Deceased Donor Liver Transplantation Recipients Research Articles

Complications and Their Resolution in Recipients of Deceased and Living Donor Liver Transplants: Findings From the A2ALL Cohort Study

The purpose of this study was to explore long-term complications in recipients of deceased donor liver transplant (DDLT) and living donor liver transplant (LDLT) in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). We analyzed 471 DDLTs and 565 LDLTs from 1998 to 2010 that were followed up to 10 years for 36 categories of complications. Probabilities of complications and their resolutions were estimated using the Kaplan-Meier method, and predictors were tested in Cox proportional hazards models. Median follow-up for DDLT and LDLT was 4.19 and 4.80 years, respectively. DDLT recipients were more likely to have hepatocellular carcinoma and higher disease severity, including Model for End-Stage Liver Disease score. Complications occurring with higher probability in LDLT included biliary-related complications and hepatic artery thrombosis. In DDLT, ascites, intra-abdominal bleeding, cardiac complications and pulmonary edema were significantly more probable. Development of chronic kidney disease stage 4 or 5 was less likely in LDLT recipients (hazard ratio [HR] 0.41, p = 0.02). DDLT and LDLT had similar risk of grade 4 complications (HR 0.89, p = 0.60), adjusted for other risk factors. Once a complication occurred, the time to resolution did not differ between LDLT and DDLT. Future efforts should be directed toward reducing the occurrence of complications after liver transplantation.

The Risk of End-Stage Renal Disease Among Living Donor Liver Transplant Recipients in the United States

Since initiation of model for end-stage liver disease (MELD)-based allocation for liver transplantation, the risk of posttransplant end-stage renal disease (ESRD) has increased. Recent US data have demonstrated comparable, if not superior survival, among recipients of living donor liver transplants (LDLT) when compared to deceased donor liver transplant (DDLT) recipients. However, little is known about the incidence of ESRD post-LDLT. We analyzed linked Scientific Registry of Transplant Recipients (SRTR) and US Renal Data System (USRDS) data of first-time liver-alone transplant recipients from February 27, 2002 to March 1, 2011, and restricted the cohort to recipients with a laboratory MELD score ≤25 not on dialysis prior to transplantation, in order to evaluate the incidence of ESRD post-LDLT, and to compare the incidence among LDLT versus DDLT recipients. There were 28 707 DDLT and 1917 LDLT recipients included in the analyses. The 1-, 3- and 5-year unadjusted risk of ESRD was 1.7%, 2.9% and 3.4% in LDLT recipients, compared with 1.5%, 3.0% and 4.8% in DDLT recipients (p > 0.05), respectively. In multivariable competing risk Cox regression models, there was no association between receiving an LDLT and risk of ESRD (sub-hazard ratio: 0.99, 95% CI: 0.77-1.26, p = 0.92). In conclusion, the incidence of ESRD post-LDLT in the United States is low, and there are no significant differences among LDLT and DDLT recipients with MELD scores ≤25 at transplantation.

Significance of Measured Intraoperative Portal Vein Flows after Thrombendvenectomy in Deceased Donor Liver Transplant Recipients with Portal Vein Thrombosis

Significance of Measured Intraoperative Portal Vein Flows after Thrombendvenectomy in Deceased Donor Liver Transplant Recipients with Portal Vein Thrombosis

Predictors of Early Hospitalization After Deceased Donor Liver Transplantation.

