Complication Of Orthotopic Liver Transplantation Research Articles

An Unusual Case of Upper Gastrointestinal Bleeding in a Patient with an Orthotopic Liver Transplant

Introduction: Neo-hepatic artery pseudoaneurysm is a rare case of upper gastrointestinal bleeding. An esophagogastroduodenoscopy is often performed to investigate and treat cases of upper gastrointestinal bleeding. It is important to be aware of this complication of orthotopic liver transplantation in the setting of an upper gastrointestinal bleed in a patient with previous hepatic artery thrombosis. We present a rare case of neo-hepatic artery pseuodoaneurysm in a patient with orthotopic liver transplant. Case Presentation: A 60 year old male with past medical history of chronic hepatitis B and cholangiocarcinoma status post liver transplantation in 2008 presented with melena and hematemesis. The patient reported history of small esophageal varices on last EGD completed in 2009. He was admitted to the Medical ICU with an initial hemoglobin of 11.5. His hemoglobin subsequently dropped to 9.0 within 2 hours of admission to ICU, and the patient was taken for esophagogastroduodenoscopy. During endoscopy, no evidence of mucosal disease of variceal disease was found. However, there was evidence of extrinsic compression of the antrum. Following EGD, the patient was taken for CT Scan of Abdomen/Pelvis. This showed a vascular mass measuring 7.4cm x 5.4cm posterior to the gastric body. Repeat upper endoscopy again demonstrated extrinsic compression of the antrum along the lesser curvature. As the endoscope was passed a 1-cm dark pigmented lesion was noted. This was concerning for re-implanted hepatic artery pseudoaneurysm which was concerning for erosion into the extrahepatic artery.Figure 1Figure 2At this point, the patient was taken for angiogram with the inability to emobilize lesion. Subsequently, the patient was taken to operating room by the transplant surgery team and underwent exploratory laparotomy with ligation of the hepatic artery. Discussion: Gastrointestinal bleeding after liver transplantation occurs in 8.9& of patients. Less than 1% are due to hepatic artery pseudoaneurysm. This is caused by visceral inflammation adjacent to the arterial wall leading to weakening of the wall. The three primary predisposing factors include hepatic arterial wall digestion due to bile from anastomotic leakage, arterial irritation due to localized abscess in inferior hepatic space, and mechanical injury from surgery. Conclusion: Hepatic artery pseudoaneurysm is a rare, and often morbid complication of transplant. Physicians should be aware of this as a rare cause of GI Bleeding.Figure 3

P158 Could chimerism testing on orthotopic liver transplant patients lead to earlier graft versus host disease intervention and in turn more effective outcomes?

Graft-versus-host disease (GVHD) is a rare but often fatal complication of orthotopic liver transplantation (OLT). Rash, fever, diarrhea and pancytopenia, all hallmarks of GVHD, are symptomatically similar to adverse drug reactions (ADR) or viral infections. In the absence of these classic symptoms, GVHD diagnosis is delayed. We present the case of a 62 year old male with alcoholic cirrhosis and hepatocellular carcinoma who received an allograft from a 0/10 HLA matched 19 year old male donor. Both were CMV seronegative and the retrospective T- and B-cell flow cytometric crossmatch were negative. Following an unremarkable early post-transplant course, the patient was discharged on post-operation day (POD) 8 only to return for a routine follow-up on POD17 complaining of diarrhea and subsequently symptoms of fever and leukopenia. Blood, bacterial stool cultures, and stool parasite antigen screen were all negative. Appropriate care was taken to treat ADR and rule out infection including EBV, CMV and C. difficile PCR. Despite temporary relief with medication adjustments the patient was readmitted on POD27 with recurring diarrhea, syncope, fever, worsening leukopenia and new-onset rash. Repeat blood and stool testing remained negative. While the skin biopsy did not meet criteria to make the diagnosis of GVHD, whole blood chimerism testing detected 90% donor cells consistent with GVHD. CD3+ T-lymphocyte chimerism testing yielded 100% donor cells. Bone marrow biopsy demonstrated hypocellular marrow ( > 20 years and degree of HLA mismatch) in the early OLT period are needed to determine if this can lead to better patient outcomes.

