Liver Transplantation Group Research Articles

Pathologic complete response to chemoembolization improves survival outcomes after curative surgery for hepatocellular carcinoma: predictive factors of response

BackgroundWe identified the predictive factors and prognostic significance of transarterial chemoembolization (TACE) for achieving pathologic complete response (pCR) before curative surgery for hepatocellular carcinoma (HCC) in hepatitis B–endemic areas. MethodsAmong 753 HCC patients treated with surgery, 124 patients underwent preoperative TACE before liver resection (LR), and 166 before liver transplantation (LT) between 2005 and 2016. Overall survival (OS) and recurrence-free survival (RFS) were analyzed. Pathologic response (PR) was defined as the mean percentage of necrotic area, and pCR was defined as the absence of viable tumor. ResultsA total of 34 (27%) and 38 (23%) patients had pCR before LR and LT, respectively. Alpha-fetoprotein (AFP) < 100 ng/mL and single tumor were significant preoperative predictors of pCR. OS and RFS were significantly improved in patients with pCR or a PR ≥ 90%, but not in patients with PR ≥ 50% after LR and LT. On multivariate analyses, PR ≥ 90% remained an independent predictor of better OS and RFS in LR and LT groups. ConclusionOverall, our data clearly demonstrate that pCR predicts favorable prognosis after curative surgery for HCC, and predictors of pCR are AFP <100 ng/mL and single tumor.

Methylmalonic acidemia/propionic acidemia \u2013 the biochemical presentation and comparing the outcome between liver transplantation versus non-liver transplantation groups

BackgroundMost patients with isolated methylmalonic acidemia (MMA) /propionic acidemia (PA) presenting during the neonatal period with acute metabolic distress are at risk for death and significant neurodevelopmental disability. The nationwide newborn screening for MMA/PA has been in place in Taiwan from January, 2000 and data was collected until December, 2016.ResultsDuring the study period, 3,155,263 newborns were screened. The overall incidence of MMA mutase type cases was 1/121,356 (n = 26), 1 cobalamin B was detected and that for PA cases (n = 4) was 1/788,816. The time of referral is 8.8 days for MMA patients, and 7.5 days for PA patients. The MMA mutase type patients have higher AST, ALT, and NH3 values as well as a lower pH value (p < 0.05). The mean age for liver transplantation (LT) is 402 days (range from 0.6–6.7 yr) with 16 out of 20 cases (80.0%) using living donors. The mean admission length shortened from 90.6 days/year (pre-LT) to 5.3 days/year (at 3rd year post-LT) (p < 0.0005). Similarly, the tube feeding ratio decreased from 67.8 to 0.50% (p < 0.00005). The anxiety level of the caregiver was reduced from 33.4 to 27.2 after LT (p = 0.001) and the DQ/IQ performance of the patients was improved after LT from 50 to 60.1 (p = 0.07).ConclusionMMA/PA patients with LT do survive and have reduced admission time, reduced tube feeding and the caregiver is less anxious.

Liver Transplantation – The Best and Last Chance of Cure for Hepatocellular Carcinoma with Portal Vein Invasion

Introduction: Hepatocellular carcinoma (HCC) with portal vein invasion is a sign of advance disease. Liver transplantation (LT) is generally not considered due to the perceived poor survival. Liver resection is the mainstay of curative treatment for this situation and yet the outcome is exceedingly poor. There has been no study compares the treatment outcomes of these two treatment modalities in this patient subgroup. Method: Consecutive patients were recruited from 2000 to 2016. Patients who received either LT or resection with pathological diagnosis of HCC and portal vein invasion were recruited. Propensity score matching was performed before comparison. Result: There were 88 eligible patients, 13 received LT and 75 received resection respectively. The median age was 55.5 years old and male was the predominant gender. Majority (61.5%) of the patients in the LT group has Vp2 (tumour invasion at the 2nd order portal vein branch) while all patients in the resection group had Vp2 disease. Significant heterogeneity was found between LT and resection group. After propensity score matching, 10 patients in the LT group were compared with 30 patients in the resection group. The median size of tumour, alpha fetoprotein level (AFP) and follow-up period of the matched population was 5cm, 1021 ng/ml and 19 months respectively. Patients in the LT group had significantly better disease-free (median 45.9 vs 5.7 months) and overall survival (median survival 58.2 vs 12.3 months, P=0.026) respectively. Conclusion: LT provides a better chance of cure in HCC patients with portal vein invasion.

Transplantable HCC in resectable cirrhosis – to resect or to transplant?

