Emergency Living Donor Liver Transplantation Research Articles

Auxiliary Partial Orthotopic Liver Transplantation Is a Safe and Effective Option for Yellow Phosphorus Toxin-induced Acute Liver Failure.

Ingestion of yellow phosphorus-containing rodenticides (YPR) or firecrackers is an important cause of acute liver failure (ALF) in young adults and children, particularly in South and South-East Asia and South America. Emergency liver transplantation is indicated in cases refractory to intensive supportive therapy, including low-volume plasma exchange. There are no published reports on the feasibility of auxiliary partial orthotopic liver transplantation (APOLT) for YPR-induced ALF. Clinical details of patients undergoing APOLT for YPR-induced ALF in 1 unit are reported. Details of postoperative follow-up, native remnant regeneration, and immunosuppression withdrawal are also reported. Between January 2021 and December 2023, 3 patients (4 y, 1.5 y, and 26 y) underwent emergency living donor liver transplantation for YPR-induced ALF. All patients were refractory to supportive therapies, including therapeutic plasma exchange, and demonstrated progression of liver injury in the form of severe encephalopathy needing intubation, ventilation, and organ support. APOLT was considered because of their young age and minimal intraoperative inotropic requirement. All explants showed confluent parenchymal necrosis with microvesicular and macrovesicular steatosis. Patients were initially maintained on standard immunosuppression. Good remnant regeneration was noted on follow-up imaging in all cases, enabling gradual withdrawal of immunosuppression. Currently, 1 child has been off immunosuppression for 15 mo and 2 others are on reduced doses of immunosuppression. All patients demonstrated good liver function. APOLT procedure can be an appropriate transplant option in YPR-related ALF for children and young adults without severe hemodynamic instability.

Emergency living donor liver transplantation under extracorporeal membrane oxygenation in an infant with biliary atresia-polysplenia syndrome

Emergency living donor liver transplantation under extracorporeal membrane oxygenation in an infant with biliary atresia-polysplenia syndrome

Live donor liver transplantation for acute liver failure: A single center experience.

Acute liver failure (ALF) is an indication for emergency liver transplantation (LT). Although centers performing only deceased donor liver transplants (DDLT) have shown improved outcomes in this situation, they still have relatively long waiting lists. An alternative would be living donor liver transplantation (LDLT), which has shown equivalent outcomes in the elective situation but there is limited evidence of its results in ALF. The purpose of this study was to assess the outcomes in patients with ALF undergoing emergency LDLT in our center in Delhi, India. We prospectively collected data on 479 patients who underwent LT in our hospital between January 2009 and December 2015 to evaluate the outcomes of those with ALF. The ALF patients were listed for transplantation after they met the Kings' College criteria and rapid evaluation was done following a protocol consisting of three phases. Patients with grade III/IV encephalopathy were put on mechanical ventilation. Data regarding their postoperative course, morbidity, and mortality were analyzed. Thirty-six (7.5%) out of the 479 patients underwent emergency LT for ALF. Their mean age was 27.5years (range 4-59years) and the male to female ratio of 2:3. Preoperative intubation was required in 15 of 25 patients who had encephalopathy. Wilson's disease was the most common cause of ALF in children while in adults, it was acute viral hepatitis. The time interval between listing and transplantation was a mean of 36 ± 12.4h. The mean graft to recipient weight ratio (GRWR) was 1.06 ± 0.3. The recipients were extubated postoperatively after a mean period of 2.6days and their mean ICU stay was 6.3days. Postoperative infection was the most common complication and required upgradation of antifungal and antibiotic treatments. Neurological complications occurred in five patients. Thirty-one of 36 (86.1%) patients survived and progressive cerebral edema and sepsis were the most common causes of mortality. Patients who died had higher model for end-stage liver disease scores, longer cold ischemia time (CIT), and higher grades of encephalopathy (though 80% patients with encephalopathy survived). There was no donor mortality. At long-term follow up of a median of 56months, 29 (80.5%) of 36 patients were still alive. In our experience, LDLT is an alternative procedure to DDLT in patients with ALF and is associated with good outcomes even in patients with high grades of encephalopathy.

Living donor liver transplantation using a graft with periportal fibrosis.