Intention-to-treat analysis of percutaneous endovascular treatment of hepatic artery stenosis after orthotopic liver transplantation.

Hepatic artery stenosis (HAS) is a rare complication of orthotopic liver transplantation (LT). HAS could evolve into complete thrombosis and lead to graft loss, incurring significant morbidity and mortality. Even though endovascular management by percutaneous transluminal angioplasty ± stenting (PTA) is the primary treatment of HAS, its longterm impact on hepatic artery (HA) patency and graft survival remains unclear. This study aimed to evaluate longterm outcomes of PTA and to define the risk factors of treatment failure. From 2006 to 2012, 30 patients with critical HAS (>50% stenosis of HA) and treated by PTA were identified from 870 adult patients undergoing LT. Seventeen patients were diagnosed by post-LT screening, and 13 patients were symptomatic due to HAS. PTA was completed successfully in 27 (90%) patients with angioplasty plus stenting in 23 and angioplasty alone in 4. The immediate technical success rate was 90%. A major complication that was observed was arterial dissection (1 patient) which eventually necessitated retransplantation. Restenosis was observed in 10 (33%) patients. One-year, 3-year, and 5-year HA patency rates were 68%, 62.8%, and 62.8%, respectively. Overall patient survival was 93.3% at 3 years and 85.3% at 5 years. The 3-year and 5-year liver graft survival rates were 84.7% and 64.5%, respectively. No significant difference was observed in patient and graft survivals between asymptomatic and symptomatic patients after PTA. Similarly, no difference was observed between angioplasty alone and angioplasty plus stenting. In conclusion, endovascular therapy ensures a good 5-year graft survival (64.5%) and patient survival (85.3%) in patients with critical HAS by maintaining HA patency with a low risk of serious morbidity (3.3%). Liver Transplantation 22 923-933 2016 AASLD.

The clinical analysis of orthotopic liver transplantation for primary biliary cirrhosis

To analyze the clinical outcome and complications of orthotopic liver transplantation (OLT) for patients with primary biliary cirrhosis(PBC). Clinical data of 25 patients with PBC who underwent OLT were analyzed retrospectively. The postoperative cumulative survival rate of the patients was calculated. The postoperative recurrence of PBC, de novo diseases and other complications were analyzed. A total of 25 patients were recruited including 22 females and 3 males. The average age was 49.1 years (range from 40 to 64 years). The score of model for end-stage liver disease (MELD) was 21.80±5.49, and the Mayo score 8.01±1.38. Four patients died after liver transplantation. The 1-year, 2-year and 7-year patient cumulative survival rates were 92.0%, 87.8% and 75.3%, respectively. Eight cases (32.0%) developed recurrent PBC based on histological evidence. The median time to recurrence was 17.5 months. One of the eight patients with recurrent PBC was diagnosed with de novo auto-immune hepatitis (AIH) simultaneously, who eventually died. Acute rejection and de novo hepatitis B virus (HBV) infection developed in thirteen (52.0%) patients and five (20.0%) patients, respectively. Two cases (8.0%) of de novo AIH were diagnosed, one of which was fatal. OLT is an effective procedure for end-stage PBC. Much attention needs to be paid to the post-transplantation complications, including recurrence of primary disease, combined de novo HBV infection, de novo AIH, etc.

Successful Diagnosis and Treatment of Biliary Cast Syndrome after Orthotopic Liver Transplantation by Percutaneous Transhepatic Choledochoscopy: A Case Report

Biliary cast syndrome (BCS) is an unusual complication of orthotopic liver transplantation (OLT). BCS is characterized by multiple intrahepatic biliary strictures, ductal dilatation, intrahepatic abscesses, and biliary anastomotic leakage. The symptoms of BCS usually include high fever, jaundice and cholestatic liver enzyme elevation; similar to the symptoms observed in some patients with intrahepatic bile duct stones. The etiology of cast development is not fully known, and its management is difficult. Limited success using endoscopic retrograde cholangiopancreatography (ERCP) or open exploration to clear casts has been reported, and failure usually results in retransplantation. We describe a diabetic man who developed a BC after deceased donor liver transplantation. Percutaneous transhepatic biliary cholangiography was performed and revealed a filling defect in both the right and left intrahepatic systems, extending down to the anastomosis. Percutaneous transhepatic choledochoscopy proved that it was consistent with BCs, and the casts were removed by stone retrieval basket, foreign body pliers, and adsorber.