Hospitalizations after solid organ transplantation may affect patient outcomes. Identification of the factors attributed to them may decrease hospitalization rates, reduce overall cost, and improve post-transplant outcomes. We examined the risk factors for early hospitalization within 30 and 90 days after liver transplantation (LT). Data on all deceased donor LT recipients (age ≥18 years) transplanted between 2/28/2002-2/27/2007 and discharged alive from the index hospitalization within 30 days of LT were collected (N = 267). Patients were followed up until December 31, 2013. Logistic regression was used to identify the predictors of 30-day hospitalization, and linear regression was used to identify the factors associated with number of days hospitalized during 30- and 90-day hospitalization after LT. Renal risk index (RRI), a recently developed and validated risk score that accurately predicts the post-LT ESRD based upon recipient factors at LT, was computed using RRI calculator ( http://rri.med.umich.edu ). One-third and more than half of the patients had at least one 30- and 90-day hospitalization, respectively. RRI decile (OR 1.12, P = 0.02) and serum sodium at LT (OR 0.90, P < 0.001) were independently associated with 30-day hospitalization after adjusting for MELD score. Serum creatinine at LT (β = 4.34, P = 0.001) and pre-LT admission days (β = 0.15, P = 0.027) affected the number of days hospitalized for 90-day hospitalization. RRI was also an independent predictor of post-LT mortality. Early hospitalizations within 30 and 90 days after deceased donor LT are common. While all post-LT hospitalization cannot be prevented, efforts should be directed toward risk-based post-discharge care, and coordination of effective transitional care through ambulatory clinics. Implementation of such processes may attenuate early post-LT hospitalization and resource utilization and improve quality.

Operating room to intensive care unit handoffs and the risks of patient harm

The goal of this study was to assess systems and processes involved in the operating room (OR) to intensive care unit (ICU) handoff in an attempt to understand the criticality of specific steps of the handoff. We performed a failure modes, effects, and criticality analysis (FMECA) of the OR to ICU handoff of deceased donor liver transplant recipients using in-person observations and descriptions of the handoff process from a multidisciplinary group of clinicians. For each step in the process, failures were identified along with frequency of occurrence, causes, potential effects and safeguards. A Risk Priority Number (RPN) was calculated for each failure (frequency×potential effect×safeguard; range 1-least risk to 1,000-most risk). Using FMECA, we identified 37 individual steps in the OR to ICU handoff process. In total, 81 process failures were identified, 22 of which were determined to be critical and 36 of which relied on weak safeguards such as informal human verification. Process failures with the greatest risk of harm were lack of preliminary OR to ICU communication (RPN 504), team member absence during handoff communication (RPN 480), and transport equipment malfunction (Risk Priority Number 448). Based on the analysis, recommendations were made to reduce potential for patient harm during OR to ICU handoffs. These included automated transfer of OR data to ICU clinicians, enhanced ICU team member notification processes and revision of the postoperative order sets. The FMECA revealed steps in the OR to ICU handoff that are high risk for patient harm and are currently being targeted for process improvement.

A meta-analysis of complications following deceased donor liver transplant

BackgroundLiver transplantation is a complex surgery associated with high rates of postoperative complications. While national outcomes data are available, national rates of most complications are unknown. Data SourcesA systematic review of the literature reporting rates of postoperative complications between 2002 and 2012 was performed. A cohort of 29,227 deceased donor liver transplant recipients from 74 studies was used to calculate pooled incidences for 17 major postoperative complications. ConclusionsThis is the first comprehensive review of postoperative complications after liver transplantation and can serve as a guide for transplant and nontransplant clinicians. Efforts to collect national data on complications, such as through the National Surgical Quality Improvement Program, would improve the ability to provide patients with informed consent, serve as a tool for individual center performance monitoring, and provide a central source against which to measure interventions aimed at improving patient care.