Background: The role of liver transplantation (LT) versus liver resection (LT) in patients with „transplantable“ and „resectable“ hepatocellular carcinoma (HCC) is a matter of ongoing controversy. The aim of this study was to analyze the outcome in these patients in our single center experience. Methods: Between 1998 and 2016, a total of 286 primary LT and 402 primary LR in patients with HCC were performed at our center and prospectively collected in an SPSS database. Selecting patients with HCC inside the Milan Criteria arising in Child A cirrhosis and excluding those with a contraindication to either LT or LR (age, ASA IV/V, vascular invasion, extrahepatic tumor) we identified 61 patients after primary LT (group A) and 49 after primary LR (group B). Secondary „salvage“ LT was attempted for recurrent HCC after primary LR. Results: The perioperative 90-day mortality was 1.6% in group A and 6.1% in group B, respectively. The 1-, 5- and 10-year OS (RFS) was 90 (86)%, 72 (62)%, and 49 (46)% in group A and 88 (61)%, 59 (20)%, and 29 (11)% in group B. „Salvage“ transplant was feasible in 13 (42%) out of 31 patients with recurrent HCC in group B. In this subgroup, the 1-, 5-, and 10-year OS calculated since LR was 100%, 100%, and 83%. Conclusion: For patients with “transplantable” and “resectable” HCC in this retrospective analysis, primary LT offered better overall and recurrence-free survival compared to primary liver resection. Intention-to-treat RCTs are needed.

Outcome of ABO-incompatible adult living-donor liver transplantation for patients with hepatocellular carcinoma

Introduction: Living-donor liver transplantation can simultaneously cure hepatocellular carcinoma and underlying liver cirrhosis, improving long-term results in patients with hepatocellular carcinoma. ABO-incompatible living-donor liver transplantation could expand the living-donor pool, reduce waiting times for deceased-donor liver transplantation, and improve long-term survival for some patients with hepatocellular carcinoma. Method: We retrospectively reviewed the medical records of patients undergoing living-donor liver transplantation for hepatocellular carcinoma from November 2008 to December 2015 at a single institution in Korea. In total, 165 patients underwent ABO-incompatible and 753 patients underwent ABO-compatible living-donor liver transplantation for hepatocellular carcinoma. Result: We performed 1:1 propensity score matching and included 165 patients in each group, finding that ABO-incompatible recipients underwent desensitization to overcome the ABO blood-group barrier, including pre-transplant plasma exchange and rituximab administration (300–375 mg/m2 body surface area). ABO-incompatible and -compatible living-donor liver-transplantation groups were followed up for 48.03 and 48.68 months, respectively, with both groups showing comparable recurrence-free survival rates (hazard ratio: 1.14, 95% confidence interval: 0.68–1.90; P = 0.630) and overall patient-survival outcomes (hazard ratio 1.10, 95% confidence interval: 0.60–2.00; P = 0.763). Conclusion: These findings suggested that ABO-incompatible liver transplantation is a feasible option for hepatocellular carcinoma patients, especially those with compensated cirrhosis with HCC within conventional Milan criteria.

Immunotherapy of tacrolimus in small volume liver transplantation of rats

Objective To detect the plasma concentration of tacrolimus and the survival time of rats after small-volume liver transplantation, and to investigate the criteria for immunological rejection after small-volume liver transplantation. Methods Lewis rats and Brown Norway rats were used to establish a small volume and normal liver volume transplantation model, which were divided into 7 groups: whole liver transplantation group (WI), small volume allogeneic liver transplantation group (SI), and whole liver allograft group (WA), small volume allogeneic liver transplantation group (SA), whole liver allograft immunotherapy group (WAT), small volume allogeneic liver transplantation immunotherapy group (SAT), small volume allogeneic liver transplantation immunotherapy modulation group (SATa). Morphological and functional changes of liver tissue were studied postoperatively, AST and tacrolimus plasma concentrations were detected, and survival was recorded. Results Compared with the WA group, the inflammatory cells infiltrated in the portal area of the SA group, the inflammatory changes of the sinusoidal endothelial cells, and the proportion of TCRpositive lymphocytes increased. Four days after transplantation, peripheral blood tests showed that CD4+ CD25+ double positive lymphocytes were significantly lower in the allograft group than in the allograft group, and the positive expression rate in the SA group (0.6%) was significantly lower than that in the WA group (1.8%). The differences were statistically significant (P<0.05). In the SAT group, the blood concentration of tacrolimus was significantly higher than that in the WAT group at each time point (P<0.05). The blood concentration of tacrolimus in the SATa group was relatively stable, and the plasma concentration of the SATa group was stable. And AST was significantly lower than the SAT group, the differences were statistically significant (P<0.05). Compared with WAT group, the proliferation and apoptosis rate of hepatocytes in SAT group and SATa group were significantly increased. The proliferation of hepatocytes in SATa group was significantly higher than that in SAT group (P<0.05). Survival analysis showed that the cumulative survival rate of the WA group was 85.7%, which was significantly higher than that of the SAT group (28.6%). The difference was statistically significant (P<0.05). The cumulative survival rate of the SATa group was 51.7%. The survival time of WAt group was (57.4±25.0) days, SAT group was (28.0±29.10) days, SATa group was (39.7±29.0) days, which were longer than untreated groups. The ratio of proliferation to apoptosis (PRA) increased with increasing time of tacrolimus. Regardless of blood concentration, tacrolimus plasma concentration was positively correlated with AST (R=0.758, P<0.05), indicating RPA was inversely correlated with AST (R=-0.962, P<0.05). Conclusion The use of tacrolimus significantly prolonged the survival time of small-volume allogeneic liver transplantation rats. Adjusting the amount of tacrolimus under the guidance of tacrolimus plasma concentration and AST serum value equation TD=-0.494TC-0.0035AST+ 260.487 to make the blood concentration relatively stable, it can further extend the allogeneic liver transplantation rat time to live. Key words: Small volume liver transplantation; Tacrolimus; Immune rejection

The power of tumor sizes in predicting the survival of solitary hepatocellular carcinoma patients.

