Adult Deceased Donor Liver Transplantation Research Articles

Early use of everolimus improved renal function after adult deceased donor liver transplantation.

BackgroundTacrolimus (TAC) is a main therapy for liver transplantation (LT) patients, but it has side effects such as chronic nephrotoxicity that progressively aggravate renal function. The purpose of this study was to retrospectively compare the renal function between a TAC group and a combination of everolimus and reduced TAC (EVR-TAC) group after deceased donor liver transplantation (DDLT).MethodsThe study comprised 131 patients who underwent DDLT between January 2013 and April 2018 at our institution. They received TAC or EVR-TAC after DDLT. Everolimus (EVR) was introduced between 1 and 6 months after DDLT.ResultsThirty-six of 131 patients (27.5%) received EVR-TAC. The incidence of chronic kidney disease (CKD; estimated glomerular filtration rate, <60 mL/1.73 m2) in the EVR-TAC group was higher than in the TAC group (25% vs. 8.4%; P=0.019). Increasing serum creatinine (n=23, 63.9%) was the most common cause for adding EVR to treatment of the posttransplant patients. There were no statistical differences in acute rejection and CKD between the two groups. The TAC trough level was significantly lower in the EVR-TAC group than in the TAC group, and the renal function of the EVR-TAC group was worse than that of the TAC group until 1 year after DDLT. However, the renal function of the EVR-TAC group improved and became similar to that of TAC group at 3 years posttransplant.ConclusionsThe present study suggests that EVR should be introduced as soon as possible after DDLT to reduce exposure to high doses of TAC to improve the renal function.

Predicting survival after liver transplantation in patients with hepatocellular carcinoma using the LiTES-HCC score

Liver transplant priority in the US and Europe follows the 'sickest-first' principle. However, for patients with hepatocellular carcinoma (HCC), priority is based on binary tumor criteria to expedite transplant for patients with 'acceptable' post-transplant outcomes. Newer risk scores developed to overcome limitations of these binary criteria are insufficient to be used for waitlist priority as they focus solely on HCC-related pre-transplant variables. We sought to develop a risk score to predict post-transplant survival for patients using HCC- and non-HCC-related variables. We performed a retrospective cohort study using national registry data on adult deceased-donor liver transplant (DDLT) recipients with HCC from 2/27/02-12/31/18. We fit Cox regression models focused on 5- and 10-year survival to estimate beta coefficients for a risk score using manual variable selection. We then calculated absolute predicted survival time and compared it to available risk scores. Among 6,502 adult DDLT recipients with HCC, 11 variables were selected in the final model. The AUCs at 5- and 10-years were: 0.62, 95% CI 0.57-0.67 and 0.65, 95% CI 0.58-0.72, which was not statistically significantly different to the Metroticket and HALT-HCC scores. The LiTES-HCC score was able to discriminate patients based on post-transplant survival among those meeting Milan and UCSF criteria. We developed and validated a risk score to predict post-transplant survival for patients with HCC. By including HCC- and non-HCC-related variables (e.g., age, chronic kidney disease), this score could allow transplant professionals to prioritize patients with HCC in terms of predicted survival. In the future, this score could be integrated into survival benefit-based models to lead to meaningful improvements in life-years at the population level. We created a risk score to predict how long patients with liver cancer will live if they get a liver transplant. In the future, this could be used to decide which waitlisted patients should get the next transplant.

Early Allograft Dysfunction Following Liver Transplant: Impact of Obesity, Diabetes, and Red Blood Cell Transfusion

PurposeWe examined the role of obesity and intraoperative red blood cell (RBC) and platelet transfusion in early allograft dysfunction (EAD) following liver transplantation (LT). MethodsThis is a retrospective analysis of 239 adult deceased-donor LT recipients over a 10-year period. EAD was defined by Olthoff’s criteria. Data collection included donor (D) and recipient (R) age, body mass index (BMI) ≥ 35 kg/m2, diabetes mellitus, allograft macrosteatosis, and intraoperative (RBC) and platelet administration. We employed logistic regression to evaluate associations of these factors with EAD. Results are presented as odds ratios (OR) and 95% confidence intervals (CI) with corresponding P values. A P ≤ .05 was considered statistically significant. ResultsEAD occurred in 85 recipients (36%). Macrosteatosis data were available for 199 donors. In the multivariate analyses, BMI-D ≥ 35 kg/m2 increased the odds of developing EAD by 156% in the entire cohort (OR 2.56, 95% CI 1.09-6.01) and by 187% in recipients with macrosteatosis data (n = 199, OR 2.87, 95% CI 1.15-7.15). Each unit of RBCs increased the odds for EAD by 8% (OR 1.08, 95% CI 1.02-1.14) and, for the subgroup of 238 recipients with macrosteatosis data, by 9% (OR 1.09, 95% CI 1.02-1.16). ConclusionWe found a significant independent association of donor obesity and intraoperative RBC transfusion with EAD but no such association for platelet administration, MELD score, age, recipient obesity, and diabetes.