Plenary Sessions

Purpose: To study long-term complications in recipients of deceased donor liver transplant (DDLT) and living donor liver transplant (LDLT) in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). Methods: We analyzed 471 DDLT and 565 LDLT from 1998 to 2010 followed up to 10 years for 39 categories of complications graded by Clavien-Dindo classification. Kaplan-Meier was used to estimate probability of complication and resolution over time, and predictors of complications were tested in Cox models. Results: Recipients of LDLT were more likely to be white, have cholestatic liver disease. DDLT recipients were more likely to have HCC, be in the ICU, on a ventilator, or have ascites. 85% and 47% of LDLT and DDLT recipients had a physiologic MELD less than 21 at the time of the transplant. Median follow-up for DDLT and LDLT was 3.12 and 3.52 years, respectively. Complications more probable in LDLT included bile leak, biliary stricture, HAT and bacteremia. In DDLT, ascites, intra-abdominal bleeding, cardiac complications and recurrent cirrhosis were more probable.Figure: No Caption available.At least one complication occurred in 70% and 73% of DDLT and LDLT, respectively. A higher probability of grade 3 or 4 complications was observed in LDLT recipients (28 % vs. 20% at 8 years, p=0.03). We found that risk factors for Grade 4 complications were DCD, dialysis at transplant, ascites, and duration of operation, but no significant difference between DDLT and LDLT (HR=0.89, p=0.60). Development of chronic kidney disease was less likely in LDLT recipients (HR 0.41, p=0.02). 95% of complications resolved in 5 years, with 86% of complications resolving in 12 months and no statistical difference between DDLT and LDLT. Biliary strictures, hernia, vascular and psychological complications had the lowest probability of resolution within 12 months. Conclusions: Biliary and vascular complications remain a challenge in LDLT while renal impairment, cardiac complications and recurrent cirrhosis are more probable in DDLT.

Post-Transplant Complications in Recipients of Deceased and Living Donor Liver Transplant.

Purpose: To study long-term complications in recipients of deceased donor liver transplant (DDLT) and living donor liver transplant (LDLT) in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). Methods: We analyzed 471 DDLT and 565 LDLT from 1998 to 2010 followed up to 10 years for 39 categories of complications graded by Clavien-Dindo classification. Kaplan-Meier was used to estimate probability of complication and resolution over time, and predictors of complications were tested in Cox models. Results: Recipients of LDLT were more likely to be white, have cholestatic liver disease. DDLT recipients were more likely to have HCC, be in the ICU, on a ventilator, or have ascites. 85% and 47% of LDLT and DDLT recipients had a physiologic MELD less than 21 at the time of the transplant. Median follow-up for DDLT and LDLT was 3.12 and 3.52 years, respectively. Complications more probable in LDLT included bile leak, biliary stricture, HAT and bacteremia. In DDLT, ascites, intra-abdominal bleeding, cardiac complications and recurrent cirrhosis were more probable.Figure: No Caption available.At least one complication occurred in 70% and 73% of DDLT and LDLT, respectively. A higher probability of grade 3 or 4 complications was observed in LDLT recipients (28 % vs. 20% at 8 years, p=0.03). We found that risk factors for Grade 4 complications were DCD, dialysis at transplant, ascites, and duration of operation, but no significant difference between DDLT and LDLT (HR=0.89, p=0.60). Development of chronic kidney disease was less likely in LDLT recipients (HR 0.41, p=0.02). 95% of complications resolved in 5 years, with 86% of complications resolving in 12 months and no statistical difference between DDLT and LDLT. Biliary strictures, hernia, vascular and psychological complications had the lowest probability of resolution within 12 months. Conclusions: Biliary and vascular complications remain a challenge in LDLT while renal impairment, cardiac complications and recurrent cirrhosis are more probable in DDLT.

Clinical Predictors of Recurrent Non-Alcoholic Steatohepatitis Following Liver Transplantation for Non-Alcoholic Fatty Liver Disease.

