Donor Liver Transplantation For Patients Research Articles

#2917 Desensitization techniques in ABO-incompatible renal transplantation: efficacy and analysis of complications

Abstract Background and Aims Living donor transplantation is the best optimal choice for the vast majority of patients with terminal renal insufficiency. However, it is limited by the AB0/ HLA incompatibility between donor and receptor. The resolution of this inconvenient relies on desensitization of isoagglutinins (anti-AB0 immunoglobulins depletion); thus transplantation could be performed safely. For desensitization there are two techniques: specific adsorption (S) and non-specific (NS) techniques, including centrifugal therapeutic plasma exchange (cTPE) and membrane-based therapeutic plasma exchange (mTPE). The aims are to evaluate the efficacy of apheresis techniques: specific versus non-specific, and identify their complications. Secondary objectives include analyzing the acute rejection rate (RR), graft survival, and complications of each technique. Method A retrospective cohort study was conducted on AB0-incompatible living donor transplantation patients at our center (Bellvitge's Hospital) from 2014 to 2022. All patients (except 1) received rituximab and induction treatment by Thymoglobulin or Basiliximab, followed by maintenance treatment (Steroids, Mycophenolate, and calcineurin inhibitors). During follow-up, protocol renal biopsies (RB) were taken at one month and between 3-6 months post-transplantation. Complications were defined as significant haematological alterations, bleeding, or major infections requiring hospitalization. According to the technique used, two cohorts were identified: specific (Glycosorb®/Vitrosorb® columns) and non-specific: mTPE (prismaflex TPE2000) and cTPE (Spectra/Optia®). Both were anticoagulated with heparin or citrate randomly. An expert nurse supervised the technique. To calculate the efficacy we considered the percentual reduction of isoagglutinins in the first session. T-student test was used to calculate the percentage of complication and compare the results. Results A total of 50 patients were selected with a mean age (MA) of 49.5 ± 11.8. Four of these did not require apheresis due to lower title isoagglutinins (<1/8). Each cohort included 23 patients: specific with MA 49.5 vs non-specific 48.4, with a mean isoagglutinin titles in specific of 61.65 vs non-specific 11.8 (p = 0.05). Isoagglutinin clearance were higher in specific techniques with 73% vs 59% non-specific (p < 0.03). Due to the dispersion in the number of sessions, results are expressed with the median (4 sessions in specific vs 3 non-specific). Total renal graft survival rate is 93.4%. At one month, it was diagnosed by biopsy an acute renal rejection rate of 16.7% in non-specific vs 18.2% specific (p > 0.05). Considering complications, they are higher with non-specific 41.7% vs specific 18% (p < 0.05). Regarding infectious issues, there are no differences in cytomegalovirus or polyomavirus infections, but there are differences in urinary infections observing in non-specific 79.2% vs specific 63% (p < 0.05). Conclusion Specific techniques are more effective in reducing isoagglutinins, show a lower rate of complications and post-transplant infections, providing greater benefit to the patient.

Effects of Antithymocyte Globulin, Basiliximab, and Induction-Free Treatment in Living Donor Kidney Transplant Recipients on Tacrolimus-Based Immunosuppression.

Induction treatment in renal transplant is associated with better graft survival. However, intensified immunosuppression is known to cause unwanted side effects such as infection and malignancy. Furthermore, the effects of the routine use of immunosuppressants in low-risk kidney transplant recipients are still not clear. In this study, we assessed the first-year safety and efficacy of induction treatment. We examined first living donor kidney transplant patients who were on tacrolimus based immunosuppression therapy. We formed 3 groups according to the induction status: antithymocyte globulin induction, basiliximab induction, and no induction. We collected outcome data on delayed graft function, graft loss, creatinine levels, estimated glomerular filtration rates, acute rejection episodes, hospitalization episodes, and infection episodes, including cytomegalovirus infection and bacterial infections. We examined a total of 126 patients (age 35 ± 12 years; 65% male). Of them, 25 received antithymocyte globulin, 52 received basiliximab, and 49 did notreceive any induction treatment. We did not observe any statistically significant difference among the 3 groups in terms of acute rejection episodes, delayed graft function, and first-year graft loss. The estimated glomerular filtration rates were similar among the groups. Overall bacterial infectious complications and cytomegalovirus infection showed similar prevalence among all groups. Hospitalization was less common in the induction-free group. In low-risk patients, induction-free regimens could be associated with a better safety profile without compromising graft survival. Therefore, induction treatment may be disregarded in first living donor transplant patients who receive tacrolimusbased triple immunosuppression treatment.