Women who undergo liver transplant have longer length of stay post-transplant compared with men.

Women on the liver transplant waitlist are at greater risk of hospitalization compared with men, but whether this impacts length of stay (LOS) post-transplant is unknown. We aimed to evaluate gender disparities in post-transplant LOS, an important surrogate of health resource utilization post-transplant. Using the UNOS/OPTN registry, we analysed all non-Status 1 adult deceased donor liver transplant recipients without exception points from 2008 to 2017. Poisson regression associated female gender with post-transplant LOS. Of 27294 transplant recipients, 36% were women. Women were more likely to be hospitalized pretransplant than men (44% vs 39%, P<.01). Post-transplant, women were more likely to have prolonged (≥20d) LOS (25% vs 22%, P<.01). In univariable analysis, female gender was associated with longer post-transplant LOS (IRR 1.09, 95%CI 1.06-1.12, P<.01). Prolonged pretransplant admission was also associated with post-transplant LOS (IRR 1.83, 95%CI 1.77-1.89, P<.01). In multivariable analysis, female gender remained independently associated with post-transplant LOS (aIRR 1.05, 95%CI 1.02-1.08, P<.01), after adjustment for age, UNOS region, insurance type, MELDNa, cirrhosis complications, and donor risk index. Pretransplant hospitalization mediated this relationship, explaining 14.1% (95%CI 9.7%-25.4%) of the total effect. Women who undergo deceased donor liver transplant have increased healthcare utilization in the peritransplant period compared with men. Reducing gender disparities in liver transplantation, including the disproportionate burden of healthcare utilization by women pre- and post-transplant, will require interventions targeted at preventing hospitalization among women on the transplant waitlist and developing tools aimed at better characterizing the severity of end-stage liver disease in women.

How to Handle Arterial Conduits in Liver Transplantation? Evidence From the First Multicenter Risk Analysis.

The aims of the present study were to identify independent risk factors for conduit occlusion, compare outcomes of different AC placement sites, and investigate whether postoperative platelet antiaggregation is protective. Arterial conduits (AC) in liver transplantation (LT) offer an effective rescue option when regular arterial graft revascularization is not feasible. However, the role of the conduit placement site and postoperative antiaggregation is insufficiently answered in the literature. This is an international, multicenter cohort study of adult deceased donor LT requiring AC. The study included 14 LT centers and covered the period from January 2007 to December 2016. Primary endpoint was arterial occlusion/patency. Secondary endpoints included intra- and perioperative outcomes and graft and patient survival. The cohort was composed of 565 LT. Infrarenal aortic placement was performed in 77% of ACs whereas supraceliac placement in 20%. Early occlusion (≤30 days) occurred in 8% of cases. Primary patency was equivalent for supraceliac, infrarenal, and iliac conduits. Multivariate analysis identified donor age >40 years, coronary artery bypass, and no aspirin after LT as independent risk factors for early occlusion. Postoperative antiaggregation regimen differed among centers and was given in 49% of cases. Graft survival was significantly superior for patients receiving aggregation inhibitors after LT. When AC is required for rescue graft revascularization, the conduit placement site seems to be negligible and should follow the surgeon's preference. In this high-risk group, the study supports the concept of postoperative antiaggregation in LT requiring AC.

Is renal replacement therapy necessary in deceased donor liver transplantation candidates with hepatorenal syndrome?: a 2-year experience at a high-volume center.

