Late-onset acute rejection after living donor liver transplantation

INTRODUCTION Standard regimens for immunosuppressive therapy after liver transplantation include calcineurin inhibitors and steroids, which result in a reduced incidence of acute rejection and improved recipient survival[1]. The long- term complications o…     

Clostridium difficile-associated diarrhea after living donor liver transplantation

AIM： To assess the incidence and analyze the risk factors for Clostridium difficile-associated diarrhea （CDAD）after living donor liver transplantation （LDLT） in adult.
METHODS： The micobiological data and medical records of 242 adult recipients that underwent LDLT at the Tokyo University Hospital were analyzed retrospectively. The independent risk factors for postoperative CDAD were identified.
RESULTS： Postoperative CDAD occurred in 11 （5%）patients. Median onset of CDAD was postoperative d 19（range, 5-54）. In the multivariate analyses, male gender （odds ratio, 4.56） and serum creatinine （≥ 1.5 mg/dL,odds ratio, 16.0） independently predicted postoperative CDAD.
CONCLUSION： CDAD should be considered in the differential diagnosis of patients with postoperative diarrhea after LDLT.     

Historical perspective of living donor liver transplantation

Living donor liver transplantation （LDLT） has gone through its formative years and established as a legitimate treatment when a deceased donor liver graft is not timely or simply not available at all. Nevertheless, LDLT is characterized by its technical complexity and ethical controversy. These are the consequences of a single organ having to serve two subjects, the donor and the recipient, instantaneously. The transplant community has a common ground on assuring donor safety while achieving predictable recipient success. With this background, a reflection of the development of LDLT may be appropriate to direct future research and patientcare efforts on this life-saving treatment alternative.     

Simultaneous splenectomy improves outcomes after adult living donor liver transplantation

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瞬时弹性扫描诊断肝纤维化准确性研究

目的验证瞬时弹性扫描（FibroScan）诊断肝纤维化的准确性。方法选取141例慢性肝病患者,每例均进行肝脏活体组织检查,并应用瞬时弹性扫描仪测量肝脏硬度,以病理检查结果为金标准,验证FibroScan诊断肝纤维化的准确性。结果肝脏硬度与肝纤维化程度密切相关,Kendall相关系数为0．74（P=0．001）。FibroScan诊断肝纤维化F1～F4、F2～F4、F3～F4、F4期的受试者工作特征曲线下面积分别为0．97、O．96、0．99、0．97。结论FibroScan诊断肝纤维化有较好的准确性。     

Analysis of infections in the first 3-month after living donor liver transplantation

AIM: To identify factors related to serious postoperative bacterial and fungal infections in the first 3 mo after living donor liver transplantation (LDLT).METHODS: In the present study, the data of 207 patients from 2004 to 2011 were reviewed. The pre-, intra- and post-operative factors were statistically analyzed. All transplantations were approved by the ethics committee of West China Hospital, Sichuan University. Patients with definitely preoperative infections and infections within 48 h after transplantation were excluded from current study. All potential risk factors were analyzed using univariate analyses. Factors significant at a P < 0.10 in the univariate analyses were involved in the multivariate analyses. The diagnostic accuracy of the identified risk factors was evaluated using receiver operating curve.RESULTS: The serious bacterial and fungal infection rates were 14.01% and 4.35% respectively. Enterococcus faecium was the predominant bacterial pathogen, whereas Candida albicans was the most common fungal pathogen. Lung was the most common infection site for both bacterial and fungal infections. Recipient age older than 45 years, preoperative hyponatremia, intensive care unit stay longer than 9 d, postoperative bile leak and severe hyperglycemia were independent risk factors for postoperative bacterial infection. Massive red blood cells transfusion and postoperative bacterial infection may be related to postoperative fungal infection.CONCLUSION: Predictive risk factors for bacterial and fungal infections were indentified in current study. Pre-, intra- and post-operative factors can cause postoperative bacterial and fungal infections after LDLT.     