The First Successful Living Donor Liver Transplantation for Acute-on-Chronic Liver Failure Caused by Severe Acute Necrotizing Pancreatitis: A Case Report

Liver transplantation (LT) is the only life-saving option when acute-on-chronic liver failure (ACLF) does not improve with conservative therapy. Acute pancreatitis (AP) can cause chronic liver disease progression to ACLF. However, deceased donor LT for patients with AP has had mixed results, and no consensus has been established regarding the indication for LT. We report the first successful living donor LT (LDLT) for ACLF caused by severe AP. The 38-year-old patient with alcoholic liver disease was transferred to our institute with worsening refractory ascites. During the pretransplant workup, she developed severe acute necrotizing pancreatitis, resulting in grade 3 ACLF. The patient's clinical course was further complicated by high levels of donor-specific antibodies and immune thrombocytopenia. The AP gradually improved after intensive care combined with artificial liver support. The patient successfully underwent urgent LDLT with upfront splenectomy and desensitization therapy, including plasm exchange, high-dose intravenous immunoglobulin, and anti-thymocyte globulin. No infection or recurrence of AP was observed postoperatively. We conclude that LDLT is a feasible option for ACLF patients caused by severe AP if a deceased donor is not readily available.

The high-volume center experience in living donor liver transplantation for patients with secondary biliary cirrhosis due to hepatolithiasis

The high-volume center experience in living donor liver transplantation for patients with secondary biliary cirrhosis due to hepatolithiasis

Outcomes of living donor liver transplantation in patients with concurrent extrahepatic malignancy

Outcomes of living donor liver transplantation in patients with concurrent extrahepatic malignancy

Feasible living donor liver transplantation for patients on chronic hemodialysis: a multicenter study in East Asian countries.

End-stage liver and kidney disease is an indication for simultaneous liver and kidney transplantation. However, in countries where deceased donor transplantation is not well established, living donor liver transplantation (LDLT) is a realistic option for patients on hemodialysis (HD). We investigated the outcomes of LDLT for patients on HD. We conducted a retrospective multicenter survey of patients on chronic HD who underwent LDLT in East Asian countries. The characteristics of donors and recipients and the short and long-term outcomes were analyzed. Between 2001 and 2021, 45 patients on HD underwent LDLT and 11 of these patients also underwent kidney transplantation (KT). The overall survival rate at 5years of the 34 patients who underwent only LDLT was 44.5%. Multivariate analysis identified a low graft recipient weight ratio (< 1%) (p = 0.048) and long HD duration (≥ 10years) (p = 0.046) as independent predictors of poor overall survival. The major complication was posttransplant bleeding, which occurred in12 patients (35%). It is important to establish the indications for LDLT, taking into consideration graft size and HD duration in candidate patients on HD.

Living Donor Liver Transplantation in Patients with Preformed Donor-Specific Anti-Human Leukocyte Antigen Antibodies Using Preoperative Desensitization Therapy According to Intensity of Donor-Specific Antibodies: A Single-Center Study.

BACKGROUND In liver transplantation (LT), preoperative desensitization therapy is considered necessary in patients positive for donor-specific anti-human leukocyte antigen antibodies (DSAs). However, the relationship between DSA intensity and the necessary desensitization therapy is unclear. MATERIAL AND METHODS A total of 37 adult living donor (LD) LTs performed between January 2016 and March 2022 were examined. Mycophenolate mofetil (MMF) was administered preoperatively in DSA-positive cases with positive lymphocyte cross-matching who underwent LDLT. In those with strongly positive DSA (mean fluorescence intensity 10 000), rituximab was administered 2 weeks before LDLT in addition to MMF. Cross-reactive epitope group antigen (CREG)-alone-positive cases were also treated with preoperative MMF when lymphocyte cross-matching was positive. RESULTS Of the 37 patients, 9 were DSA-positive, 7 were CREG-alone-positive, and the others were double-negative. Of 9 DSA-positive cases, desensitization therapy was performed in 7, among which rituximab administration was performed in 3 strongly DSA-positive cases. Of 7 CREG-alone-positive cases, 2 were lymphocyte cross-match-positive and underwent desensitization therapy. The 1-year survival rate was 100% in both DSA- and CREG-alone-positive cases. The frequency of T-cell mediated rejection in DSA-positive, CREG-alone-positive, and double-negative cases was 22%, 43%, and 29%, respectively, with no significant difference. Antibody-mediated rejection occurred in only 1 patient, who was strongly DSA-positive and blood-group incompatible. There was also no significant difference among the 3 groups in terms of the frequency of biliary complications or 90-day mortality. CONCLUSIONS Satisfactory LDLT results were achieved in DSA- and CREG-alone-positive cases following desensitization therapy.