Biliary Cast Syndrome: Hepatic Artery Resistance Index, Pathological Changes, Morphology and Endoscopic Therapy.

Background:Biliary cast syndrome (BCS) was a postoperative complication of orthotopic liver transplantation (OLT), and the reason for BSC was considered to relate with ischemic type biliary lesions. This study aimed to evaluate the relationship between BCS following OLT and the hepatic artery resistance index (HARI), and to observe pathological changes and morphology of biliary casts.Methods:Totally, 18 patients were diagnosed with BCS by cholangiography following OLT using choledochoscope or endoscopic retrograde cholangiopancreatography. In addition, 36 patients who did not present with BCS in the corresponding period had detectable postoperative HARI on weeks 1, 2, 3 shown by color Doppler flow imaging. The compositions of biliary casts were analyzed by pathological examination and scanning electron microscopy.Results:HARI values of the BCS group were significantly decreased as compared with the non-BCS group on postoperative weeks 2 and 3 (P < 0.05). Odds ratio (OR) analysis of HARI 1, HARI 2, HARI 3 following the operation was >1 (OR = 1.300; 1.223; and 1.889, respectively). The OR of HARI 3 was statistically significant (OR = 1.889; 95% confidence interval = 1.166–7.490; P = 0.024). The compositions of biliary casts were different when bile duct stones were present. Furthermore, vascular epithelial cells were found by pathological examination in biliary casts.Conclusions:HARI may possibly serve as an independent risk factor and early predictive factor of BCS. Components and formation of biliary casts and bile duct stones are different.

Influence of Hydroxyethyl Starch on Renal Function After Orthotopic Liver Transplantation

BackgroundPostoperative renal impairment (RI) is one of the most common complications in orthotopic liver transplantation (OLT), and it occurs in 17% to 95% of the patients who undergo the surgery. MethodsWe reviewed 394 consecutive patients who underwent OLT. On the basis of the preoperative renal function level (presence of renal failure (RF): SCr >1.5 mg/dL before OLT), the patients were divided into an RF group and a non-RF group. In each group, the patients were subdivided into 4 subgroups according to the type and dosage of the intra-operative use of HES (hydroxyethyl starch). The changing tendency of the SCr (serum creatinine) of each group and the ratio of the change in the SCr within the first postoperative week were compared. ResultsIn total, 139 of 394 patients (35%) had RI within the first week after OLT (RI group); 104 patients (75%) in the RI group and 181 patients (71%) in the non-RI group required HES transfusions. The multivariate logistic regression analysis identified old age, a low pre-operative platelet level, and massive red blood cell transfusions as risk factors for the postoperative development of RI. The changing tendency of the SCr and the ratio of change in the SCr among the different HES subgroups showed no significant difference in the RF group or in the non-RF group. ConclusionsPerioperative use of HES 200/0.5 or HES 130/0.4 has no significant effect on renal function in the first postoperative week in patients undergoing OLT.

Changes in the Concentrations of Mediators of Inflammation and Oxidative Stress in Exhaled Breath Condensate During Liver Transplantation and Their Relations With Postoperative ARDS.