Non-alcoholic fatty liver disease (NAFLD) is expected to become the leading US indication for liver transplant (LT) in the near future. NAFLD after LT has been described in case series, heterogenous populations, and single center experiences. No study to date has described histologic recurrent non-alcoholic fatty liver disease (rNAFLD) and non-alcoholic steatohepatitis (rNASH) in LT patients undergoing annual per protocol liver biopsies. The aim of this study was to determine rNAFLD and rNASH rates and their predictive risk factors. Methods: Cohort study of deceased donor LT recipients at a single center from 4/2005-6/2012. Patients with a diagnosis of NAFLD and cryptogenic cirrhosis suspected to be NAFLD were included. Patients underwent per protocol annual liver biopsies up to 5 years from LT. Donor and recipient characteristics were explored as possible risk factors for rNAFLD and rNASH. rNASH was defined as the presence of NASH using the NASH-CRN Histologic Scoring System. General estimating equation with binomial distribution was used to analyze the repeated liver biopsies. Results: 76 patients with cirrhosis due to NAFLD underwent LT. 63 had ≥1 planned liver biopsy. 88.9% had documented NAFLD pre-LT. 11.1% were cryptogenic but clinical suspicion of NAFLD was documented. There were 173 annual protocol biopsies in this analysis: 105 biopsies from 42 patients showed rNAFLD, 17 biopsies from 11 patients showed rNASH. The cumulative rate of rNAFLD and rNASH was 66.6% and 17.5%, respectively. In multivariable analysis, risk factors for rNASH were donor BMI (p=0.0001), recipient pre-LT coronary artery disease (p=0.01), and number of years after LT (p<0.0001). Donor characteristics not predictive of rNASH include ischemic time and cause of death. Recipient characteristics not predictive of rNASH include gender, age, race, weight, BMI, immunosuppression, allograft rejection, diabetes, hepatocellular carcinoma, combined liver kidney transplant, hypertension, cholesterol, triglycerides, or HgbA1C%. Conclusion: Our study confirms high rates of rNAFLD and rNASH following LT and establishes possible risk factors for recurrence. This data supports the development of larger trials to better understand the impact of rNASH on long term LT outcomes and to explore treatments/interventions to prevent rNASH.

Chronic Kidney Disease Stage Progression Comparing Living Donor and Deceased Donor Liver Transplant Recipients.

Background It is unknown how the progression of chronic kidney disease (CKD) compares in recipients of living donor (LD) vs deceased donor (DD) liver transplants. We hypothesize that access to living donation expedites transplant, eliminating the waiting period that deceased donors incur. Consequently, CKD stage progression will be reduced. Materials and Methods We performed a retrospective review of 958 adult LD (n=218) and DD (n=740), single-organ primary liver transplants from Jan 2003 and Dec 2012 among two institutions and analyzed CKD progression. Patients beyond Milan criteria and neuroendocrine tumors were excluded. Immunosupression and anti-viral therapy was consistent among all groups. The primary end point was the incidence of CKD progression of at least one stage from evaluation to transplant and at least two stage CKD progression at 1, 3 and 5 years post-transplant. Results Demographics were comparable between LD and DD with the exception of MELD scores (16 vs 23) and GFR at time of evaluation (109 vs 72 mg/dl, p<0.01). The time from evaluation to transplant was significantly lower in LD vs DD (65 vs 398 days, p<0.01). Kaplan-Meier estimates of 5 year graft and patient survival were similar in the LD (80%, 90%) and DD (75%, 81%) (p=0.72 and 0.13, respectively). CKD progression of at least one stage from the time between evaluation to transplant was lower in the LD when compared to DD group (12% vs 34%, p=<0.01). Although, the incidence of at least one stage CKD progression after transplantion was higher in LD when compared to DD transplant (1yr: 57% vs 28%; 3yr: 61% vs 31%; and 5yr: 60% vs 31%), the progression from the time of evaluation to CKD stage three or greater after transplant remained overall lower in LD vs DD (1yr: 25%* vs 31%; 3yr: 20% vs 34%; and 5yr: 15% vs 34%). Conclusions Living donor liver transplantation provides excellent graft and patient survival, reducing significantly the overall incidence clinically significant CKD stage progression when compared to deceased donors. This observation likely reflects earlier access to transplantation in living donor liver transplant recipients rather than quality of the organs at transplantation between LD vs DD.

System-Level Risks of Postoperative Pneumonia in Deceased Donor Liver Transplant Recipients.