Healthcare utilization and outcomes of living donor liver transplantation for patients with APASL-defined acute-on-chronic liver failure.

Liver transplantation (LT) is associated with excellent survival in patients with acute-on-chronic liver failure (ACLF). There is a lack of data assessing the healthcare utilization and outcomes of patients with APASL-defined ACLF undergoing living donor liver transplantation (LDLT). Our aim was to assess pre-LT healthcare utilization and post-LT outcomes in such patients. Patients with ACLF who underwent LDLT at our center between 1st April 2019 and 1st October 2021 were included. Seventy-three ACLF patients willing to undergo LDLT were listed; eighteen patients died within 30days. Fifty-five patients underwent LDLT (age:38.05 ± 14.76years; alcohol:52.7%; males:81.8%). Most were in grade II ACLF (87.3%) at the time of LDLT (APASL ACLF Research Consortium [AARC] score: 9.05 ± 1; MELD NA: 28.15 ± 4.13). Survival rate was 72.73%; mean follow-up period of 925.21days; 58.2% (32/55) developed complications during the first year post-LT; 45% (25/55) and 12.7% (7/55) developed infections within and after 3months. Pre-LT, each patient required a median of 2 (1-4) admissions for 17 (4-45) days. Fifty-six percent (31/55) of patients underwent plasma exchange pre-LDLT. A median amount of Rs. 8,25,090 (INR 26,000-43,58,154) was spent to stabilize the patient (who were sicker and waited longer to undergo LDLT); though post-LT survival benefit was not observed. LDLT was associated with 73% survival and, thus, is a viable option in those with APASL-defined ACLF. There was a pre-LT high healthcare resource utilization of plasma exchange, with the intention of optimization, while survival benefit has not been demonstrated.

Analysis of Short-Term and Long-Term Outcomes of Living Donor Liver Transplantation for Patients with a High Model for End-Stage Liver Disease Score

The Model of End-Stage Liver Disease (MELD) scoring system can predict short-term survival among patients awaiting liver transplantation and is used to allocate organs prioritizing liver transplantation. Patients with high MELD scores have been reported to have worse early graft dysfunction and survival. However, recent studies have shown that patients with high MELD scores had satisfactory graft survival, although they showed more postoperative complications. In this study, we examined the effect of the MELD score on the short-term and long-term prognosis of living donor liver transplantation (LDLT). This study included 102 patients who underwent LDLT in our institution between 2005 and 2020. The patients were divided into 3 groups according to MELD score (low MELD group: ≤20, moderate MELD group: 21-30, and high MELD group: ≥31). Perioperative factors were compared among the 3 groups, and cumulative overall survival rates were calculated using the Kaplan-Meier method. The patients' characteristics were comparable, and the median age was 54 years. Hepatitis C virus cirrhosis was the most common primary disease (n=40), followed by hepatitis B virus (n=11). The low MELD group consisted of 68 patients (median score: 16, 10-20); the moderate MELD group, 24 patients (median score: 24, 21-30); and the high MELD group, 10 patients (median score: 35, 31-40). The mean operative time (1241 min versus 1278 min versus 1158 min, P=.19) and mean blood loss (7517 mL vs 11162 mL vs 8808 mL, P=.71) were not significantly different among the 3 groups. The vascular and biliary complication rates were similar. The periods of intensive care unit and hospital stay tended to be longer in the high MELD group, but the difference was insignificant. The 1-year postoperative survival rate (85.3 % vs 87.5 % vs 90.0 %, P=.90) and overall survival rate were also not significantly different among the 3 groups. Our study showed that LDLT patients with high MELD scores do not have a worse prognosis than those with low scores.