A 57-year-old woman with familial amyloid polyneuropathy (FAP) was scheduled to undergo living donor liver transplantation (LDLT), but the operation was cancelled because the only potential donor had chronic alcohol-related liver disease. One year later, FAP-related neurological symptoms progressed rapidly, and emergency LDLT was planned. The donor's hepatic function had returned to normal range after 1 year of abstinence. The left liver graft volume was equivalent to 37.7% of the standard liver volume (SLV) of the recipient. However, a liver biopsy revealed mild fibrosis (score, F1). LDLT was successfully performed without any complications. The recipient's neurological findings returned to normal. One year after LDLT, the liver graft volume was equivalent to approximately 90% of the SLV, and the fibrosis had improved. LDLT using a graft with a fibrosis score of up to F1 may be an acceptable alternative for recipients with normal hepatic function.

How to Use Rituximab in ABO-Incompatible Pediatric Living Donor Liver Transplantation: A Single Center Experience.

(Background) Previous studies have demonstrated the safety of ABO-incompatible living donor liver transplantation (LDLT) using preoperative plasmapheresis and rituximab. However, no reports have so far described the timing and dosage of rituximab administration for pediatric LDLT. The aim of this study is to determine the optimal dosage and timing of rituximab treatment in patients undergoing pediatric ABO-incompatible LDLT. (Methods) Between May 2001 and July 2013, 222 LDLTs were performed for 217 patients. Emergency LDLTs were excluded, because there was not adequate time to prepare these patients for ABO-incompatible LDLT. Those cases included 32 ABO-incompatible LDLTs in 31 patients, and 12 cases (11 patients) were administered rituximab. The anti-ABO antibody titers were reduced preoperatively by plasmapheresis in all cases who were administered rituximab. Rituximab was used from January 2004 for recipients over two years of age (first period; 375 mg/m2 two weeks before LDLT in two cases, second period; 50 mg/m2 two weeks before LDLT in two cases and third period: 200 mg/m2 three weeks before LDLT in eight cases). (Results) The ABO-incompatible LDLT recipient survival rate (87.1%) was significantly lower than that of the other recipients (97.3%) (p=0.008). Two patients who were administered 375 mg/m2 of rituximab died of Pneumocystis jiroveci pneumonia and hemophagocytic syndrome, respectively. One patient who was administered 50 mg/m2 of rituximab underwent re-transplantation due to antibody-mediated complications (intrahepatic biliary strictures). All eight patients who were administered 200 mg/m2 of rituximab survived. The mean CD20+ lymphocyte count was 0.1% at the time of LDLT and 5.4% six months after LDLT. (Conclusion) In the preoperative management of patients undergoing pediatric ABO-incompatible LDLT, the administration of 200 mg/m2 of rituximab three weeks before LDLT is optimally safe and effective.

Three cases of adult‐onset type II citrullinemia treated with different therapies: Efficacy of sodium pyruvate and low‐carbohydrate diet

We report three cases of adult-onset type II citrullinemia (CTLN2) treated with different therapies including one case successfully treated with p.o. administration of sodium pyruvate and low-carbohydrate diet. Although recent advances in liver transplantation have enabled successful treatment of patients with CTLN2, several issues concerning liver transplantation remain. Further, there is still an urgent need for therapies that do not rely on liver transplantation. The first case was a 41-year-old man who developed impaired consciousness in 1992. The patient was treated with conventional therapy for hepatic encephalopathy and died of severe brain edema. The second case was a 31-year-old man who suddenly presented a syncope-like attack with hyperammonemia. He was treated with carbohydrate-restricted diet but the encephalopathy could not be controlled, and he received emergency living donor liver transplantation. The third patient was a 67-year-old man who developed abnormal behavior with hyperammonemia. He has remained well with oral sodium pyruvate and a low-carbohydrate diet without receiving liver transplantation.