Oxidative stress and inflammatory responses are thought to be involved in the pathogenesis of ARDS, which is one of the most serious complications of orthotopic liver transplantation (OLT). The collection of exhaled breath condensate (EBC) is a noninvasive method for obtaining clinical samples from the lungs. However, the changes of mediators of inflammation and oxidative stress in EBC remain unclear. Therefore, the aim of this study was to investigate the changes of mediators in EBC from OLT subjects and the relations between these mediators and ARDS. The levels of mediators of oxidative stress (superoxide dismutase [SOD], malondialdehyde [MDA], H2O2, NO, and 8-iso-prostaglandin F2α) and of inflammatory factors (tumor necrosis factor-α[TNF-α], interleukin [IL]-8, and IL-10) were measured in EBC and serum samples collected from 28 subjects before OLT surgery and at 2 and 4 h after the anhepatic phase. The diagnostic value for ARDS until the 3 days following transplantation was evaluated. Eighteen subjects developed ARDS after OLT. The concentrations of TNF-α, IL-8, MDA, NO, H2O2, and 8-iso-prostaglandin F2α were much higher in the ARDS group than in the control group, whereas the levels of IL-10 and SOD were lower in the ARDS group than in the control group. The serum levels of mediators of oxidative stress or inflammation were closely related to EBC levels. Receiver operating characteristic analysis showed that areas under the curves for MDA, NO, H2O2, 8-iso-prostaglandin F2α, TNF-α, IL-8, SOD, and IL-10 were 0.88, 0.88, 0.78, 0.84, 0.84, 0.94, 0.81, and 0.84 at 2 h after graft reperfusion and 0.98, 0.88, 0.92, 0.79, 0.95, 0.83, 0.88, and 0.97 at 4 h after graft reperfusion. EBC analysis is a noninvasive method for detecting mediators of inflammation and oxidative stress from the lungs. This method could be used to predict the higher incidence of ARDS induced by OLT.

Downregulation of Lung Toll‐Like Receptor 4 Could Effectively Attenuate Liver Transplantation‐Induced Pulmonary Damage at the Early Stage of Reperfusion

Acute lung injury (ALI) is a severe complication of orthotopic liver transplantation (OLT) with unclear underline mechanism. Toll-like receptor 4 (TLR4) has been identified as a key receptor mediating inflammation. We hypothesized that TLR4-mediated pulmonary inflammation may contribute to development of ALI during OLT. Patients with or without ALI were observed for serum cytokines and expression of TLR4 on peripheral blood polymorphonuclear leukocytes (PMNs). Next, rats which underwent orthotopic autologous liver transplantation (OALT) were divided into sham and model groups. Pulmonary function and the level of TLR4 expression and cytokines were analyzed. Furthermore, the role of TLR4 in OALT-mediated ALI was assessed in rats treated with TLR4-siRNA before OALT. The PMNs TLR4 expression and the serum TNF-α and IL-β level were higher in patients with ALI than those with non-ALI. Interestingly, lung TLR4 expression was significantly increased after 8 hours of OALT with increased levels of TNF-α and IL-β, which lead to lung pathological damage and an increase of lung myeloperoxidase content. Moreover, knockdown of TLR4 reduced lung cytokines release and reversed the above pathologic changes after OALT and finally improved rats' survival rate. In conclusion, TLR4 overexpression, potentially by stimulating proinflammatory cytokine overproduction, contributes to the development of ALI after OLT.

Risk Factors of Acute Renal Failure After Orthotopic Liver Transplantation: Single-center Experience

BackgroundAcute renal failure (ARF) is one of the most significant complications of orthotopic liver transplantation (OLT), associated with increased mortality rate and the development of chronic renal dysfunction. The aim of the study was to determine the perioperative risk factors for ARF in patients without previous history of renal disease who are undergoing OLT. Materials and methodsForty-six patients who developed ARF after OLT performed in 1 transplant center were included in the study, and 52 consecutive patients without that complication served as a control group. Renal dysfunction was defined as a glomerular filtration rate <60 mL/min/1.73 m2. The data concerning preoperative diseases, perioperative renal function, first-line immunosuppressive therapy, and blood transfusion requirement were retrospectively analyzed and compared among groups. Logistic regression modeling was used to determine risk factors for ARF. ResultsPatients who developed ARF were significantly older (mean age 53.3 vs 46.3 years, P = .057), had higher level of preoperative (0.79 vs 0.71 mg/dL, P = .0062) and intraoperative (0.85 vs 0.74 mg/dL, P = .0045) creatinine. The risk factors for ARF were intraoperative and 24-hour post-transplant creatinine level >0.9 mg/dL and high-dose tacrolimus-based immunosuppression. Transfusion of ≤6 units of red blood cells diminished the risk of ARF. Sex and preoperative diseases were not predictive to ARF in our regression models. ConclusionCareful operative technique with low blood loss and immunosuppressive therapy of low nephrotoxic potential should be recommended in older patients to diminish the risk of renal dysfunction after orthotopic liver transplantation. Patients with higher levels of perioperative creatinine should be considered to have first-line immunosuppression without calcineurin inhibitors or with low-dose immunosuppressants of known nephrotoxic potential.