A Multicenter, Randomized, Open-Label Study to Compare the Efficacy and Safety of Tacrolimus and Corticosteroids in Combination With or Without Mycophenolate Mofetil in Liver Transplantation Recipients Infected With Hepatitis B Virus

Mycophenolate mofetil exhibits pharmacologic mechanisms different from calcineurin inhibitors. Therefore, the dose of calcineurin inhibitors can be reduced along with side effects for effective immunosuppression. We aimed to evaluate the efficacy and safety of tacrolimus and corticosteroid in combination with or without mycophenolate mofetil in living donor liver transplantation (LDLT) recipients infected with hepatitis B virus (HBV). A randomized, open-label, comparative, multicenter, phase IV study was conducted with 119 patients from January 2014 to September 2017. In the full analysis set population, 58 and 59 patients were included in the study group (triple-drug regimen: TacroBell+My-rept+corticosteroid) and the control group (dual-drug regimen: TacroBell+corticosteroid), respectively. In the per protocol set population, 49 and 42 patients were included in the study and control groups, respectively. In the full analysis set population, the incidence of biopsy-proven acute cellular rejection (rejection activity index score ≥4) was 3.4% in the study group; however, this finding was not observed in the control group (P = .468). Hepatitis B virus recurrence was observed in one patient in the control group. No cases of biopsy-proven acute cellular rejection and HBV recurrence were observed in the per protocol set population. The incidences of serious adverse events were 25.9% and 18.0% in the study and control groups, respectively; however, the difference between the groups was not statistically significant (P = .376). Although the study involved a small number of patients, the triple-drug regimen can be considered safe and effective for immunosuppression after living donor liver transplantation in patients infected with HBV.

Comparison of liver resection and living donor liver transplantation in patients with hepatocellular carcinoma within Milan criteria and well-preserved liver function.

Liver resection (LR) and liver transplantation (LT) are curative treatments for hepatocellular carcinoma (HCC). The main purpose of this study was to compare the survival of LR and LDLT in patients with HCC within the Milan criteria. The results of the LR (n=67) and LDLT (n=391) groups were compared for overall survival (OS) and disease-free survival (DFS). Twenty-six of the HCCs in the LRs met the Milan and Child A criteria. Also, 200 of the HCC patients in the LDLTs met the Milan criteria, of which 70 also met the Child A criteria. Early mortality was higher in the LDLT group (13.9% vs 1.47%; p=0.003). The 5-year OS was higher in the LDLTs than the LRs, but not statistically significant (84.6% vs 74.2%; p=0.287). However, 5-year DFS was better in the LDLT group (96.8% vs 64.3%; p<0.001). When the LRs (n=26) and the LDLTs (n=70) that met both Milan and Child A criteria were compared, 5-year OS was similar (81.4% vs 74.2%; p=0.512), but DFS was better in the LDLTs (98.6% vs 64.3%; p<0.001). LR can be justified as the first-line treatment for HCC patients who meet Milan and Child A criteria in terms of early mortality and OS.

Is it acceptable to perform duct to duct anastomosis during living donor liver transplantation in patients with hepatocellular carcinoma treated with external beam radiotherapy before?

Byeong-Gon Na, Dong-Hwan Jung, Gil-chun Park, Shin Hwang, Ki-Hun Kim, Chul-Soo Ahn, Deok-Bog Moon, Tae-Yong Ha, Young-In Yoon, Sung-Gyu Lee. Korean J Transplant 2022;36:307. https://doi.org/10.4285/ATW2022.F-4483

Feasible living donor liver transplantation for patients on chronic hemodialysis: a multicenter study in Eastern countries

Kenei Furukawa, Suk Kyun Hong, Keita Shimata, Takashi Ito, Takeo Toshima, Nobuhisa Akamatsu, Mureo Kasahara, Toru Ikegami, Kwang-Woong Lee. Korean J Transplant 2022;36:119. https://doi.org/10.4285/ATW2022.F-2393

Deceased donor liver transplantation in patients on direct oral anticoagulants at the time of transplant surgery: A case series.