Interobserver discrepancy in liver fibrosis using transient elastography

Summary. Transient elastography is a useful method to assess liver fibrosis, but uncertainties still exist regarding reliability and reproducibility of the technique. We aimed to improve knowledge on interobserver variability with the procedure and tried to find factors associated with such variability. This was a cross‐sectional study to compare the results of transient elastography performed by two different operators, one test made just after the other. We assessed both results with correlation tests and with repeated parametric or nonparametric tests, as needed. We also carried out a multivariate analysis to find factors associated with discrepancy in the results obtained by the two operators. We included a total of 333 pairs of transient elastography tests, belonging to 274 different patients. A total of 325 pairs of tests (97.6%) were valid. Results of the first and the second tests were, respectively, median (and interquartile range) of direct measurement 6.2 (4.6–10.6) and 6.0 (4.4–10.1) kPa (P = 0.012), and mean ± standard deviation of log₁₀ of direct measurement 0.892 ± 0.316 and 0.871 ± 0.324 (P = 0.001). In 87 pairs of tests (26.7%), a discrepancy of at least 2 kPa between both results was found, and in 15 pairs of tests (4.6%), a discrepancy of at least 10 kPa was found. Discordance of at least one stage between both measurements was noted in 74 pairs of tests (22.8%). An association was found between higher stiffness and discrepancy between both operators (P < 0.001). Although transient elastography is a very convenient test to assess liver fibrosis in clinical practice, interobserver discrepancy in results is common and represents a significant problem with the technique. Discrepant results are more common in patients with higher values of stiffness.     

端端吻合胆道重建在活体肝移植中的应用

目的:探讨端端吻合胆道重建在临床活体肝移植中的应用效果、并发症及处理原则.方法:回顾性分析活体肝移植24例临床资料;其中右半肝活体肝移植6例,左半肝移植16例,左外叶2例;胆道重建均采用供肝肝管与受体胆管端端吻合,并置"T"管外引流.结果:24例活体肝移植中,18例采用供肝的左肝管和受体的胆总管吻合,5例采用供肝的右肝管和受体的肝总管吻合,1例右肝管是两个开口,将右前肝管和受体的肝总管行端端吻合,右后肝管与胆总管行端侧吻合.2例患者发生胆漏;1例出现胆道狭窄;术后胆管炎2例;1例术后3mo拔"T"管后出现胆汁性腹膜炎,再次行胆道引流术,术后恢复.胆道并发症总发生率为25%;发生时间在术后2d-9mo.结论:端端吻合胆管重建是活体肝移植中胆管重建的可行、有效的方法.     

Longitudinal assessment of liver stiffness by transient elastography for chronic hepatitis B patients treated with nucleoside analog

Aim: To evaluate the association between liver stiffness measured by transient elastography (FibroScan) and the efficacy of long‐term nucleoside analog (NA) treatment for patients with chronic hepatitis B. Methods: Study 1: Forty‐four chronic HBV patients had liver stiffness measured by FibroScan and underwent liver biopsy. Study 2: Group A: 22 patients started NA treatment at entry and FibroScan was done annually for 3 years. Group B: 23 patients started NA treatment prior to pretreatment FibroScan measurement, and FibroScan was done for from 3 to 5 years after the start of NA treatment. Results: Study 1: The FibroScan values were significantly correlated with fibrosis stage (r = 0.672, P < 0.0001). Optimal cutoff of FibroScan values were 6.1 kPa for ≥ F1, 6.3 kPa for ≥ F2, 8.9 kPa for ≥ F3 and 12.0 kPa for F4. Study 2: For Group A, the baseline median FibroScan value was 8.2 kPa. FibroScan values significantly decreased annually for 3 years after the start of NA treatment (6.4 kPa, 5.8 kPa and 5.3 kPa at years 1, 2 and 3, respectively). For Group B, the FibroScan values did not significantly improve over the 3 years after the start of NA treatment. Conclusions: Liver stiffness, measured by transient elastography, of chronic hepatitis B patients treated with NA showed a rapid decline in the first 3 years followed by a more steady transition for from 3 to 5 years irrespective of long term virological effect.     

成人间活体肝移植现状

活体供肝是解决世界性供肝短缺问题的重要手段,儿童活体肝移植于1988年开始应用于临床,成人间活体右半肝肝移植则于1996年由香港范上达教授首次应用于临床,由于供体的安全性问题,直到2000年以后,成人间活体肝移植(A-ALDLT)才在全世界广泛开展.由于A-ALDLT仅有10余年历史,加上手术难度及风险极大,且涉及供、受体两个人的安全,因而在外科临床上仍有很多疑难问题尚未解决,拟从以下几方面简述近年的一些技术创新及存在的问题.     

Liver stiffness measurement using transient elastography and hepatocellular carcinoma

Liver fibrosis has been gaining noticeable attention because it may lead to end-stage liver cirrhosis and ultimately to hepatocellular carcinoma. Thus, a precise estimation of the degree of liver fibrosis is crucial for predicting prognosis and deciding management of patients with chronic liver diseases. Many non-invasive approaches for the evaluation of liver fibrosis have been developed. Among these procedures, transient elastography has recently drawn great attention. Transient elastography has been reported to be well correlated with the degree of liver fibrosis by many investigators and various institutions. Since the degree of liver fibrosis is considered as a strong predictor of risk for hepatocellular carcinoma development, several trials have been performed to verify the usefulness of measurement of liver stiffness to predict the emergence of hepatocellular carcinoma. From these studies, transient elastography seems to be a promising procedure to predict the risk of hepatocellular carcinoma; however, further cohorts with long-term monitoring of liver stiffness are needed to confirm the usefulness of this method.     

