Living Liver Transplantation Research Articles

Successful Treatment of Pediatric Refractory Burkitt Lymphoma PTLD after Liver Transplantation using Anti-CD19 Chimeric Antigen Receptor T-Cell Therapy

In the immunocompromised setting, recipients of solid-organ or hematopoietic stem-cell transplants carry an increased risk of post-transplant lymphoproliferative disorder (PTLD). Burkitt lymphoma (BL) PTLD is a rare form of monomorphic B-cell PTLD, which lacks a standard best treatment. Here, we report the successful treatment of refractory BL-PTLD with autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy. A male patient was diagnosed with BL-PTLD, with an increasing Epstein-Barr virus (EBV) viral load, at 21 months after undergoing living liver transplantation from his mother due to neonatal biliary atresia. After 10 cycles rituximab +/− intensive chemotherapy and surgical tumor resection, the tumors significantly advanced. Next-generation sequencing (NGS) was performed on formalin-fixed paraffin-embedded tumor tissue, revealing one mutation in exon 5, TP53: p.A159 V, which may be associated with chemo-resistance. Thus, treatment was started with autologous anti-CD19 CAR T-cell therapy. We administered 9.0 × 106/kg autologous anti-CD19 CAR T-cells, after conditioning with cyclophosphamide and fludarabine. Unexpectedly, the patient experienced only mild (Grade II) cytokine release syndrome (CRS) without neurotoxicity. Finally, he went into complete remission (CR), and has achieved 16-month event-free survival to date. In addition, liver function has remained stably within the normal range without any immunosuppressive therapy. The literature includes only five previously reported BL cases treated with CAR T-cell therapy. In conclusion, the present case suggests that autologous anti-CD19 CAR T-cell therapy may represent a new therapeutic option for some cases of refractory BL-PTLD. Clinical trial number: ChiCTR2000032211.

Mothers’ Experiences With Pregnancy and Childbirth Following Pediatric Living Liver Transplant Donation: A Qualitative Descriptive Study

BackgroundHalf of pediatric living liver transplantation donors are mothers, including women of reproductive age. Reports on pregnancy and childbirth after living donor liver transplantation are limited to medical aspects, and mothers’ experiences remain unclear. We describe the experiences of women who became pregnant and gave birth after living donor liver transplantation. MethodsWe used a qualitative descriptive approach. Eleven women who became pregnant and delivered following pediatric living liver transplant donation participated in face-to-face, in-depth interviews. Data collected via semi-structured interviews were assessed using an inductive qualitative analysis. The study was conducted in accordance with the Declaration of Helsinki. ResultsWomen’s experiences with pregnancy and childbirth following pediatric living liver transplant donation were categorized as follows: explanation and consultation on pregnancy and childbirth after liver donation; physical and mental burden after liver donation; concern about the effects of donor surgery on pregnancy and childbirth; consideration for own body; concern about the physical condition of my child, who is the recipient; and the presence of health professionals with which to easily consult. ConclusionAfter donation, mothers are physically burdened and experiences anxiety about the physical condition of the recipient as well as about pregnancy and childbirth. Therefore, continuous psychosocial support is necessary.

Analysis of biliary MICRObiota in hepatoBILIOpancreatic diseases compared to healthy people [MICROBILIO]: Study protocol.

The performance of the microbiota is observed in several digestive tract diseases. Therefore, reaching the biliary microbiota may suggest ways for studies of biomarkers, diagnoses, tests and therapies in hepatobiliopancreatic diseases. Bile samples will be collected in endoscopic retrograde cholangiopancreatography patients (case group) and living liver transplantation donors (control group). We will characterize the microbiome based on two types of sequence data: the V3/V4 regions of the 16S ribosomal RNA (rRNA) gene and total shotgun DNA. For 16S sequencing data a standard 16S processing pipeline based on the Amplicon Sequence Variant concept and the qiime2 software package will be employed; for shotgun data, for each sample we will assemble the reads and obtain and analyze metagenome-assembled genomes. The primary expected results of the study is to characterize the specific composition of the biliary microbiota in situations of disease and health. In addition, it seeks to demonstrate the existence of changes in the case of illness and also possible disease biomarkers, diagnosis, interventions and therapies in hepatobiliopancreatic diseases. NCT04391426. Registered 18 May 2020, https://clinicaltrials.gov/ct2/show/NCT04391426.