PurposeHepatorenal syndrome (HRS) is a fatal complication in patients with end-stage liver disease awaiting liver transplantation (LT). HRS often develops in patients with high model for end-stage liver disease (MELD) score. This study investigated the outcomes of peritransplant management of HRS in a high-volume LT center in Korea for 2 years.MethodsA total of 157 recipients that deceased donor liver transplantation (DDLT) from January 2017 to December 2018 were included. In-hospital mortality (IHM) was analyzed in relation to pre- and posttransplant application of renal replacement therapy (RRT).ResultsPrimary diagnoses for DDLT were alcoholic liver disease (n = 61), HBV-associated liver cirrhosis (n = 48), retransplantation for chronic graft failure (n = 24), and others (n = 24). Mean MELD score was 34.6 ± 6.2 with 72 patients at Korean Network for Organ Sharing MELD status 2 (45.9%), 43 at status 3 (27.4%), 36 at status 4 (22.9%), and 6 at status 5 (3.8%). Pretransplant RRT was performed in 16 patients (10.2%) that did not show IHM. Posttransplant RRT was performed in 69 patients (44.0%), for whom IHM incidence was 15.9%. In 53 patients that had undergone de novo posttransplant RRT, IHM incidence increased to 20.8%. IHM in the 88 patients not requiring RRT was 2.3%.ConclusionThe majority of adult DDLT recipients in Korean MELD score-based allocation system have very high MELD scores, which is often associated with HRS. Pretransplant RRT appears to improve posttransplant survival outcomes. We thereby recommend that, if indicated, pretransplant RRT be performed while awaiting DDLT.

In Situ Left Lateral Sectionectomy in Deceased Donor Liver Transplantation: Could This Be Another Solution for a Large-for-Size Graft? A Case Report

BackgroundLarge-for-size (LFS) graft should be avoided when performing an adult deceased donor liver transplantation (DDLT) as it is associated with abdominal compartment syndrome, severe graft injury, and primary graft nonfunction. When inadvertently facing with LFS graft intraoperatively, the most commonly reported approach has been a surgical reduction of the right lobe despite its technical difficulty in addition to ongoing coagulopathy after graft reperfusion. We report a case where we performed a left lateral sectionectomy instead of a right lobe modification. Case ReportA 44-year-old 58.4 kg female patient was admitted with drug-induced acute hepatic failure and underwent an emergency DDLT. The donor was a 51-year-old 60.0 kg man. At the time of procurement, the liver was noted to be hypertrophic. The estimated graft/recipient weight ratio was 3.49%. After completing the vascular and bile duct anastomosis, the abdomen could not be closed due to its large graft size. Because of the hypertrophic left lateral lobe and ongoing coagulopathy, we decided to perform an in situ left lateral sectionectomy rather than right posterior sectionectomy or right hemihepatectomy. The next day, the liver function failed to improve, and the patient’s blood pressure began to decline gradually. Computed tomography showed severe inferior vena cava (IVC) compression by the graft, and the patient underwent transjugular IVC stent placement. Soon after, the patient’s blood pressure improved and liver function gradually normalized. The patient was discharged uneventfully on postoperative day 45. ConclusionUnder specific conditions, in situ left lateral sectionectomy is a solution for unexpected LFS graft during DDLT.

De Novo Head and Neck Cancer After Liver Transplant With Antibody-Based Immunosuppression Induction

BackgroundPowerful antibody-based immunosuppression induction is now used routinely during organ transplantation and may place patients at even higher risk of post-transplant cancer. Materials and methodsIncidence of de novo head and neck cancer was extracted from the records of 1685 consecutive adult deceased donor liver transplant recipients with a minimum 1-year follow-up from 2001 to 2015. There were 121 patients positively identified as having developed de novo head and neck cancer post–liver transplant. Records of these patients were analyzed to determine demographics, history of cancer pre–liver transplant, de novo cancer type and location, treatment modalities, and alcohol and tobacco exposure. ResultsOf the 121 patients who developed cancer of the head and neck (7%), there were 103 cutaneous (6%) and 25 noncutaneous (1%). For noncutaneous cancers, factors associated with increased risk of cancer included alcohol abuse (P < .001), any smoking history (P = .05), and increasing exposure to tobacco (P < .01). Ten-year Cox regression patient survival demonstrates a survival disadvantage for patients who develop noncutaneous cancer (P = .06) but a survival advantage for patients who develop cutaneous cancer (P < .01). ConclusionsThe incidence and pattern of head and neck cancer in this population of liver transplant recipients was similar to those published previously, suggesting that induction immunosuppression does not increase risk of these types of cancers. Long-term survival was worse for patients with noncutaneous cancers, but better for those with cutaneous cancers, though the reason is unclear.