Association of Operative Start Time With Surgical Complications in Orthotopic Liver Transplantation (OLT).

Association of Operative Start Time With Surgical Complications in Orthotopic Liver Transplantation (OLT).

Successful management of splenic artery steal syndrome with hepatic artery stenosis in an orthotopic liver transplant recipient

Splenic artery steal syndrome is an uncommon but serious complication of orthotopic liver transplantation. We report a case of splenic artery steal syndrome with hepatic artery stenosis in a 65-year-old male liver transplant recipient who was successfully managed by hepatic artery stenting and splenic artery embolization in a single procedure. A 65-year-old man underwent orthotopic liver transplantation due to alcoholic cirrhosis using a piggyback technique. Relevant parameters were measured. The splenic blood flow was apparently reduced and arterial perfusion of the graft was restored. The patient was still in good condition after 4 months of follow-up. The success of this strategy indicates that the patency of the hepatic artery should be maintained and the splenic artery should be embolized to assure sufficient blood supply of the graft.

Preservation of the arterial vascularisation after hepatic artery pseudoaneurysm following orthotopic liver transplantation: long-term results.

Hepatic artery pseudoaneurysm (HAP) is a serious complication of orthotopic liver transplantation (OLT). The aim of this study was to determine risk factors for HAP and the best management of this complication. Between 1990 and 2005, 787 OLT were performed at our center. Patients who developed HAP were identified from our prospective database and risk factors of HAP were identified. Management of HAP was analyzed retrospectively. There were 16 OLT (2.5%) complicated by HAP [median delay =13 days; range: 4-100 days]. Presentation was massive bleeding with shock (n=13), pain (n=2), or transient gastrointestinal bleeding (n=1). Bacteriological culture of HAP wall or ascites fluid was positive in 13 (81%) patients. Bilio-enteric anastomosis and biliary leak were identified as risk factors for HAP (p=0.011 and 0.002, respectively), whereas indication for OLT, surgical technique (full-graft OLT versus other techniques), and re-LT were not. Mortality rate after HAP rupture was 53% (7/13), but no deaths occurred in the 3 patients treated before rupture. Treatment included: excision and immediate revascularization [n=7; early mortality =2 (28%), long-term graft survival =4 (57%)], hepatic artery ligation [n=5; early mortality =3 (80%);, long-term graft survival with good liver function =0], and endovascular treatment [n=2; early mortality =0, long-term survival with good liver function =2]. HAP post-OLT carries a high mortality rate when detected after rupture, but recognition before rupture usually allows a successful outcome. Reconstruction with bilio-enteric anastomosis and postoperative biliary leak increase the risk for HAP. In these settings, CT with contrast injection should be performed to screen for HAP when there is any suspicion. Graft revascularization should be attempted whenever possible.