Sarcopenia Severity Based on Computed Tomography Image Analysis in Patients with Cirrhosis.

Standardized sex-specific cut-offs for sarcopenia in cirrhosis are needed to identify the risk of clinical complications and to discriminate the severity of sarcopenia. We aimed to compare clinical characteristics between patients with cirrhosis categorized according to the severity of sarcopenia. Computed tomography images were taken at the 3rd lumbar vertebra from 603 patients with cirrhosis and 129 adult donors for living liver transplantation. Patients with skeletal muscle index (SMI) two standard deviations (SD) below the sex-specific mean value of young donors (18–40 years old) were categorized as having severe sarcopenia whereas patients with SMI between −1 and −2 SD of the sex-specific young adult mean values were categorized as having sarcopenia. In the cirrhosis group, 408 patients (68%) were male with the mean age of 57 ± 0.4 years, and MELD score of 14 ± 0.4. Patients were divided into three groups: severe-sarcopenic (SMI < 30 cm2/m2 in females and <42 cm2/m2 in males), sarcopenic (30 ≤ SMI < 37 cm2/m2 in females and 42 ≤ SMI < 50 cm2/m2 in males) and non-sarcopenic (SMI ≥ 37 cm2/m2 in females and ≥50 cm2/m2 in males). Patients with cirrhosis and severe sarcopenia had lower muscle radiodensity and higher plasma neutrophil as well as neutrophil to lymphocyte ratio levels than both non- and sarcopenic groups. The frequency of alcohol-induced cirrhosis, refractory ascites, hepatic encephalopathy, CRP > 20 mg/mL, and severe malnutrition was also higher in severe-sarcopenic patients. The interval between sarcopenia and severe sarcopenia may reflect a window of opportunity in which to intervene and mitigate muscle wasting to improve patient outcomes.

Respiratory Complications Among Living Liver Donors: A Single-Center Retrospective Observational Study.

The safety of living liver donors is considered a high priority. In this study, we aimed to highlight the incidence and risk factors of respiratory complications among living liver transplant donors at our institute. We evaluated data of 178 related living liver donors who were seen from January 2014 to December 2018. We recorded significant respiratory complications, such as pulmonary embolism, pleural effusion, pneumothorax, pneumonia, acute lung injury, acute respiratory distress syndrome, and transfusion-related acute lung injury. Complications were noted as clinically evident and/or needing intervention. We also recorded the frequency of nonrespiratory complications and duration of intensive care unit and hospital stays. Ten donors (5.6%) developed significant respiratory complications: 2 (1.1%) had pulmonary embolisms, 3 (1.7%) developed symptomatic pleural effusion that required thoracentesis, and 4 (2.25%) had chest infections. The remaining donor (0.6%) had unexplained respiratory insufficiency. Logistic regression analyses identified age ≥ 35 years and previous surgery as the main risk factors of significant respiratory complications. There were no recorded cases of pneumothorax, acute lung injury, acute respiratory distress syndrome, and transfusion-related acute lung injury. Raw surface collection (14.6%) and biliary leakage (7.9%) were the most frequent nonrespiratory complications. There was no significant difference between patients with and without significant respiratory complications with regard to intensive care unit and hospital stays. Despite the low incidence of significant respiratory complications among our living liver donor cohort, close monitoring and early management are essential to achieve better prognosis, especially in donors older than 35 years or those with previous surgery.

