1 kg (range, 42-75), and a mean body mass index (BMI) of 21 (range, 17.9-23.4).

Results

After 9 years the overall patient survival rate was 94.12%, whereas the graft survival rate was 63.35%. Normal glucose and insulin levels were maintained either fasting or during oral glucose tolerance test (OGTT). The group of recipients of pediatric organs was compared with patients receiving organs from adult donors (n = 125); the mean glucose values were lower in the pediatric group, whereas insulin production was higher in the adult patients. Early venous thrombosis was 17.6% in the pediatric group and 20% in adult recipients (Fisher exact test, P = not significant [NS]).

Conclusion

Pediatric donors restored insulin independence in adult diabetic recipients, representing a valid source of organs for pancreas transplantation.     

Short-term Results of Liver Transplantation With Octogenarian Donors

Background

There are increasingly more patients awaiting liver transplantation while the number of donors has remained stable. It has been proven that grafts from donors older than 60 years have comparable results with those from younger donors. It is unclear whether this is so with donors older than 80 years old.

Long-term Clinical Outcomes of Kidney Re-transplantation

Background

Kidney re-transplantation is commonly considered to have a higher immunological risk than first kidney transplantation. Because of the organ shortage and increasing waiting lists, long-term outcomes of kidney re-transplantation are being studied. However, reports of re-transplantation outcomes are not common. We have reported our 30 years of experience with second kidney transplantations.

Liver Transplantation With Old Grafts: A Ten-Year Experience

Background

The persistent scarcity of donors has prompted liver transplantation teams to find solutions for increasing graft availability. We report our experience of liver transplantations performed with grafts from older donors, specifically over 70 and 80 years old.

Outcomes of liver transplantation in candidates with portal vein thrombosis

Objective

The objective of the present study was to analyze the incidence of portal vein thrombosis (PVT), comparing morbidity and mortality rates among those affected with and those free of this complication. In the PVT group, we also analyzed mortality related to partial (PPVT) and total (TPVT) thrombosis.

Methods

We undertook a retrospective study of orthotopic liver transplantations from deceased donors in 617 recipients from January 1991 until October 2008. Recipients were classified according to whether they had PVT. In all cases, we considered age, sex, Model for End-stage Liver Disease score, Child-Pugh score, indication for transplantation, type of thrombosis, surgical technique blood product transfusion, and survival rate.

Results

There were 48 patients with PVT (7.78%) among 670 transplantations in 617 recipients in our institution. Concerning the type of thrombosis, 28 (58.3%) were partial and 20 (41.7%) total with complete occlusion of the portal vein lumen.

Conclusion

PVT in liver transplant candidates is a rare event (7.8%) that entails greater difficulty in the procedure, expressed as a longer operative time, greater consumption of blood products, and complex surgical techniques. The prognosis for these patients depends on the type of thrombosis: patients with TPVT showed a higher mortality, whereas those with PPVT had survival rates comparable to those of candidates with a permeable portal vein.     

Living donor renal transplantation: prognostic factors on graft survival

Introduction

Living donor renal transplantation is a treatment option for patients on dialysis in view of the ever-growing transplantation waiting lists and the stagnation in the number of deceased donors.

Objectives

The objectives of this study were to provide retrospective review of our living donor kidney transplantation series (1978-2003) and analysis of graft survival prognostic factors.

Materials and Methods

Among 121 living donor transplantations, the donor mean age was 50.9 years (SD, 1.53) and recipient mean age was 30.4 years (SD, 1.4). Eighty-eight percent of donors were women, 90% were related: siblings 21%, parents 69%, and spouses 6.6%. Kidney failure was of nephrological etiology in 65% of patients and urologic in 15.6%. Eighty-four percent were primary grafts and 16% were second ones. Also, 66.7% of kidneys were placed in the iliac fossa and the rest were left orthotopic approaches. Other analyzed variables included donor gender, acute rejection episodes (ARE), creatinine levels at 1 and 6 months, hypertension (HT), and pediatric recipients.

Results

Univariate analysis (Kaplan-Meier) showed that, in patients suffering from ARE or not, the mean graft survival was 7.5 and 15 years, respectively (P <.05). Mean graft survival among patients with nephrological problems was 8 years and in those with urologic etiology 15 years (P < .05). Multivariate analysis with Cox regression showed that etiology, ARE, and creatinine level at 6 months after transplantation were independent prognostic variables for graft failure. The overall graft survival rates were 78% at 5 years, 58% at 10 years, 42% at 15 years, and 24% at 20 years follow-up.

Conclusion

Living donor kidney transplantation is a valid treatment choice for end-stage patients with excellent graft survival rates, especially in cases of urologic etiology. Development of new immunosupressant strategies will help improve outcomes.