-

Outcome of living donor liver transplantation in patients with preoperative portal vein thrombosis

Background and study aimsPortal vein thrombosis (PVT) is no longer an absolute contraindication for living donor liver transplantation (LDLT). This study aimed to assess the short-term outcomes of LDLT and compare the 1-year survival rates between patients with and without preoperative PVT. Patients and methodsThis combined prospective and retrospective cohort study was conducted on patients who underwent LDLT at Ain Shams Centre for Organ Transplantation (ASCOT) between 2008 and 2020. The study included 60 patients with PVT and 60 patients without PVT. The two groups were compared in terms of preoperative data, operative details, postoperative complications, and 1-year survival. ResultsMost patients with PVT were Child C (65%) and had higher model for end stage liver disease scores (16.23 ± 4.03) compared to the non-PVT group (13.9 ± 4.5). The PVT group showed longer cold ischemic time (CIT), hospital stay, and intensive care unit stay and significantly shorter 1-year survival rate (63.3%) compared to the non-PVT group (86.7%) (P = 0.003). Those with PVT grades I, II, and III had 1-year survival rates of 72.5%, 50%, and 40%, respectively. ConclusionPreoperative PVT reduces the 1-year survival after transplantation, with patients with higher PVT grades exhibiting lower 1-year survival. LDLT for PVT still remains challenging and requires further studies.

Outcomes of ABO-incompatible adult living donor liver transplantation for patients with hepatocellular carcinoma beyond the milan criteria

Boram LEE, Jai Young CHO*, Suk Kyun HONG, YoungRok CHOI, Hae Won LEE, Nam-Joon YI, Kwang-Woong LEE, Kyung-Suk SUH, Ho-Seong HAN. Ann Hepatobiliary Pancreat Surg 2022;26:S327. https://doi.org/10.14701/ahbps.2022S1.EP-46

Is it acceptable to perform duct to duct anastomosis during living donor liver transplantation in patients with hepatocellular carcinoma treated with radiotherapy before?

Is it acceptable to perform duct to duct anastomosis during living donor liver transplantation in patients with hepatocellular carcinoma treated with radiotherapy before?

Prognostic impact of serum soluble PD-1 and ADV score for living donor liver transplantation in patients with previously untreated hepatocellular carcinoma

Shin HWANG*, Deok-Bog MOON, Gi-Won SONG, Dong-Hwan JUNG, Kyung Jin LEE, Yun Kyu KIM, Hunji YANG, Da Eun AN, Sion LEE. Ann Hepatobiliary Pancreat Surg 2022;26:S298. https://doi.org/10.14701/ahbps.2022S1.EP-16

Outcomes of ABO-incompatible adult living donor liver transplantation for patients with hepatocellular carcinoma beyond the milan criteria

Boram LEE, Jai Young CHO*, Suk Kyun HONG, YoungRok CHOI, Hae Won LEE, Nam-Joon YI, Kwang-Woong LEE, Kyung-Suk SUH, Ho-Seong HAN. Ann Hepatobiliary Pancreat Surg 2022;26:S80. https://doi.org/10.14701/ahbps.2022S1.OP-3-6

Usefulness of Living Donor Liver Transplantation for Patients After Undergoing the Kasai Operation for Biliary Atresia

Living donor liver transplantation (LDLT) has been actively performed for patients with poor clearance of jaundice after the Kasai operation for biliary atresia (BA). The present study clarified the usefulness of LDLT for BA. Between 2000 and 2020, 24 patients (late group) underwent radical surgery for BA in our institute. The overall survival rate, native liver survival rate, and proportion of LDLT in the late group were retrospectively compared with those of 47 patients treated before 1999 (early group). P values <.05 was considered statistically significant. The overall survival rates at 5, 10, and 15 years were 57%, 54%, and 49%, respectively, in the early group and 100%, 100%, and 100% in the late group (P < .001). The native liver survival rates at 5, 10, and 15 years were 57%, 52%, and 39%, respectively, in the early group and 57%, 49%, and 42% (P=.993) in the late group. In the early group, LDLT was performed in 7 of 47 patients (15%), and the overall survival rate after LDLT was 71%. In the late group, LDLT was performed in 11 of 24 patients (46%), and the overall survival rate after LDLT was 100%. The long-term outcomes after the Kasai operation for BA have improved in recent years. There were no marked differences in long-term native liver survival before and after 2000. LDLT was actively introduced for patients with poor clearance of jaundice after the Kasai operation, and the survival rate significantly improved.