Publication Activity on Liver Transplantation from Southeastern European Countries: A Bibliometric Analysis

Background: Liver transplantation (LT) has become a field with rich publication activity; however, there is a paucity of research regarding LT publications from southeastern European (SEE) countries. Understanding the factors that influence the publication output is essential to direct the research and to promote the publication of high-quality papers. Methods: A bibliometric analysis was performed in PubMed for articles published on LT-related clinical experience from 11 countries from the SEE region before 2020. Data included the number of publications, citations, journal (cumulative) impact factors (IFs) and first/senior author gender and profession. Results: 188 publications fitted the inclusion criteria. 25.5% of papers were published in journals without IFs. Most papers came from Greece (43.6%, 199.663 IFs), Romania (29.3%, 60.695 IFs) and Croatia (16%, 45.645 IFs). In the top three countries, first authors were dominantly male physicians. Senior authors were also mostly male (63.3-88%), with varying professions depending on the country (p=0.008). Conclusions: The overall LT publication activity from the SEE countries is modest. The authors of Greece are the most productive in the region. The high liver LT activity does not necessarily translate into high publication output. LT communities in the SEE countries should find solutions on how to increase research and publication output.

Factors Associated With Growth After Deceased and Live Donor Pediatric Liver Transplantation

BackgroundThere are limited data on predictors of growth after pediatric liver transplantation. MethodsWe reviewed the impact of graft type, ethnicity, and biliary complications (BC) on growth after pediatric liver transplantation (LT). We compared preoperative and 6-, 12-, and 24-month weight, height, and body mass index (BMI) percentiles between living donor (LD), deceased donor full-size (DD-full), and deceased donor split (DD-split) graft recipients. We also compared length of stay (LOS) between groups. ResultsWe had 98 patients (DD-split: 32; DD-full: 43, LD: 23). The Median Pediatric End-stage Liver Disease (PELD) scores, exception points, albumin, bilirubin, failure to thrive, and presence of ascites were similar among groups. The DD-full group had the lowest preoperative percentiles in all categories and exceeded these at 24 months. The DD-split group was at preoperative percentiles at 24 months. The LD group had parallel weight curves compared to the DD-full group and exceeded only the preoperative weight percentile at 24 months. Black patients had the lowest percentiles in all categories (P < .01). The BC group caught up weight and BMI percentile at 24 months but had persistent decrease in height percentiles. Patients without BC exceeded preoperative height percentiles. The longer LOS group had lower height and BMI percentiles at 24 months; however, there was no statistical difference. ConclusionDD-full and black patients seem to benefit the most from LT in terms of growth. BC seems to affect height percentiles. Patients with longer LOS had lower height and BMI percentiles (P>.05). Longer follow up and larger cohorts are necessary to improve the power of these findings.

Is Unenhanced Computed Tomography Reliable in the Assessment of Macrovesicular Steatosis in Living Liver Donors?

In this retrospective study, we aimed to determine the diagnostic value of unenhanced computed tomography in the assessment of macrovesicular steatosis in potential living liver transplant donors by using biopsy as a reference standard. This retrospective study was approved by our institutional review board, and all included patients provided written informed consent. Our study group included 181 donor candidates (mean age of 35.9 ± 9.3 y) who underwent unenhanced computed tomography and subsequent needle biopsy (mean period after scan of 12.74 d) in the right hepatic lobe (at least 2 samples per patient). Histologic degree of macrovesicular steatosis was determined. A radiologist with 10 years of experience assessed steatosis ofthe right hepatic lobe by using 2 methods: (1) a 4-point visual grading system that used attenuation comparison between the liver and hepatic vessels and (2) the liver attenuation index, which was calculated with region of interest measurements of hepatic attenuation. We used statistical analyses to compare accuracy in the diagnosis of macrovesicular steatosis. Our study population was divided into 3 groups according to histologic steatosis grade. Group 1 consisted of 157 candidates with 0% to 5% steatosis, group 2 consisted of 11 candidates with 6% to 15% steatosis, and group 3 consisted of 13 candidates with 16% to 100% steatosis. Mean liver attenuation (in Hounsfield units ± standard deviation) was 58.93 ± 5.07 for group 1, 47.8 ± 4.17 for group 2, and 39.11 ± 6.5 for group 3. Significant differences in liver attenuation were observed between groups using one-way analyses of variance (F = 107307; P < .01). For visual grading, correlation coefficient for computed tomography was 0.959. Unenhanced computed tomography to assess liver attenuation represents an objective and noninvasive means for detection of hepatic steatosis. This method can prevent unnecessary biopsies.