Background: Pneumonia (PNA) is one of the most common postoperative infections occurring in deceased donor liver transplant (DDLT) recipients, and significantly impacts cost of care and patient outcomes. In addition to pathophysiologic factors, system level factors can contribute to the development of post-operative PNA. We applied Fault Tree Analysis, a system engineering method of risk assessment, to determine system-level factors that contribute to the development of PNA after DDLT. Methods: A fault tree was constructed using a systematic literature review and expert clinician interviews. Results: In total, 54 potential system failures leading to bacterial PNA were identified.Figure: No Caption available.Only 6 of the 54 potential failures have been investigated in the literature: prolonged intubation, postoperative encephalopathy, pulmonary edema, over-resuscitation, intraoperative transfusion and duration of the transplant procedure. The fault tree revealed two key findings: 1) limited safeguards in the provision of care, implying failures easily result in a postoperative PNA 2) lack of literature investigating the risk of most potential failures leading to PNA. Conclusions: We identified a lack of redundancy in the system and a discrepancy between the processes of care and the focus of the current literature. System failures are an understudied source of PNA, but contrary to pathophysiology are often actionable.

A Multi-Center Observatioinal Study of 30 Day Complications (Cx) after Deceased Donor Liver Transplantation (DDLT) in the Model for End Stage Liver Disease Score Era.

Introduction: Few large studies exist characterizing the number and severity of post DDLT Cx. A multi-center study was conducted to identify and classify the 30 day post DDLT Cx according to the Clavien-Dindo system and to identify risk factors for 30 day Cx and mortality. Methods: 3 LT programs (3 different regions) contributed data for a total of 450 LT recipients from 1/1/05 - 12/31/09. Donor, intraoperative and recipient data were collected including demographics, surgical details, disease etiology, ischemia times, organ type, recipienst status and medical history and all 30 day post DDLT Cx were captured and graded. Primary outcomes: number/severity of Cx, proportion with Cx Grades 3-5 and death within 30 days. Secondary outcomes: length of stay and graft outcome. Effects of risk factors on outcomes was calculated in both linear and logistic regression models using Cx as both continuous and dichotomous outcome variables and Cox proportionate hazard models. Results: At least one Cx occurred in 79.3 % of recipients with a mean of 4.1 per patient. Grades 3-5 Cx occurred in 62.9 % of recipients. Most frequent Cx grades were IIIA (18%) and IVA (30.9%). Infection was the most common Cx (40.4%) followed by pulmonary Cx (25.1%). Univariate analysis revealed significant risk factors for Grades 3-5 complication: MELD, hospitalized status, cold ischemia time, RBC transfusion at LT, and pre-LT dialysis. Table 1 reveals significant risk factors identified in multivariate analyses of Cx/patient, Grades 3-5 Cx and death.Table 1: No Caption available.Conclusions: Cx occur in the majority of DDLT recipients in the first post operative month. Pre-LT renal insufficiency, pre-LT ICU care and red cell transfusions during LT are strong predictors of Cx. Cx also have an incremental adverse association with LOS, graft and patient survival.

Liver Transplantation for Biliary Atresia in Japan - Analysis of the Registry Data of the Japanese Liver Transplantation Society (JLTS).