Absence of peripheral blood chimerism in graft‐vs‐host disease following orthotopic liver transplantation: case report and review of the literature

Graft-vs-host disease (GVHD) is a rare and often fatal complication of orthotopic liver transplantation (OLT). The skin is frequently involved early in disease progression, but clinical and histopathological features may be nonspecific, presenting a diagnostic challenge. While the detection of peripheral blood chimerism has been proposed as a diagnostic criterion for post-OLT GVHD, it is not known whether peripheral blood chimerism is an absolute requirement for the diagnosis. We report a case of a 57-year-old man who developed post-OLT GVHD with cutaneous, enteric, and bone marrow involvement. We also review the epidemiology, pathogenesis, clinical presentation, histopathology, molecular diagnostic techniques, and treatment of GVHD following liver transplantation. In our patient, analysis of the peripheral blood by short-tandem repeat polymerase chain reaction did not detect circulating donor lymphocytes. Donor lymphocytes were detected in the buccal mucosa, however, confirming the diagnosis. A review of chimerism patterns in 63 previously published cases of post-OLT GVHD reveals that this is the first reported case in which chimerism was absent in the peripheral blood but present in another site. Peripheral blood chimerism may be absent in cases of post-OLT GVHD. A combination of clinical, histopathological, and molecular features is therefore required to make this challenging diagnosis.

Imaging Curriculum of Complications in Orthotopic Liver Transplantation

OPEN ACCESSJuly 5, 2013Imaging Curriculum of Complications in Orthotopic Liver Transplantation Puneet Bhargava, MD, Adeel Seyal, Mariam Moshiri, Chandana Lall, Sadaf Zaidi, MD, Lorenzo Mannelli, Andre Dick, Sandeep Vaidya, Orpheus Kolokythas, Manjiri Dighe Puneet Bhargava, MD University of Washington School of Medicine Google Scholar More articles by this author , Adeel Seyal Harrison Medical Center Google Scholar More articles by this author , Mariam Moshiri University of Washington Google Scholar More articles by this author , Chandana Lall University of California, Irvine Google Scholar More articles by this author , Sadaf Zaidi, MD University of Washington School of Medicine Google Scholar More articles by this author , Lorenzo Mannelli University of Washington School of Medicine Google Scholar More articles by this author , Andre Dick University of Washington School of Medicine Google Scholar More articles by this author , Sandeep Vaidya University of Washington School of Medicine Google Scholar More articles by this author , Orpheus Kolokythas University of Washington School of Medicine Google Scholar More articles by this author , Manjiri Dighe University of Washington School of Medicine Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.9465 SectionsAboutAbstract ToolsDownload Citations ShareFacebookTwitterEmail AbstractAbstract Introduction: Orthotopic liver transplantation is an established treatment for patients with end-stage liver disease or acute liver failure. The procedure is distinct from living related liver transplantation with regard to surgical technique, postoperative anatomy, and some complications. The aim of this imaging curriculum is to educate radiology, surgery, gastroenterology, hepatology, and internal medicine trainees regarding basic anatomy of the post-orthotopic transplant liver, its various complications, and the role of imaging in their diagnosis. Methods: This presentation provides an opportunity to learn imaging characteristics of complications of orthotopic liver transplantation in an interactive format. We have included relevant information and highlighted important teaching points in a series of PowerPoint presentations. This presentation is given to our incoming radiology residents to familiarize them with various aspects of imaging of orthotopic liver transplantation. Results: Another version of this presentation has been presented in the University of Washington Annual Radiology Review Course for the last 3 years with excellent feedback. Discussion: This resource has been designed to focus on imaging findings and includes a brief description of clinical information. Laboratory data and its details are not included as the focus of this resource is on understanding imaging findings. Adding more cases in quiz format at the end of the presentation will help reinforce learning. Educational Objectives By the end of this module, the learner will be able to: Understand basic surgical anatomy and various surgical techniques employed during orthotopic liver transplantation.Identify the normal imaging appearance of a liver transplant on various modalities.Identify complications associated with orthotopic liver transplantation and their basic management. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Instructor's Guide for OLT.doc Imaging of OLT Teaching file.pptx To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. Copyright & Permissions© 2013 Bhargava et al. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.KeywordsOrthotopic Liver TransplantationLiver TransplantationTeaching FileComplicationsImagingTransplantation Disclosures None to report. Funding/Support None to report. Loading ...