Adult-to-Adult Living Donor Liver Transplantation: Postoperative Outcomes and Quality of Life in Liver Donors: First Report in Thailand

BackgroundDeceased donor liver transplantation is a rare procedure in Northern Thailand because of cultural issues. Living donor liver transplantation (LDLT) can decrease waiting list mortality for the patients who have end-stage liver disease. In Thailand, our center is the only active adult-to-adult LDLT program. This study is the first report of outcomes and health-related quality of life in liver donors. ObjectivesThe aim of this study was to evaluate the postoperative outcomes and health related quality of life in living liver transplant donors at the Transplant Center in Thailand. Materials and methodsAll patients undergoing liver resection for adult-to-adult LDLT at our center between March 2010 and July 2018 were evaluated in a cross-sectional study. The effect of donor demographics, operative details, postoperative complications (Clavien-Dindo classification), hospitalization, and health related quality of life was evaluated through health-related quality of life questionnaires (short-form survey, SF–36) ResultsA total of 14 donor patients were included in this study with an age range from 26 to 51 years (mean 39.86 years, standard deviation [SD] = 8.59 years). The patients were 71.43% female and 28.57% male. The majority of patients had primary and secondary education (57.14%) and were married (64.29%). After hepatectomy, there was no mortality in the evaluated donors. The Clavien-Dindo classification of postoperative complications were as follows: Grade I (none), Grade II (50%), Grade IIIa (7.14%), and Grade IIIb (7.14%). The serum levels of total protein and albumin were decreased on postoperative day 5. The hospital stays averaged 11.5 days (SD = 4.9 days) and ranged from 5 to 22 days. After considering each aspect of the donors’ postoperative quality of life, the highest mean score was related to physical composite scores in physical roles with a mean of 96.42 (SD = 13.36) and physical function with a mean of 95.35 (SD = 13.36). Moreover, the mental composite scores in social function was the highest mean of 91.96 (SD = 12.60) and role emotion was a mean of 90.47 (SD = 27.51). ConclusionsLiving donor hepatectomy was safe, with an acceptable morbidity, and recognized as a safe procedure with an excellent long-term health quality of life.

Liver Graft and Spleen Elastography After Living Liver Transplantation: Our First Results

Aim of the studyLiver transplantation is widely applied as a standard and effective management of end-stage liver diseases, hepatocellular carcinoma, and acute liver failure. Investigation of morphologic and functional changes in the transplanted graft, gastrointestinal system, and spleen after transplantation is an important ground for assessment of post-transplantation results, early changes related to complications, and evaluation of response to treatment modalities. The aim of this study was to investigate the dynamics of changes in elastography of the liver graft and spleen after living-related liver transplantation. Material and methodsThe study included 14 cirrhotic patients after living-related liver graft transplantation. Stiffness of the spleen and liver was evaluated before transplantation and at 1, 3, and 6 months after transplantation with a Supersonic Aixplorer Multi Wave device. Each procedure consisted of measuring the density in 10 points (spots) of the organ. The final result was calculated as the mean value of successful measurements (must have been > 60% of all measurements) and expressed in kilopascals. ResultsThe mean value of the liver and spleen stiffness before transplantation was 27 kPa (14–31 kPa) and 51 kPa (38–92 kPa), respectively. The stiffness of the spleen gradually reduced after transplantation to 40.3, 35.4, and 24.1 kPa (P = .001) at 1, 3, and 6 months. The stiffness of the liver graft in patients without complications was stable at 4–5 kPa, whereas the same value in patients with complications was increased (≥ 7.5 kPa). In 5 patients, endoscopic investigation confirmed the significant reduction of varicose veins after surgery. ConclusionElastography of the liver graft and spleen after liver transplantation can be recommended as a useful-for-patient 1-off method of investigation.