Impact of liver steatosis on the correlation between liver stiffness and fibrosis measured by transient elastography in patients coinfected with human immunodeficiency virus and hepatitis C virus

Summary. We assessed the effect of different hepatic conditions such as fibrosis, steatosis and necroinflammatory activity on liver stiffness as measured by transient elastography in HIV/HCV‐coinfected patients. We studied all consecutive HIV/HCV‐coinfected patients who underwent liver biopsy and elastography between January 2007 and December 2008. Liver fibrosis was staged following METAVIR Cooperative Study Group criteria. Steatosis was categorized according to the percentage of affected hepatocytes as low (≤10%), moderate (<25%) and severe (≥25%). A total of 110 patients were included. Fibrosis was distributed by stage as follows: F0, n = 13; F1, n = 47; F2, n = 29; F3, n = 18; and F4, n = 3. Liver biopsy revealed the presence of hepatic steatosis in 68 patients (low to moderate, n = 53; and severe n = 15). By univariate regression analysis, fibrosis, necroinflammatory activity, and the degree of steatosis were correlated with liver stiffness. However, in a multiple regression analysis, steatosis and fibrosis were the only independent variables significantly associated with liver stiffness. With a cut‐off of 9.5 kPa to distinguish patients with F ≤ 2 from F ≥ 3, elastography led to a significantly higher number of misclassification errors (25%vs 5%; P = 0.014), most of which were false positives for F ≥ 3. Our study suggests that the correlation between liver stiffness and fibrosis as estimated by transient elastography may be affected by the presence of hepatic steatosis in HIV/HCV‐coinfected patients.     

Quality of life and psychological outcome of donors after living donor liver transplantation

AIM: To investigate the health related quality of life (HRQoL) and psychological outcome of donors after living donor liver transplantation. METHODS: Participants were 92 consecutive liver transplant donors who underwent hepatectomy with- out middle hepatic vein at West China Hospital of Sichuan University between January 2007 and Sep- tember 2010. HRQoL was measured using the Chinese version of the Medical Outcomes Study Short Form-36 (SF-36), and psychological symptoms were measured using the Symptom Checklist-90-Revised (SCL-90-R). Data collected from donors were compared to previ- ously published data from the general population. Clin- ical and demographic data were collected from medical records and questionnaires.RESULTS: The general health score of the SF-36 was significantly lower in females (59.78 ± 12.25) than in males (75.83 ± 22.09). Donors more than 40 years old scored higher in social functioning (85.71 ± 14.59) and mental health (82.61 ± 20.00) than those younger than 40 (75.00 ± 12.13, 68.89 ± 12.98; social func- tioning and mental health, respectively). Donors who had surgery more than two years prior to the study scored highest in physical functioning (P = 0.001) and bodily pain (P = 0.042) while those less than one year from surgery scored lowest. The health of the liver recipient significantly influenced the general health (P = 0.042), social functioning (P = 0.010), and role- emotional (P = 0.028) of donors. Donors with full-time employment scored highest in role-physical (P = 0.005), vitality (P = 0.001), social functioning (P = 0.016), mental health (P 0.001), the physical component summary scale (P 0.001), and the mental compo- nent summary scale (MCS) (P 0.001). Psychological measures indicated that donors were healthier than the general population in obsessive-compulsive behav- ior, interpersonal sensitivity, phobic anxiety, and para- noid ideation. The MCS of the SF-36 was significantly correlated with most symptom scores of the SCL-90-R. CONCLUSION: HRQoL and psychological outcome were favorable in living liver transplant donors after donation. Specifically, gender, age, time since opera- tion, recipient health condition, and employment after donation, influenced postoperative quality of life.     

Management of anti-allogeneic antibody elimination by apheresis in living donor liver transplantation

In this study, we report on the indications and efficacy of the elimination of antiallogeneic antibodies in living donor liver transplant recipients. Seven patients incompatible with the ABO-blood type were subjected to apheresis before transplantation. The procedure resulted in titers being decreased to less than a score of 8. After transplantation, apheresis was also performed in 6 cases and continuous hemodiafiltration in 1 case. In addition, three out of 11 ABO-blood type incompatible recipients were administered anti-CD20 antibody (rituximab). Two crossmatch positive patients were subjected to apheresis before transplantation, and in these cases the titers were reduced to less than a score of 2. Moreover, these two patients had no acute rejections after transplantation. We concluded that apheresis is effective for preventing acute rejection induced by pre-existing anti-A and/or anti-B antibodies, as well as antidonor specific antibodies, but is not effective in some patients who had accelerated humoral rejection.     