Diagnostic Value of Magnetic Resonance Cholangiopancreatography for Biliary Complications in Orthotopic Liver Transplantation: A Meta-analysis

Background and ObjectiveMagnetic resonance cholangiopancreatography (MRCP) is a noninvasive procedure to diagnose biliary complications. The aim of the present meta-analysis was to establish the overall diagnostic accuracy of MRCP to diagnose biliary complications post–orthotopic liver transplantation (OLT). MethodsA systematic review was performed by searching electronic bibliographic databases prior to May 2012. Sensitivity, specificity, and other measures of the accuracy of MRCP for diagnosis of post-OLT were summarized using a random-effects or a fixed-effects model. Receiver operating characteristic curves were used to summarize overall test performance. ResultsFourteen studies, which involved 892 subjects were eligible for the analysis. The summary estimates of sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under cure of MRCP for diagnosis of biliary complications were as follows: 0.95, 0.92, 10.23, 0.08, 206.59, and 0.979, respectively. The results for biliary strictures in four studies involving 177 subjects were 0.94, 0.95, 0.96, 0.09, 178.33, and 0.973 respectively. ConclusionsMRCP is a sensitive and specific technique to diagnose biliary complications.

Long-term clinical outcomes of biliary cast syndrome in liver transplant recipients

Biliary cast syndrome (BCS) is an uncommon complication of orthotopic liver transplantation (OLT), so the long-term treatment outcomes of BCS are not well characterized. The purpose of this study was to evaluate the long-term treatment outcomes and prognosis of BCS after OLT. The medical records of 1097 patients who underwent OLT from January 2000 to September 2009 were reviewed. Those patients who had BCS were evaluated with respect to the treatment method, overall survival and relapse rates, and relapse-free time. Twenty-three patients (2.1%) were diagnosed with BCS with a mean overall follow-up of 59.9 months. All the patients had benign biliary strictures and repeatedly underwent balloon dilatation by an endoscopic or percutaneous approach. Primary biliary cast removal was tried with the endoscopic method from 11 patients and with the percutaneous methods from 12 patients. Casts were completely removed by repetitive procedures in 22 patients, but BCS relapsed in 12 patients (55%). Persistent biliary strictures were significantly associated with the BCS relapse frequency (0.37 versus 0.05 times per year, P = 0.006). The 5-year overall survival rate for BCS patients after OLT was 87%. The risk factors associated with early relapse were female sex, hepatic artery stenosis, and acute cellular rejection. In a multivariate analysis, acute cellular rejection was the only significant risk factor for early relapse (hazard ratio = 11.1, 95% confidence interval = 1.9-63.2, P = 0.007). In conclusion, patients with BCS frequently relapse, and multiple interventions and the treatment of biliary strictures are needed. Acute cellular rejection after OLT is a significant risk factor for early relapse.

Clinicopathologic study on complications of orthotopic liver transplantation in 54 patients with chronic hepatitis B viral infection.