Visibility of B1 and Right/Left Dissociation Using Gd-EOB-DTPA-enhanced T1-weighted Magnetic Resonance Cholangiography in Live Liver Transplant Donors

PurposeWe aimed to determine the visibility of bile ducts of the caudate lobe (B1s) and right/left (R/L) dissociation on contrast-enhanced T1-magentic resonance cholangiography after gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid administration (CE-T1-MRC) in live liver donors. Materials and MethodsIn 300 live liver donors who underwent CE-T1-MRC, the visibility and R/L dissociation of B1 were evaluated. Confidence level of B1 visibility and depiction of the presence of R/L dissociation on axial and coronal reconstruction images were compared. Strength of agreement between R/L dissociation on MRC and that on intraoperative cholangiography was evaluated. ResultsAt least 1 B1 was visible on CE-T1-MRC in 142 of 300 subjects (47.3%; a total of 195 B1s; 0.64 [SD, 0.80], 0-4 branches per person). Of 195 subjects with visible B1, 55 ducts showed R/L dissociation (28.2%; right-to-left crossover, n = 28; left-to-right crossover, n = 27). The confidence level of B1 visibility on axial images of MRC was significantly higher than that on coronal images of MRC (P < .001). Of 55 B1s with R/L dissociation, axial images were superior to coronal images in depicting B1 crossover in 31 and vice versa in 2 (equal between axial and coronal images in 22). The agreement for R/L dissociation between CE-T1-MRC and intraoperative cholangiography was excellent (κ = 0.819; 95% CI, 0.722-0.917). ConclusionBile ducts of the caudate lobe with R/L dissociation can be occasionally identified on CE-T1-MRC. Axial reconstruction is superior to coronal counterpart.

Atrophy of the Rectus Abdominis After Left-Side Donor Hepatectomy: Comparison of Upper Abdominal Midline vs Mercedes Incision

ObjectiveThis study of living liver transplant donors compared postoperative atrophy of the rectus abdominis after an upper abdominal midline incision vs a Mercedes incision. MethodsA total of 110 donors underwent left-side donor hepatectomy in our hospital from 2007 to 2016. We analyzed the postoperative computed tomography data of 102 cases 3, 6, and 12 months after surgery. Donors were categorized as having a midline incision (MID group, n = 39) or a Mercedes incision (MER group, n = 63). The rectus abdominis was assessed on computed tomography images, and the percentage of muscle thickness (PMT) was compared in the 2 groups. ResultsPatient age, sex, and body mass index did not differ in the 2 groups. Laparoscope-assisted hepatectomy was only performed in the MID group, while open hepatectomy was performed mainly in the MER group. The mean PMT of the rectus abdominis did not change 3, 6, and 12 months after surgery in the MID group but decreased to 80%, 76%, and 72% of the baseline value in the MER group 3, 6, and 12 months after surgery, respectively. The PMT values were significantly lower in the MER group than in the MID group at all 3 time points (P < .001). In the MER group, rectus abdominis atrophy was significantly worse on the right side than on the left. There was no significant difference in morbidity between the 2 groups. ConclusionIn living donor liver transplant, the Mercedes incision resulted in significantly greater atrophy of the rectus abdominis in donors compared with the midline incision.

8. Efficacy of high volume plasma exchange in transplant free survival in pediatric ALF with advanced hepatic encephalopathy