Critical Importance of Low-Dose Tissue Plasminogen Activator Policy for Treating Intraoperative Pulmonary Thromboembolism During Liver Transplantation

Tissue plasminogen activator (tPA) has been reported to treat intraoperative pulmonary thromboembolism (PTE) during liver transplantation (LT). However, tPA administration is often delayed due to fear of uncontrolled bleeding and storage in a refrigerator outside of operating rooms. Various dosages of tPA were used. We hypothesize that a policy of tPA storage and low dosage use improves patient outcomes. At a transplantation center, a multidisciplinary committee has implemented a tPA policy since April 2014, which includes the following: (1) timely administering of low-dose tPA (0.5-4 mg) for intraoperative PTE; (2) keeping 2 vials of tPA (2 mg/vial) in the operating room at room temperature; and (3) transferring unused tPA vials to the cardiology catheterization laboratory for next-day use. A prospective observational study was conducted to record the incidence and outcome of PTE during LTs. Over the next 19 months, 99 adult deceased donor LTs were performed with 1 (1.0%) intraoperative PTE. A 45-year-old woman with hepatitis C developed PTE within 5 minutes after graft reperfusion. A 2-mg tPA was immediately administered via a central venous line with hemodynamic improvement and clot lysis. Thromboelastography was normalized in 90 minutes. Five LT cases developing intraoperative PTE have been reported to receive "standard" dosages of tPA (20-110 mg) or urokinase (4400 IU/kg), which were administered more than 20 minutes after the diagnosis of PTE. One intraoperative death and one later mortality were noted with intracranial hemorrhages/infarction of 3 cases. The multidisciplinary low-dose tPA policy for PTE was suggested to be effective.

Endoscopic treatment of anastomotic biliary stricture after adult deceased donor liver transplantation with multiple plastic stents versus self-expandable metal stents: a systematic review and meta-analysis.

Anastomotic biliary strictures (ABSs) occur in up to 15% of patients after liver transplantation (LT). The aim of this study was to compare the efficacy and safety of self-expandable metal stents (SEMS) versus multiple plastic stents (MPS). Databases were searched through April 2017. The outcome measures were technical success, stricture resolution, recurrence and complications. We synthesized the findings descriptively and performed a meta-analysis. Three randomized controlled trials and one retrospective cohort study were identified, including 179 MPS and 119 SEMS patients. Outcome data were pooled in a meta-analysis that showed an advantage of SEMS in terms of the number of ERCP procedures (mean difference: 1.69 ERCP; 95% CI, 1-2.39; P < 0.00001) and treatment days (mean difference: 40.2 days; 95% CI, 3.9-76.4; P = 0.03), with no differences in terms of ABS resolution or recurrence. Fourteen case series reported MPS outcomes and fifteen reported SEMS outcomes, including 647 and 419 patients, respectively. Based on low-quality evidence, we cannot draw any reliable conclusions on the superiority of MPS or SEMS strategies. Even though shorter treatment times and fewer ERCP procedures support the use of SEMS, whether one technique has well-defined advantages over the other remains unclear.

Association Between Flushed Fluid Potassium Concentration and Severe Postreperfusion Syndrome in Deceased Donor Liver Transplantation.

BackgroundsPredicting the occurrence of severe postreperfusion syndrome (PRS) is clinically challenging. We investigated whether the flushed fluid potassium concentration (FFK) was associated with severe PRS in deceased donor liver transplantation (DDLT).Material/MethodsForty adult DDLT recipients were enrolled in this retrospective study. Effluent solution samples were collected at the end of the portal vein flush, and the FFK was determined using a point-of-care blood gas analyzer. The risk factors associated with severe PRS and the clinical outcomes in 2 groups were compared.ResultsSevere PRS occurred in 22 out of 40 patients (55.0%). The FFK of the severe PRS group was significantly higher than that of the non-severe PRS group (median, 9.6 vs. 5.8, P<0.001). Other variables associated with severe PRS included the donor risk index (DRI), Child-Turcotte-Pugh score, donor type, donor warm ischemia time, and Model for End-stage Liver Disease score. The area under the receiver operator characteristic curve for the FFK was 0.982, and the best cut-off value of the FFK for predicting severe PRS was 6.75 mmol/L (100.0% sensitivity and 88.9% specificity). A significant positive correlation was observed between the FFK and DRI (R=0.714). Patients who experienced severe PRS had a higher early allograft dysfunction rate (63.6% vs. 22.2%, P=0.019) and a longer hospital stay (median, 33.0 vs. 24.0, P=0.034).ConclusionsBoth the severity of the recipient’s liver disease and the donor graft factors play an important role in the development of severe PRS in DDLT. An FFK of more than 6.75 mmol/L was associated with severe PRS after reperfusion.