Emergency versus elective living-donor liver transplantation: a comparison of a single center analysis

PurposeWe studied the risk factors for postoperative mortality between patients who underwent emergency or elective living-donor liver transplantation (LDLT).MethodsForty-seven patients underwent LDLT in our institute, 16 for emergencies and 31 as elective procedures. The emergency LDLT status was applied to cases in which the time period between referral to our institution and transplantation did not exceed 10 days, and in which liver failure was accompanied by the presence of any degree of hepatic encephalopathy.ResultsWith regard to preoperative factors, age (P = 0.03), the model for end-stage liver disease score (P = 0.001), preoperative tracheal intubation (P = 0.001), ratio between arterial oxygen tension and fractional inspired oxygen (PaO2/FiO2 ratio) (P = 0.03), steroid therapy use (P = 0.001), lymphocyte count (P = 0.02), and cases requiring hemodiafiltration (P = 0.001) differed significantly between the two groups. Postoperative pneumonia occurred more frequently in emergency LDLT patients than in elective LDLT patients (P = 0.006). Invasive pulmonary aspergillosis (IPA) was the main cause of postoperative death in emergency LDLT patients, and, in a univariate analysis, a preoperative status of high serum (1 → 3)-β-d-glucan (>20 pg/ml, P = 0.001), advanced age (>52 years, P = 0.02), and a low PaO2/FiO2 ratio (<320, P = 0.01) were identified as factors predictive of IPA.ConclusionCareful perioperative management, including preoperative investigation of aspergillosis and empiric antibiotic therapy, should be considered for emergency LDLT patients who fulfill IPA risk factors.

Outcomes of Patients with Benign Liver Diseases Undergoing Living Donor versus Deceased Donor Liver Transplantation

Background/AimsThe number of people undergoing living donor liver transplantation (LDLT) has increased rapidly in many transplant centres. Patients considering LDLT need to know whether LDLT is riskier than deceased donor liver transplantation (DDLT). The aim of this study was to compare the outcomes of patients undergoing LDLT versus DDLT.MethodsA total of 349 patients with benign liver diseases were recruited from 2005 to 2011 for this study. LDLT was performed in 128 patients, and DDLT was performed in 221 patients. Pre- and intra-operative variables for the two groups were compared. Statistically analysed post-operative outcomes include the postoperative incidence of complication, biliary and vascular complication, hepatitis B virus (HBV) recurrence, long-term survival rate and outcomes of emergency transplantation.ResultsThe waiting times were 22.10±15.31 days for the patients undergoing LDLT versus 35.81±29.18 days for the patients undergoing DDLT. The cold ischemia time (CIT) was 119.34±19.75 minutes for the LDLT group and 346±154.18 for DDLT group. LDLT group had higher intraoperative blood loss, but red blood cell (RBC) transfusion was not different. Similar ≥ Clavien III complications, vascular complications, hepatitis B virus (HBV) recurrence and long-term survival rates were noted. LDLT patients suffered a higher incidence of biliary complications in the early postoperative days. However, during the long-term follow-up period, biliary complication rates were similar between the two groups. The long-term survival rate of patients undergoing emergency transplantation was lower than of patients undergoing elective transplantation. However, no significant difference was observed between emergency LDLT and emergency DDLT.ConclusionsPatients undergoing LDLT achieved similar outcomes to patients undergoing DDLT. Although LDLT patients may suffer a higher incidence of early biliary complications, the total biliary complication rate was similar during the long-term follow-up period.

Living donor liver transplantation for acute liver failure in pediatric patients caused by the ingestion of fireworks containing yellow phosphorus

Yellow phosphorus is a protoplasmic toxicant that targets the liver. The ingestion of fireworks containing yellow phosphorus, either by children who accidentally consume them or by adults who are attempting suicide, often results in death due to acute liver failure (ALF). We present the outcomes of 10 children who ingested fireworks containing yellow phosphorus. There were 6 boys and 4 girls, and their ages ranged from 21 to 60 months. One patient remained stable without liver complications and was discharged. Three patients died of hepatorenal failure and cardiovascular collapse, and living donor liver transplantation (LDLT) was performed for 6 patients. The patients had grade II or III encephalopathy, a mean alanine aminotransferase level of 1148.2 IU/L, a mean aspartate aminotransferase level of 1437.5 IU/L, a mean total bilirubin level of 6.9 mg/dL, a mean international normalized ratio of 6.6, a mean Pediatric End-Stage Liver Disease score of 33.7, and a mean Child-Pugh score of 11.3. Postoperatively, 2 patients had persistent encephalopathy and died on the second or third postoperative day, and 1 patient died of cardiac arrest on the first postoperative day despite a well-functioning graft. The other 3 patients were still alive at a mean of 204 days. In conclusion, the ingestion of fireworks containing yellow phosphorus causes ALF with a high mortality rate. When signs of irreversible ALF are detected, emergency LDLT should be considered as a lifesaving procedure; however, if yellow phosphorus toxicity affects both the brain and the heart in addition to the liver, the mortality rate remains very high despite liver transplantation.