Background and Aims: Prompt management with supportive care and liver support strategies, largely determine the outcome of acute liver failure (ALF). The aim of this work was to analyze the effect of high volume plasma exchange (HVPE) on the outcome of children with ALF. Methods: In this single centre prospective interventional trial done between May 2015 to April 2018, all children with ALF (diagnosed as per the Paediatric Acute Liver Failure study group definition) with Hepatic Encephalopathy (HE) Grade III and IV weighing more than 10 kg were offered to receive HVPE. Twenty-three ALF patients agreed to receive HVPE with standard medical therapy (SMT) and another 23 age and gender matched children who received SMT alone were included as controls. Endpoint of the study was survival with native liver/liver transplantation (LT) or death by 30 days hospital stay. The primary outcome measures were transplant free survival in days and proportions of transplant free survival at day 7 and at day 30. The HVPE procedure was undertaken on three consecutive days at the interval of 24 h. For each HVPE 1.5-2 times the plasma volume was exchanged. Results: The baseline characteristics of the groups were similar. In the HVPE group, 12 received 3 or more sessions of HVPE whereas 11 patients received 1 or 2 sessions of HVPE. In the HVPE group 12 died, 5 (21.7%) were transplanted and 6 (26.1%) survived with native liver (SNL). In the SMT alone group, 11 (47.8%) died, 4 (17.4%) were transplanted and 8 (34.7%) SNL. Median Transplant free survival in HVPE group was 8.2 (IQR 3.2–20.2) days versus 5 (IQR 2–11) days in the SMT alone group (Mean Difference 4.37, 95% CI 2–10.7, p = 0.172). Transplant free survival on day 7 was 13/23 (56.5%) and 9/23 (39.1%) (OR 2.02, 95%CI 0.62–6.5, p = 0.38) while on day 30 was 6/23 (26.1%) and 8/23 (34.7%) (OR 0.66, 95%CI 0.18–2.34, p = 0.75) in the HVPE and SMT group respectively. Overall survival on day 7 was 17/23 (73.9%) and 12/23 (52.2%) (OR 2.59, 95%CI 0.75–8.9, p = 0.22) while on day 30 was 11/23 and 12/23 (OR 0.84, 95%CI 0.26–2.7, p = 1) in the HVPE and SMT group respectively. Conclusions: Although half of the sample size did not receive the 3 sessions of HVPE, yet compared with the SMT alone group, HVPE did prolong the transplant free survival in days and improve the proportions of patients surviving on day 7 but these comparisons did not reach the level of statistical significance. HVPE may have a potential role as a bridging therapy for LT. The authors have none to declare.

Comparison between Cadaveric Whole Liver and Live Donor Partial Liver Transplantation in High Risk Patients with MELD Score more than 40

Comparison between Cadaveric Whole Liver and Live Donor Partial Liver Transplantation in High Risk Patients with MELD Score more than 40

A Ten Year Retrospective Review of Infections in the First 12 Months Post Paediatric Liver and Liver-Kidney Transplantation at a Single Centre in Johannesburg, South Africa

Introduction Two paediatric liver transplant centres exist in South Africa, one in Johannesburg and the other in Cape Town. The programme in Johannesburg at Wits Donald Gordon Medical Centre (WDGMC) began in 2005 and is now the largest volume paediatric liver transplant unit in the country. WDGMC also hosts the only live donor paediatric liver transplant programme in sub-Saharan Africa. This research determined the incidence and profile of infectious events in the first year after transplantation. Materials and Methods This retrospective record review included paediatric liver and liver/kidney transplants from 2005-2015. The paediatric population was defined as any recipient <18 years of age on the day of transplant. Only laboratory confirmed infections were included. Ethics approval was obtained from the University’s Institutional Review Board. Information was sourced from clinical records and pathology reports. Statistical analysis was carried out using SAS version 9.4 with a 5% significance level. Results and Discussion There were 69 transplants in 65 patients.Most were female (42/69;61%), median age was 49 months (IQR 27-152) and biliary atresia was the most common indication for transplant (42%).A total of 253 infections occurred, mainly in the first three months after transplant. The most common site was bloodstream, followed by the abdomen and urinary tract. Bacterial infections occurred most commonly (193/253;76.3%). Of these, gram negative organisms predominated (120/193; 62.2%) and klebsiella species (50/120; 41.7%) was most frequently identified. In the gram positive group (72/193; 37.3%), enterococcus faecium predominated (25/72; 34.7%). Drug resistance was higher in the gram negative group (75.0%; 36/48) when compared to the gram positives (22.9% (11/48). Prevalence of viral infection was 16.6% (42/253) and fungal was 7.1% (18/253). Candida parapsilosis was the most commonly identified fungus. TB prophylaxis is not routinely administered and there was only one case of mycobacterial infection. This is the first study of its kind from sub-Saharan Africa. Gram negative infections were the most common, mirroring findings from the USA and Israel. What differed was that candida parapsilosis, not albicans, was the most frequently identified fungus and the most common primary site of infection was not the abdomen, but rather the bloodstream. Risk factors that may predispose to infection are severe malnutrition at the time of transplant and delayed referrals of young children with advanced disease. Conclusion Our findings suggest that standard TB prophylaxis may not be warranted, even in a country with high TB infection rates. This research has resulted in an urgent policy review in the transplant unit which has prioritised the nutritional status of children pre-transplant and implemented stringent infection control measures to prevent bloodstream infections. Study data were collected and managed using REDCap1 electronic data capture tools hosted at University of the Witwatersrand. This research was supported by Wits Donald Gordon Medical Centre, Johannesburg, South Africa. Data capture performed by the medical student group, Chanceplant from the University of the Witwatersrand.