Comparative Peripheral Blood T Cells Analysis Between Adult Deceased Donor Liver Transplantation (DDLT) and Living Donor Liver Transplantation (LDLT).

BackgroundT lymphocytes are an essential component of allograft rejection and tolerance. The aim of the present study was to analyze and compare the characteristics of T cell subsets in patients who underwent deceased donor liver transplantation (DDLT) versus living donor liver transplantation (LDLT).Material/MethodsBetween April 2013 and June 2014, 64 patients underwent adult liver transplantation. The distribution of peripheral blood T lymphocyte subsets before transplantation and at 4, 8, 12, and 24 weeks post-transplantation were monitored serially.ResultsIn the serial peripheral blood samples, the absolute CD3+ T cell counts in the LDLT group were higher than those in the DDLT group (p=0.037). The CD4+, CD8+, CD4/CD8, Vδ1, Vδ2, and γδ T cell counts did not change significantly over time in either group. The Vδ1/Vδ2 ratio was higher in patients with cytomegalovirus (CMV) infection than in patients without CMV infection (0.12 versus 0.26; p=0.033). The median absolute CD3+ and CD8+ T cell counts in patients with biopsy-proven acute rejection (BPAR) were 884 (range, 305–1,320) and 316 (range, 271–1,077), respectively, whereas they were 320 (range, 8–1,167) and 257 (range, 58–1,472) in patients without BPAR. The absolute CD3+ and CD8 T cell counts were higher in patients with BPAR than in patients without BPAR (p=0.007 and p=0.039, respectively).ConclusionsWith the exception of CD3+ T cells, T cell populations did not differ significantly between patients who received DDLT versus LDLT. In liver transplantation patients, CMV infection and BPAR were closely associated with T cell population changes.

In Situ Posterior Graft Segmentectomy for Large-for-Size Syndrome in Deceased Donor Liver Transplantation in Adults: A Case Report

Large-for-size syndrome (LFSS) is controversial in pediatric living donor liver transplantation patients and is associated with a poor graft outcome. Similar situations in deceased donor liver transplantation (DDLT) in adults have not been reported frequently, and there are no official guidelines worldwide. Deceased donation is extremely limited in Japan, and when a larger liver is allocated for a very sick small recipient in Japan, transplantation with a plan to address LFSS might be necessary. The patient is a 58-year-old female patient who had acute liver failure with coma. The graft-recipient weight ratio (GRWR) was 2.74%. Although the graft was enlarged by reperfusion, the intraoperative Doppler ultrasound, performed after reperfusion, showed sufficient graft in-flow and out-flow. However, when the liver graft was situated appropriately into the right phrenic space supported by the rib cage and diaphragm, the blood flow in the hepatic vein and portal vein was significantly reduced. Graft blood flow did not improve without removing it from the right subphrenic space. Therefore, we decided to perform an in situ graft posterior segmentectomy, so that the graft right lobe was properly accommodated in the patient's right subphrenic space. After the segmentectomy of the graft, an intraoperative Doppler sonogram showed significantly improved blood flow. LFSS could be a significant operative challenge in adult DDLT, especially in areas with limited chances of DDLT. In situ posterior segmentectomy in the demarcated area could be a solution for treating patients with LFSS.