Background: Since the establishment of Kasai procedure, liver transplantation for biliary atresia (BA) has been the second line treatment in Japan. Liver transplant (LTx) in Japan started as living donor liver transplantation (LDLT) in 1989, and the deceased donor liver transplantation (DDLT) is still quite limited. LTx for BA in Japan has such a special background, and the national data specified to the LTx for BA has not been reported yet. Patients and methods: We analyzed data for all cases of biliary atresia transplanted in Japan and enrolled in the registry of JLTS until December 2011. During the study period, 1735 LDLTs and 18 LTx from heart-beating donors were performed for BA in Japan. The patients were categorized into 6 groups according to the age at the transplant; 0-5 m, 6-11m, 1-4y, 5-9y, 10-17y, and 18y and older, for analysis of post-transplant survival. Results: The most common timing of the transplant was 1-4y (n=539, 30.7%), followed by 6-11months (n=504, 29.0%). Adult (18y-) were 146 cases (9.9%), with the oldest 46 years. In 18 DDLT recipients, only 3 were less than 18 years. Overall cumulative patient survival of the primary transplants (n=1644) was 90.4%, 88.5%, 85.6%, and 83.4%, at 1,5,10, and 15 years after the transplant, respectively. The transplants done in patients 10 years and older was poor than younger patients. Most of the living donors were one of the parents, and there was no influence of the mother as the donor on the graft survival. Discussion: Most of the LTx for BA should be done after previous laparotomy, but the survival rate was satisfactory in the current result. The reasons for the poor result in older age group should be elucidated. Higher incidence of pulmonary complications, small-for-size problems in LDLT, or long-lasting intractable infections, will be those. Maternal microchimerism is proposed as the etiologic factor for BA, but mother as the donor did not influence the result of LDLT for BA. Conclusion: Current result of LTx for BA in Japan is satisfactory in the unique background, in contrast to western countries. The reason of the relatively poor outcome of older patients should be clarified to improve the result more.

Comparison of outcomes in ideal donor and extended criteria donor in deceased donor liver transplant: A prospective study

IntroductionThe number of patients who could benefit from liver transplantation markedly exceeds the number of available donors. This increasing gap has fuelled efforts to maximize existing donor pool and identify new avenues. Aims and objectivesTo compare the outcome in deceased donor liver transplant (DDLT) based on extended donor selection criteria. Materials and methodsDonor and recipients' data were analyzed following DDLT from Mar 2007 to Feb 2013. Donors were grouped into either ideal donor (ID) or extended criteria donor (ECD) based on donor and graft related characteristics. Primary nonfunction (PNF) and patient survival were the primary endpoints while early graft dysfunction (EGD) and incidence of major postoperative complications were the secondary endpoints of the study. ResultsWe had a total of 6 mortalities (13%) at the end of 1 year. The Kaplan Meier survival analysis at 7 days, 3, 6 and 12 months were not statistically different (p > 0.05). PNF occurred in three (6.5%) patients and was not significantly different nor influenced by cumulative number of risk factors in the subgroup analysis (p < 0.3). However, the incidence of EGD was significantly influenced by the cumulative number of risk factors (p < 0.005). A total of 12 (26.1%) patients were graded with 3 or more complications according to the 'Clavien Dindo Grade' for major post operative complications, although it did not reach a statistical significance in the various subgroups. Univariate analysis of the donor risk factors showed that none of these factors were predictive for PNF and mortality in deceased donor liver transplant recipients. ConclusionAlthough the incidence of early graft dysfunction is statistically more with increase in number of donor risk factors, the overall survival and outcome in extended criteria liver donors are similar to that of an ideal donor. With the supply demand gap widening, extended criteria for selection of deceased donors will definitely expand the donor pool without adversely affecting the outcome of liver transplantation.

Readmission after living donor liver transplantation: predictors, causes, and outcomes.

Complications following liver transplantation requiring readmission may be serious and potentially life threatening. Most reports on readmission have been about after deceased donor liver transplantation (DDLT). We hypothesized that readmission after living donor liver transplantation (LDLT) is due to different reasons and analyzed our experience. We retrospectively analyzed the records of 172 consecutive patients who underwent liver transplantation at our institute between January 2010 and June 2012. The primary outcome measure was readmission. We classified readmission into early (<3months after discharge) and late (>3months). The study population was 140 after excluding pediatric patients (12), DDLT recipients (2), and those who died during the index admission (18). Their median age was 42years, and there were 117 males and 23 females. Thirty-eight patients were readmitted (56 episodes) after LDLT. There were 35 early and 21 late readmission episodes. The most common cause for early readmissions was infection (46%) and that for late readmissions was biliary stricture (62%). On univariate analysis, pretransplant portal vein thrombosis, more than one bile duct in the liver graft, revised arterial anastomosis or two arteries in the graft, and higher serum alkaline phosphatase levels at discharge were significantly associated with readmission. Readmission was also significantly associated with a higher overall mortality than non-readmission in which there was no mortality. Pretransplant portal vein thrombosis, more than one bile duct in the liver graft, revision of the arterial anastomosis or two arteries in the graft, and higher serum alkaline phosphatase levels at discharge were significantly associated with readmission. Infective and biliary complications were the commonest causes of early and late readmission after LDLT.