Living with a foreign organ: counselling needs of living liver transplant recipients

urpose: Liver transplantation can be a lifesaving option for people with acute/chronic liver failure. Although liver transplantation has positive outcomes, the recipients experience many physical, psychological and social problems. It is of great importance to satisfy their needs for counselling so that they can overcome these problems. The aim of the study was to describe the counselling needs of living liver transplant recipients. Materials and Methods: A descriptive qualitative research design was used. The study was conducted between November 2012 and December 2012. In-depth interviews were performed with sixteen participants who had experiences of living liver transplantation. Data were analyzed with inductive content analysis. Results: The liver transplant recipients’ counselling needs were categorized into two main themes: ‘’pre-transplantation period counselling needs’’ and ‘’post-transplant period counselling needs’’. Subthemes were also identified and described. The first main theme had three subthemes (causes and symptoms of liver failure, treatment process, living donors) and the second main theme had four subthemes (medications used, possible complications, sexuality and body image and life after transplantation). Conclusions: The results indicate that the living liver transplant recipients’ currently have insufficient knowledge about transplantation periods and they need counselling.

Living-Donor Liver Transplant: An Analysis of Postoperative Outcome and Health-Related Quality of Life in Liver Donors.

Living-donor liver transplant represents an established alternative to deceased-donor liver transplant. The procedure is considered safe for donors; however, concerns about the donors' health-related quality of life and health status have not been fully addressed. Here, we aimed to assess the health-related quality of life and postoperative and 1-year clinical outcomes in living liver transplant donors. All patients undergoing liver resection for adult-to-adult living-donor liver transplant at our center between December 1999 and March 2013 were evaluated retrospectively. Health-related quality of life was evaluated in a second assessment through written health-related quality of life questionnaires (the Short Form 36 assessment tool) sent to all patients who underwent liver resection for living-donor liver transplant between 1989 and 2012. We identified 104 patients who underwent liver resection for living-donor liver donation between December 1999 and March 2013. Postoperative morbidity was 35.9%, with 56.8% of patients having minor complications. No postoperative, 30-day, or 90-day mortality was evident. At year 1 after transplant, 30 patients (28.8%) had (ongoing) complications, of which 80% were considered minor according to Clavien-Dindo classification. Regarding health-related quality of life, liver donors were characterized as having significantly higher scores in the general health perception component in the Short Form 36 assessment tool (P < .001). We found no significant results in other assessment components (all P > .05). Liver donors are characterized by an excellent health-related quality of life that is comparable to the general population. Because some donors tend to have concerns regarding their employment status after the procedure, a comprehensive and critical evaluation of potential donors is needed.