Predicting End-Stage Renal Disease After Liver Transplant

Few equations have been developed to predict end-stage renal disease (ESRD) after deceased donor liver transplant. This retrospective observational cohort study analyzed all adult deceased donor liver transplant recipients in the Scientific Registry of Transplant Recipients (SRTR) database, 1995–2010. The prediction equation for ESRD was developed using candidate predictor variables available in SRTR after implementation of the allocation policy based on the model for end-stage liver disease. ESRD was defined as initiation of maintenance dialysis therapy, kidney transplant or registration on the kidney transplant waiting list. We used Cox proportional hazard models to develop separate equations for assessing risk of ESRD by 6 months posttransplant and between 6 months and 5 years posttransplant. Variables in the 6-month equation included recipient age, history of diabetes, history of dialysis before liver transplant, history of malignancy, body mass index, serum creatinine and liver donor risk index. Variables in the 6-month to 5-year equation included recipient race, history of diabetes, hepatitis C status, serum albumin, serum bilirubin and serum creatinine. The prediction equations have good calibration and discrimination (C statistics 0.74–0.78). We have produced risk prediction equations that can be used to aid in understanding the risk of ESRD after liver transplant.

Portal Vein Stenosis: A Rare Yet Clinically Important Cause of Delayed-onset Ascites after Adult Deceased Donor Liver Transplantation: Two Case Reports

Vascular complications following liver transplantation are well documented. While complications involving the portal vein are less common than the hepatic artery, portal vein complications can lead to potentially life-threatening sequelae including graft loss. Portal vein stenosis is an infrequent complication following liver transplant. The majority of these complications are seen in living donor liver transplants and pediatric liver transplants. We present 2 cases of delayed onset portal vein stenosis in adult deceased donor liver transplantation (ADDLT). The first patient presented with refractory ascites twelve months after ADDLT. He was diagnosed and successfully treated with percutaneous transhepatic portovenography and venoplasty. The second patient had a history of irradiation to his portal bed in the setting of cholangiocarcinoma. He developed refractory ascites and esophageal variceal bleeding >2 years after ADDLT. He underwent percutaneous transhepatic portovenoplasty, but eventually required placement of a portal stent due to continued problems with recurrent ascites. These 2 cases highlight the importance of considering portal vein stenosis in the differential diagnosis of late-onset ascites following liver transplantation, especially if there have been any predisposing risk factors such as portal bed irradiation or prior splenectomy.

Impact of MELD-Based Allocation on End-Stage Renal Disease After Liver Transplantation

The proportion of patients undergoing liver transplantation (LT), with concomitant renal dysfunction, markedly increased after allocation by the model for end-stage liver disease (MELD) score was introduced. We examined the incidence of subsequent post-LT end-stage renal disease (ESRD) before and after the policy was implemented. Data on all adult deceased donor LT recipients between April 27, 1995 and December 31, 2008 (n = 59 242), from the Scientific Registry of Transplant Recipients, were linked with Centers for Medicare & Medicaid Services' ESRD data. Cox regression was used to (i) compare pre-MELD and MELD eras with respect to post-LT ESRD incidence, (ii) determine the risk factors for post-LT ESRD and (iii) quantify the association between ESRD incidence and mortality. Crude rates of post-LT ESRD were 12.8 and 14.5 per 1000 patient-years in the pre-MELD and MELD eras, respectively. Covariate-adjusted post-LT ESRD risk was higher in the MELD era (hazard ratio [HR]= 1.15; p = 0.0049). African American race, hepatitis C, pre-LT diabetes, higher creatinine, lower albumin, lower bilirubin and sodium >141 mmol/L at LT were also significant predictors of post-LT ESRD. Post-LT ESRD was associated with higher post-LT mortality (HR = 3.32; p < 0.0001). The risk of post-LT ESRD, a strong predictor of post-LT mortality, is 15% higher in the MELD era. This study identified potentially modifiable risk factors of post-LT ESRD. Early intervention and modification of these risk factors may reduce the burden of post-LT ESRD.