To study the complication incidence of 54 patients with chronic HBV infection following orthotopic liver transplantation (OLT) and risk factors associated with HBV recurrence and hepatocellular carcinoma (HCC) recurrence or metastasis post-OLT. The light-microscopic appearance of hepatic allograft biopsies in 54 patients with chronic HBV infection following OLT was examined. The related clinical data were analyzed. The incidence and occurrence time of post-OLT complications were studied. Furthermore, the relationship between hepatitis B virus recurrence and acute rejection and the relationship among HCC recurrence/metastasis, acute rejection, tumor diameter, and portal vein invasion were particularly studied. Frequent complications of patients with chronic HBV infection following OLT were acute rejection [38 (70.4%); occurrence time: 5-365 days], chronic rejection [1 (1.9%); occurrence time: 10.7months], bile duct complications [24 (44.4%);occurrence time: 7-940days], HBV recurrence [7 (13.0%); occurrence time: 1-540days], HCV infection [3 (5.6%); occurrence time: 60days, 60days, 33months], CMV infection [8 (14.8%); occurrence time: 67-90days], and HCC recurrence or metastasis [17 (31.5%); occurrence time: 2-41months]. At the end of 1year post-OLT, 95% of patients with post-hepatitis B cirrhosis were alive. At the end of 3years post-OLT, 85% of patients with post-hepatitis B cirrhosis were alive. However, at the end of 1year post-OLT, 67.6% of patients with post-hepatitis B HCC were alive. At the end of 3years post-OLT, 50% of patients with post-hepatitis B HCC were alive. The number of acute rejection episodes in patients with recurrent HBV infection and in those without recurrent HBV infection was 0.86±1.46 times/patient and 1.07±0.90 times/patient, respectively (p>0.05); the number of moderate acute rejection episodes (RAI score ≥4) in patients with recurrent HBV infection and in those without recurrent HBV infection was 0.29±0.49 times/patient and 0.50±0.63 times/patient (p>0.05). Incidence of patients with ≥3 episodes of acute rejection in patient with recurrent HBV infection and in those without recurrent HBV infection was 14.3 and 10.6% (p>0.05). Furthermore, the number of acute rejection episodes in patients with HCC recurrence or metastasis and in those without HCC recurrence or metastasis was 1.12±0.93 times/patient and 1.06±1.39 times/patient, respectively (p>0.05). The number of moderate acute rejection episodes (RAI score ≥4) in patients with HCC recurrence or metastasis and in those without HCC recurrence or metastasis was 0.65±0.79 times/patient and 0.65±1.06 times/patient, respectively (p>0.05). Incidence of patients with ≥3 episodes of acute rejection in patients with HCC recurrence or metastasis and in those without HCC recurrence or metastasis was 5.9 and 17.6%, respectively (p>0.05). The tumor diameter in patients with HCC recurrence or metastasis was 6.72±3.40 cm; however, that in patients without HCC recurrence or metastasis was 3.55±2.17 cm (p=0.0047). The incidence of portal vein invasion in patients with HCC recurrence or metastasis and in those without HCC recurrence or metastasis was 68.75 and 33.3%, respectively (p=0.006). There was no significant difference between HBV recurrence and acute rejection post-liver transplantation in patients with chronic HBV infection. There was no significant difference between HCC recurrence and acute rejection. The tumor diameter in patients with HCC recurrence or metastasis was significantly greater than that in patients with no HCC recurrence or metastasis. Portal vein invasion was significantly more frequent in patients with HCC recurrence or metastasis than in those with no HCC recurrence or metastasis.

Spontaneous spinal epidural hematoma and spinal cord infarction following orthotopic liver transplantation: Case report and review of the literature

Background:Spinal epidural hematomas are rare conditions. Although the exact cause remains unknown in up to 40% of cases, anticoagulation therapy, neoplasm, thrombolytic therapy, internal jugular vein thrombosis, and prolonged Valsalva maneuvers associated with pregnancy may be contributing factors. The source of bleeding appears to be the dorsal internal vertebral venous plexus (IVVP).Case Description:A 65-year-old female patient with hepatitis C-related cirrhosis underwent orthotopic liver transplantation (OLT). The patient developed SSEH due to congestion of the IVVP in the peri-transplant period. Concurrent spinal cord infarction occurred, likely secondary to hypoperfusion during a cardiac arrest.Conclusion:This case study should increase awareness of SSEH as a complication of OLT.

Renal replacement therapy before, during, and after orthotopic liver transplantation

Acute kidney injury (AKI) is a common complication of orthotopic liver transplantation (OLT) occurring both in the pre- and postoperative period. It significantly worsens prognosis. Performing renal replacement therapy (RRT) is difficult in these patients and may cause numerous problems. The patients usually remain in serious condition, are hemodynamically unstable, at risk of brain edema, and suffer from acidosis and electrolyte imbalance. They require multi-drug treatment, parenteral nutrition, and use of life support devices. Here, we present the advantages and disadvantages of selected RRT methods, as well as problems associated with anticoagulation. We also discuss the possible extrarenal indications for RRT in liver transplant patients and the preliminary data on intraoperative RRT.