Clinical Outcomes of Living Liver Transplantation According to the Presence of Sarcopenia as Defined by Skeletal Muscle Mass, Hand Grip, and Gait Speed

BackgroundSarcopenia is an independent predictor of death after living-donor liver transplantation (LDLT). However, the ability of the Asian Working Group for Sarcopenia criteria for sarcopenia (defined as reduced skeletal muscle mass plus low muscle strength) to predict surgical outcomes in patients who have undergone LDLT has not been determined. MethodsThis study prospectively enrolled 366 patients who underwent LDLT at Kyushu University Hospital. Skeletal muscle area (determined by computed tomography), hand-grip strength, and gait speed were measured in 102 patients before LDLT. We investigated the relationship between sarcopenia and surgical outcomes after LDLT performed in three time periods. ResultsThe number of patients with lower skeletal muscle area has increased to 52.9% in recent years. The incidence of sarcopenia according to the Asian Working Group for Sarcopenia criteria was 23.5% (24/102). Patients with sarcopenia (defined by skeletal muscle area and functional parameters) had significantly lower skeletal muscle area and weaker hand-grip strength than did those without sarcopenia. Compared with non-sarcopenic patients, patients with sarcopenia also had significantly worse liver function, greater estimated blood loss, greater incidence of postoperative complications of Clavien-Dindo grade IV or greater (including amount of ascites on postoperative day 14, total bilirubin on postoperative day 14, and postoperative sepsis), and longer postoperative hospital stay. Multiple logistic regression analysis revealed sarcopenia as a significant predictor of 6-month mortality. ConclusionsThe combination of skeletal muscle mass and function can predict surgical outcomes in LDLT patients.

Optimal adaptive statistical iterative reconstruction-V percentage in abdominal low dose enhanced CT of living liver transplantation infants

Objective To explore the optimal adaptive statistical iterative reconstruction-V (ASIR-V) percentage in abdominal low-dose enhanced CT in infants with living liver transplantation (LDLT). Methods Twenty consecutive infants (liver transplant candidates or patients after liver transplantation, body weight≤15.0 kg) were prospectively included as the test group in this study. All the infants underwent three-phase enhanced CT, hepatic artery, portal venous inflow and portal venous phase. Images were reconstructed with filtered back projection (FBP), 0, ASIR-V, 20% ASIR-V, 40% ASIR-V, 60% ASIR-V, 80% ASIR-V and 100% ASIR-V, respectively. The objective (noise SD, CT value of abdominal aorta, liver and spleen) and subjective (image quality score) analysis of image quality were conducted. The effective dose (ED) was also recorded. In order to test our conclusion, 10 infants with similar characteristics to test group were prospectively collected as validation group. The similar scanning protocol combined with the best ASIR-V were used. The image score and ED were recorded. One-way analysis of variance or Kruskal-Wallis H test were used to compare CT value, noise SD and image quality scores. Friedman M test was used to compare image quality score and independent-sample t test was used to compare ED between the test and validation group. Results CT value of all tissues derived from images reconstructed with different ASIR-V was similar in each phase (P>0.05). The noise SD had statistically significant differences among images reconstructed with different ASIR-V (P 0.05). The ED of the test group was (2.52±0.54) mSv, and significantly lower than that of validation group (1.49±0.18) mSv (P<0.05). Conclusion The best image quality can be obtained with forty percent ASIR-V whilethe radiation dose can be effectively reduced. Key words: Liver transplantation; Tomography,X-ray computed; Radiation dosage

The donor advocacy team: a risk management program for living organ, tissue, and cell transplant donors.

Although the incidence of living donor death is low in Japan, statistics show one living liver donor death in more than 7000 living liver transplants. Thus, medical transplant personnel must recognize that the death of a living organ or tissue transplant donor can occur and develop an appropriate risk management program. We describe how Nagasaki University Hospital established and implemented a Donor Advocacy Team (DAT) program: a risk management program for initiation in the event of serious, persistent, or fatal impairment of an organ, tissue, or cell transplantation from a living donor. The purposes of the DAT program are as follows: 1. To disclose official information without delay. 2. To provide physical and psychological care to the patient experiencing impairment and their family. 3. To provide psychological care to the medical staff in charge of the transplant. 4. To standardize the responses of the diagnosis and treatment department staff and other hospital staff. 5. To minimize the damage that the whole medical transplantation system may suffer and leverage the occurrence for improvement. To address (1) and (5), actions, such as reporting and responses to the government, mass media, transplant-related societies, and organ transplant networks, have been established to ensure implementation.