Vascular complications after adult living donor liver transplantation:Evaluation with ultrasonography

Living donor liver transplantation(LDLT) has beenwidely used to treat end-stage liver disease with improvement in surgical technology and the application of new immunosuppressants. Vascular complications after liver transplantation remain a major threat to the survival of recipients. LDLT recipients are more likely to develop vascular complications because of their complex vascular reconstruction and the slender vessels. Early diagnosis and treatment are critical for the survival of graft and recipients. As a non-invasive, cost-effective and non-radioactive method with bedside availability, conventional gray-scale and Doppler ultrasonography play important roles in identifying vascular complications in the early postoperative period and during the follow-up. Recently, with the detailed vascular tracing and perfusion visualization, contrastenhanced ultrasound(CEUS) has significantly improved the diagnosis of postoperative vascular complications. This review focuses on the role of conventional grayscale ultrasound, Doppler ultrasound and CEUS for early diagnosis of vascular complications after adult LDLT.     

Donor safety and remnant liver volume in living donor liver transplantation

AIM:To evaluate the relationship between donor safety and remnant liver volume in right lobe living donor liver transplantation(LDLT).METHODS:From July 2001 to January 2009,our liver transplant centers carried out 197 LDLTs.The clinical data from 151 cases of adult right lobe living donors(not including the middle hepatic vein) were analyzed.The conditions of the three groups of donors were well matched in terms of the studied parameters.The donors' preoperative data,intraoperative and postoperative data were calculated for the three groups:Group 1 remnant liver volume(RLV) 35%,group 2 RLV 36%-40%,and group 3 RLV 40%.Comparisons included the different remnant liver volumes on postoperative liver function recovery and the impact of systemic conditions.Correlations between remnant liver volume and post-operative complications were also analyzed.RESULTS:The donors' anthroposomatology data,op-eration time,and preoperative donor blood test indicators were calculated for the three groups.No significant differences were observed between the donors' gender,age,height,weight,and operation time.According to the Chengdu standard liver volume formula,the total liver volume of group 1 was 1072.88 ± 131.06 mL,group 2 was 1043.84 ± 97.11 mL,and group 3 was 1065.33 ± 136.02 mL.The three groups showed no statistically significant differences.When the volume of the remnant liver was less than 35% of the total liver volume,the volume of the remnant had a significant effect on the recovery of liver function and intensive care unit time.In addition,the occurrence of complications was closely related to the remnant liver volume.When the volume of the remnant liver was more than 35% of the total liver volume,the remnant volume change had no significant effect on donor recovery.CONCLUSION:To ensure donor safety,the remnant liver volume should be greater than the standard liver volume(35%) in right lobe living donor liver transplantation.     

Simplifying living donor liver transplantation

BACKGROUND:Living donor liver transplantation is a complex surgical operation.Treatment policies and operative techniques evolved in the last two decades.DATA SOURCES:Our center's experience in living donor liver transplantation was reviewed in conjunction with relevant publications in the literature.RESULTS:The surgical techniques and perioperative surgical therapeutics could be modified towards simplicity.Examples include regular inclusion of the middle hepatic vein without compromising the venous outflow...     

活体肝移植术后受体胆系并发症的影响因素及影像学表现

目的:探讨活体肝移植(LDLT)术后受体胆系并发症发生的影响因素及其影像学表现.方法:纳入2007-01/2011-03在我院接受活体肝移植的患者119例,回顾性分析其在术后随访的多层螺旋CT(MDCT)及MRI图像,重点观察胆道系统,观察有无各种胆系并发症,必要时结合各种后处理技术,包括多平面重建、最大密度投影等.将结果与其同期随访的临床及其他辅助检查对照,并探讨其发生原因.结果:119例患者术后1-18mo随访中,胆系并发症共计22例,发生率约18.5%.其中包括9例胆汁淤积、5例胆管炎、4例胆管狭窄和4例胆漏.各种并发症的主要发生时间不一致,发生的影响因素复杂.胆汁淤积、胆管炎及胆管狭窄在MDCT、MRI图像上可良好显示,并有各自的影像学特点,MRI价值大于MDCT.目前两种检查技术对胆漏的诊断价值有限.结论:LDLT术后胆系并发症发生的解剖生理复杂,影像学价值大,其中MRI优于MDCT.建议临床医生在LDLT受体术后随访时如怀疑有胆系并发症首选MRI检查.