Left-sided grafts for living-donor liver transplantation and split grafts for deceased-donor liver transplantation: Their impact on long-term survival

A small-for-size graft is important in living-donor liver transplantation (LDLT) and deceased-donor liver transplantation (DDLT). First, we confirmed the effect of initial graft volume on survival using a rat model of liver transplantation (LT). We then evaluated the actual long-term survival based on graft type in 1421 LTs (including 1364 LDLTs) at Kyoto University and 2000 DDLTs at the Mayo Clinic, to evaluate donor safety in LDLT and the possibility of shifting to split orthotopic liver transplantation (SOLT) in DDLT. In the rat model, SOLTs with 40%- and 20%-grafts had a poor survival. A total of 697 pediatric LTs showed good long-term outcomes (survival rate was 0.764 at 21.2 years). The survival rate of 724 adult LTs was 0.664 at 17.8 years. The survival rates of auxiliary partial orthotopic liver transplantation with a left-sided graft (0.421 at 15.0 years) and SOLT with a left-sided graft (0.000 at 0.8 years) need to be improved. Although the survival rate of 1965 adult DDLTs with a whole-liver graft in the Mayo Clinic was 0.727 at 12.8 years, that of adult SOLT was 0.595 at 11.0 years. From the viewpoint of greater donor safety and expanded donor candidates in LDLT, the choice of a left-sided graft still remains controversial. A shift to SOLT to achieve excellent results should be established to resolve a donor shortage in DDLT.

Suspect the Donor With Potential Infection in the Adult Deceased Donor Liver Transplantation

Introduction Liver transplantation is the treatment of choice for end-stage liver disease. However, the shortage of donors is still the major problem in most Asian countries. Using extended donor criteria may maximize the deceased donor pool, but some high-risk donors may show adverse recipient outcomes due to preexisting infection. Materials and Methods This study included deceased donor liver transplant patients from June 2002 through June 2007. We retrospectively reviewed the clinical manifestations of donors and recipients. The donors showed no definite infection at the time the organs were matched to the recipients. Routine sputum, urine, blood, and bile cultures were obtained from the donor during the perioperative period. According to the final reports of the cultures, the recipients divided into two groups: donor infection (DI) and no donor infection (NDI). Results This study included 59 donor and 72 recipients, including 34 who received a graft from a donor with a positive culture (47.2%) finally, defined as the DI groups, and 38 recipients (52.8%) as the NDI group. Most of them had positive sputum cultures, followed by urine cultures. Staphylococcus aureus was the most common pathogen. Using a stepwise logistical regression model to analyze the significant donor characteristics, donor admission to the intensive care unit (ICU) for 7 days or longer ( P ≤ .0001), previous cardiopulmonary cerebral resuscitation (CPCR) ( P = .036), and inotropic agents ( P = .022) were the only three independent factors to predict donor infection. To compare the outcomes between DI and NDI groups, the days of recipient ICU or hospital admission, the 1-week or 1-month mortality rate, and the overall survival showed no significant difference between both groups. However, the hospital mortality rate was mildly higher in the DI group ( P = .050). Conclusion Donors with prolonged ICU admissions, rescue by CPCR, and use of inotropic agents carried an high risk of potential infections. Our data did not show a significant increase in adverse outcomes if the recipient received a graft from a potentially infected donor. However, there may be an increased risk of hospital mortality. We should be careful in using these potentially infected donors in selective recipients.

Adult liver transplantation using live ABO-incompatible grafts in western countries