The Stratifying Value of Hangzhou Criteria in Liver Transplantation for Hepatocellular Carcinoma

Background/AimsThe selection criteria for patients with hepatocellular carcinoma (HCC) as candidates for deceased donor liver transplantation (DDLT) are well studied. In this era of limited deceased donor organs, the value of living donor liver transplantation (LDLT) for HCC remains controversial. The aim of the present study was to verify the stratification value of the Hangzhou criteria for LDLT.MethodsThe data of 47 LDLT recipients and 94 matched DDLT recipients at our center were evaluated. Overall survival and tumor-free survival were calculated. Prognostic factors influencing post-liver transplantation (LT) survival were identified. The stratification values of the Hangzhou criteria and Milan criteria were compared.ResultsLDLT recipients spent much less time on the waiting list. The post-LT survival of recipients fulfilling the Milan criteria and recipients fulfilling the Hangzhou criteria were comparable (P>0.05). The overall and tumor-free survival did not differ statistically between the two groups. In both groups, more recipients not meeting the Milan criteria but with a satisfactory outcome were identified by the Hangzhou criteria. Among recipients who did not meet the Hangzhou criteria, tumor-free survival was better for the LDLT recipients than the DDLT recipients (P = 0.024).ConclusionsThe Hangzhou criteria are reliable for stratifying HCC patients in terms of prognosis. HCC patients fulfilling the Hangzhou criteria gain satisfactory survival from LT. Outcomes after LDLT are better than those after DDLT for HCC patients who do not meet the Hangzhou criteria.

Operative outcomes of adult living donor liver transplantation and deceased donor liver transplantation: A systematic review and meta-analysis

Living donor liver transplantation (LDLT) has emerged as an alternative to deceased donor liver transplantation (DDLT) because of the increasing number of patients waiting for liver transplantation (LT). However, whether it can achieve operative outcomes similar to those achieved with DDLT for adult patients remains controversial. We conducted this meta-analysis to compare the operative outcomes of LDLT and DDLT recipients. A literature search was performed to identify clinical controlled studies comparing LDLT and DDLT that were published before October 2013. Four perioperative outcomes [duration of the recipient operation (DRO), red blood cell (RBC) transfusion requirement, length of the hospital stay, and cold ischemia time (CIT)] and 5 postoperative complication outcomes (biliary complications, vascular complications, intra-abdominal bleeding, perioperative death, and retransplantation) were the main outcomes assessed. Nineteen studies with a total of 5450 patients were included in the meta-analysis. In comparison with DDLT, LDLT was associated with a significantly longer DRO and a shorter CIT. We found that biliary complications [odds ratio (OR) = 3.08, 95% confidence interval (CI) = 1.97-4.81, P < 0.001], vascular complications (OR = 2.16, 95% CI = 1.32-3.54, P = 0.002), and retransplantation (OR = 1.76, 95% CI = 1.09-2.83, P = 0.02) occurred more frequently for LDLT recipients, and the subgroup analysis indicated that the biliary complication rate decreased dramatically with greater LDLT experience. No significant difference was observed in RBC transfusion requirements, the lengths of hospital stays, intra-abdominal bleeding rates, or perioperative mortality between LDLT and DDLT recipients. In conclusion, LDLT is associated with a higher rate of surgical complications after transplantation. A reduction of postoperative complication rates can be achieved as centers gain greater experience with LDLT. However, LDLT is still an excellent alternative to DDLT because it facilitates access to LT.