Applicability of living donor liver transplantation to high-urgency patients.

Cadaveric liver donors are scarce in Hong Kong, and the application of liver transplantation to high-urgency patients is limited. We evaluated the use of grafts from living donors in this setting. From July 1994 to January 1998, 49 consecutive adult patients who were intensive care unit-bound because of acute or chronic liver failure were put on a high-urgency list for liver transplantation. Family members were not solicited for living donation, and the initiation and decision for living donor liver transplantation (LDLT) was based on the donor's voluntary intent. Assessment of the living donor, including blood tests, computed tomographic volumetry, and angiography, was performed only after informed consent was executed. In 25 of 49 (51%) patients, no family member volunteered as living donor; 23 died awaiting donor organs, and 2 received a cadaveric graft. Twenty-four (49%) patients had 36 family members who volunteered as living donors. Before evaluation of living donor was completed, two patients received a cadaveric liver transplant. LDLT was not performed in nine patients because of recipient contraindications (n=4), ABO blood group incompatibility (n=3), and withdrawal of donor (n=2). Eight of these nine patients died, and one received a cadaveric liver graft. The remaining 13 (27%) patients received grafts from living donors. Four of 5 (80%) patients who underwent cadaveric liver transplantation and 11 of 13 (85%) who underwent LDLT survived. Thus, emergency transplantation from living donors increased the applicability of liver transplantation from 10% to 37%, and the survival rate after emergency LDLT (85%) was superior to that of the remaining patients (11%). When cadaveric organ donation is scarce, emergency liver transplantation from living donors can be applied to high-urgency adult patients.

APPLICABILITY OF LIVING DONOR LIVER TRANSPLANTATION TO HIGH URGENCY PATIENTS

50 PURPOSE We studied the outcome of adult patients listed for emergency liver transplantation in a transplant program with extreme shortage of cadaveric grafts and evaluated the applicability of living donor liver transplantation (LDLT) in this setting. METHODS Forty-four patients who were ICU-bound due to acute or chronic liver failure with life expectancy without a liver transplant of less than 7 days were put on a high urgency list (UNOS status 1) for liver transplantation. Family members were not solicited for living donation and the initiation and decision for LDLT was based on the donor's voluntary intent. Assessment of the living donor, including blood tests, CT volumetry and angiography, were performed only after informed consent was executed. ABO blood group compatibility was mandatory. RESULTS In 21 of 44 (48%) patients, no family member volunteered as living donor; 20 died awaiting donor organs and one received a cadaveric graft 6 days after listing. Twenty-three (52%) patients had 35 voluntary donors (1 volunteer, 12; 2 volunteers, 10; 3 volunteers, 1). Before evaluation of living donor was completed, 2 patients received a cadaveric liver transplant. LDLT was not performed in 9 patients because of recipient contraindications (n=4), donor-recipient blood group incompatibility (n=3), and withdrawal of donor (n=2). Eight of these 9 patients died and one received a cadaveric liver graft. The remaining 12 (27%) patients received grafts (left lobe, 3; extended right lobe, 9) from living donors (father, 3; husband, 3; wife, 2; brother, 2; sister, 1; uncle, 1). Eleven of 12 (92%) patients who underwent LDLT were alive at a median follow-up of 17 months (range, 1 to 43 months). All 4 patients who underwent cadaveric liver transplantation also survived. Thus, emergency transplantation from living donors increased the applicability of liver transplantation from 9% to 36% and the survival rate of patients who underwent emergency LDLT (92%) was superior to that of those who did not have a suitable voluntary living donor (13%). CONCLUSIONS In a liver transplant center where cadaveric organ donation is scarce, emergency liver transplantation from living donors should be offered to high urgency patients.