In Western countries, the indication for liver transplantation using ABO-incompatible (ABO-I) donors remains controversial. The risks of ABO-I transplantation include antibody-mediated hyperacute rejection, a higher incidence of severe acute rejection, hepatic artery thrombosis, and biliary complications.1-3 Subsequently, the results of adult deceased donor liver transplantation using ABO-I grafts are poor, with an approximately 20% chance of 5-year graft survival.4 Histologically, the liver grafts are complicated by widespread hemorrhagic necrosis with intraorgan thrombosis and prominent arterial deposition of antibody and complement. Demetris et al.3 termed this syndrome “single-organ disseminated intravascular coagulation.” Prophylactic antilymphocyte globulin, plasmapheresis, splenectomy, soluble antigen, and ABO immunoadsorbents have been used with varying degrees of success but might be associated with a higher incidence of sepsis and do not improve the outcome for adult patients.5, 6 It has been concluded, therefore, that the use of ABO-I liver grafts is justified only in limited situations, such as in emergencies. ABO-I, ABO-incompatible; LDLT, living donor liver transplantation. It is another story, however, in Eastern countries, where the availability of deceased donor organs falls short of the population need and living donor liver transplantation (LDLT) is almost the only procedure that offers hope to patients with end-stage liver disease. All donors must be related to the patients; most of them are within three degrees of consanguinity or a spouse. If the patients have no ABO-identical or -compatible donors, ABO-I donors are the only available option. According to the Japanese Registry of Living Donor Liver Transplantation across ABO Blood Type Barrier, 97 ABO-I LDLTs were performed in Japan before March 2005; this corresponds to approximately 5% of the total adult (≥16 years of age) LDLTs performed. The 5-year survival rate of the patients was 38% before 2001 and improved to 63% among patients who underwent ABO-I after 2002. Some Japanese transplant surgeons7, 8 commented that the improvement was provided by innovative postoperative portal vein infusion therapy. The main purpose of this therapy is to control any local disseminated intravascular coagulation arising in ABO-I grafts. Three agents, methylprednisolone, prostaglandin E1, and gabexate mesylate, are infused continuously for 3 weeks after transplantation through a catheter placed in the portal vein during surgery. Prostaglandin E1 improves hepatic blood flow and microcirculation through its vasodilating effects and inhibits platelet/leukocyte adhesion. Gabexate mesylate is a serine protease inhibitor that inhibits thrombin, Xa, and platelet aggregation. These agents are logical choices for controlling local disseminated intravascular coagulation and immune responses. Systemic anti-rejection therapy basically follows the kidney protocol: pre- and postoperative plasmapheresis, splenectomy, and triple-immune prophylaxis, including steroids, tacrolimus, and antiproliferative agents. Recent advances in immunomodulatory therapy for ABO-I grafts include the use of anti-CD20 monoclonal antibody or soluble complement receptor9 as an alternative to splenectomy for B-cell depletion. More recently, the Kyoto group10 began infusing the two agents (methylprednisolone and prostaglandin E1) through a hepatic artery instead of the portal vein. They emphasized better graft survival with a reduced risk of portal vein thrombosis. The protocol described by Troisi et al.11 for an ABO-I barrier in this issue of Liver Transplantation is partly new but not entirely unexpected. Immunoadsorption with immobilized blood antigen A or B is used for ABO-I living donor kidney transplantation.12 The use of daclizumab instead of cyclophosphamide has been tried in ABO-I deceased donor liver transplantation.13 Of note is that this article11 is the first report from a Western country on ABO-I LDLT for an adult patient series. The report is very encouraging although the number is small and the follow-up period is short. We agree with the conclusions of the authors that the protocol deserves further application with immunologic studies. ABO-I liver grafting in adults may no longer be considered experimental but should be considered as a reasonable clinical option when no blood group–compatible liver is available for a critically ill patient. At the same time, however, liver transplantation using live ABO-I grafts should be a rare event. In LDLT, the physical and psychologic sacrifice by the donor is significant and is associated with high expectations of a good outcome for themselves and the recipient.14 The precise indication requires further debate in the Western countries where cadaveric organ is available, as the authors commented in the Discussion. The authors thank Dr. Hiroto Egawa (Kyoto University) for ABO-I LDLT data in Japan and Dr. Sumihito Tamura (University of Tokyo) for critical review of the article.

Adult Living Donor Versus Deceased Donor Liver Transplantation: A 6-Year Single Center Experience

No long-term (>3 years) prospective comparison of adult-to-adult living donor liver transplantation (A2ALLTx) to adult deceased donor liver transplantation (ADDLTx) has been reported. This is a prospective, IRB approved, 6-year comparison of A2ALLTx to ADDLTx. Data include: age, gender, ethnicity, primary liver disease, waiting time, pretransplant CTP/MELD score, cold ischemia time (CIT), perioperative mortality, acute and chronic rejection, graft and patient survival, charges and post-transplant complications. In 6 years, 202 ADDLTx (74.5%) and 69 A2ALLTx (25.5%) were performed at VCUHS. Hepatitis C virus (HCV) was the most common reason for transplantation in both groups (48.1% vs. 42%). Data regarding overall patient and graft survival, monetary charges and retransplantation rates were similar. Comparison of patient/graft survivals, retransplantation rates in patients with and without HCV were not statistically different. A2ALLTx patients had less acute rejection (11.5% vs. 23.9%) and more biliary complications (26.1% vs. 11.4%). Overall, A2ALLTx is as durable a liver replacement technique as the ADDLTx. Patients with A2ALLTx were younger, had lower MELD scores, less acute rejection and similar histological HCV recurrence. Biliary complications were more common in A2ALLTx but were not associated with increased graft loss compared to ADDLTx.