Hepatitis C disease severity in living versus deceased donor liver transplant recipients: An extended observation study

Donor factors influence hepatitis C virus (HCV) disease severity in liver transplant (LT) recipients. Living donors, because they are typically young and have short cold ischemic times, may be advantageous for HCV-infected patients. Among HCV-infected patients in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) surviving >90 days and followed for a median 4.7 years, advanced fibrosis (Ishak stage ≥3) and graft loss were determined. The 5-year cumulative risk of advanced fibrosis was 44% and 37% in living donor LT (LDLT) and deceased donor LT (DDLT) patients (P = 0.16), respectively. Aspartate aminotransferase (AST) activity at LT (hazard ratio [HR] = 1.38 for doubling of AST, P = 0.005) and biliary strictures (HR = 2.68, P = 0.0001) were associated with advanced fibrosis, but LDLT was not (HR = 1.11, 95% confidence interval [CI] 0.73-1.69, P = 0.63). The 5-year unadjusted patient and graft survival probabilities were 79% and 78% in LDLT, and 77% and 75% in DDLT (P = 0.43 and 0.32), with 27% and 20% of LDLT and DDLT graft losses due to HCV (P = 0.45). Biliary strictures (HR = 2.25, P = 0.0006), creatinine at LT (HR = 1.74 for doubling of creatinine, P = 0.0004), and AST at LT (HR = 1.36 for doubling of AST, P = 0.004) were associated with graft loss, but LDLT was not (HR = 0.76, 95% CI: 0.49-1.18, P = 0.23). Donor type does not affect the probability of advanced fibrosis or patient and graft survival in HCV-infected recipients. Thus, while LDLT offers the advantage of shorter wait times, there is no apparent benefit for HCV disease progression. Biliary strictures have a negative effect on HCV fibrosis severity and graft survival, and a high AST at LT may be an important predictor of fibrosis risk post-LT.

Outcomes of Liver Transplantation for Porto-Pulmonary Hypertension in Model for End-Stage Liver Disease Era

Porto-pulmonary hypertension (POPH), once considered an absolute contraindication for liver transplantation (LT), has become a more accepted indication because of the evolution of treatment with prostacyclin analogues, phosphodiesterase inhibitors and endothelin receptor antagonists. An exception model for end stage liver disease (MELD) score of 22 is assigned to candidates with documentation of effective treatment. We examined the post-transplant outcomes of patients who received LT for POPH with exception. Scientific Registry of Transplant Recipients data on 34,318 adult (≥ 18 years) deceased donor LT recipients transplanted between March 1, 2002 and August 31, 2010 were reviewed. The diagnosis of POPH was ascertained from MELD exception forms. Patients were followed from the time of transplant until the earlier occurrence of death or end of the follow-up period. Cox regression was used to evaluate the predictors of post-LT mortality and graft failure. During the study period, 34,318 patients received deceased donor LT. Seventy eight out of 34,318 patients were transplanted for POPH with MELD exception. The 1-year adjusted risks of patient death and graft failure for patients transplanted under exception rules for POPH were significantly higher than with POPH adult recipients who did not receive exception points (death:hazard ratio [HR] = 2.25, p = 0.005 and graft failure HR = 1.96, p = 0.012). This study of national data suggests that treated POPH continues to be associated with inferior early post-transplant outcomes.

A New Technique for Complete Portal Vein and Superior Mesenteric Vein Thrombosis in a Liver Transplant Recipient

We describe a deceased-donor liver transplant recipient with grade 3 complete portal vein and superior mesenteric vein thromboses, which was successfully managed with an extensive thrombectomy through the venotomy site of superior mesenteric vein. In this case report, we suggest our method as an option for grade 3 portal vein thromboses, and discuss other options available for recipients with portal vein thromboses.