BackgroundVascular invasion, rather than tumor size, was applied into the 7th edition of the AJCC TNM staging system to predict survival of solitary hepatocellular carcinoma (HCC) patients. However, does this mean tumor size is of little value in prognostic prediction? The current study was designed to explore the prognostic ability of tumor sizes in solitary HCC.MethodsA total of 18 591 patients with solitary HCC categorized as T1 and T2 were retrieved from the Surveillance Epidemiology and End Results (SEER) database. The Cox proportional hazards regression model was adopted to evaluate the impact of tumor sizes on overall survival (OS) and disease‐specific survival (DSS) in general and in subgroups stratified by vascular invasion and surgery type.ResultsLarge tumor sizes (>39 mm) were associated with unfavorable clinicopathologic characteristics. Compared with tumors ≤30 mm, tumors between 31‐50 mm and tumors >50 mm showed significantly worse OS and DSS in general using multivariate analysis (all P < 0.001). In subgroup analyses, for patients without vascular invasion, tumor size was a notable prognostic indicator for OS in the radiofrequency ablation group (P < 0.001), rather than in the liver resection or transplantation group. Nevertheless, for patients with vascular invasion, tumor sizes exhibited a notable impact on OS in the liver resection and transplantation group.ConclusionsThe AJCC TNM staging system for solitary HCC would be more comprehensive if tumor sizes were integrated into the T2 classification. Additionally, for T1 patients, tumor sizes play no role in the choice between resection and transplantation.

Long-term outcomes of combined hepatocellular-cholangiocarcinoma after hepatectomy or liver transplantation: A systematic review and meta-analysis

Combined hepatocellular-cholangiocarcinoma (cHCC-CC) is a rare primary liver malignancy. We conducted a systematic review and meta-analysis to assess the evidence available on the long-term outcomes of cHCC-CC patients after either hepatectomy or liver transplantation (LT). Relevant studies published between January 2000 and January 2018 were identified by searching PubMed and Embase and reviewed systematically. Data were pooled using a random-effects model. A total of 42 observational studies involving 1691 patients (1390 for partial hepatectomy and 301 for LT) were included in the analysis. The median tumor recurrence and 5-year overall survival (OS) rates were 65% (range 38%-100%) and 29% (range 0-63%) after hepatectomy versus 54% (range 14%-93%) and 41% (range 16%-73%) after LT, respectively. Meta-analysis found no significant difference in OS and tumor recurrence between LT and hepatectomy groups. Hepatectomy rather than LT should be considered as the prior treatment option for cHCC-CC.

Meta-analysis of patient survival and rate of alcohol relapse in liver-transplanted patients for acute alcoholic hepatitis.

This review investigated survival and alcoholic relapse following liver transplantation (LT) in patients with severe acute alcoholic hepatitis (AH) without 6months of alcohol abstinence. All studies comparing acute AH patients undergoing LT with a control group were included. CENTRAL, MEDLINE, and Web of Science databases were searched. Survival benefits or odds ratios (OR) and 95% confidence intervals (CI) were assessed by meta-analyses using a random effects model. The study was registered in PROSPERO (CRD42017057971). According to the search results, two separate meta-analyses were performed: meta-analysis A compared early LT with medical therapy alone in patients with severe AH that were not responding to medical therapy and meta-analysis B compared LT outcome in patients with AH and chronic alcoholic cirrhosis (AC). The search yielded 2232 articles. Eight studies were included in the two meta-analyses-two studies in meta-analysis A and six studies in meta-analysis B. The two studies (n = 70) included in meta-analysis A revealed that 1-year patient survival was significantly higher in the LT group compared with the medical therapy-alone group (survival benefit, 15.88; 95% CI, 3.98-63.35; p < 0.0001). The six studies in meta-analysis B (including 1091 patients) showed that 1-year (survival benefit, 1.65; 95% CI, 0.95-2.89; p = 0.08), 3-year (survival benefit, 1.31; 95% CI, 0.79-2.18; p = 0.30), and 5-year survival (survival benefit, 1.54; 95% CI, 0.92-2.56; p = 0.10) were not significantly different between AH and AC groups. There was no significant difference in the rate of alcohol relapse between the groups (OR, 1.26; 95% CI, 0.53-2.96; p = 0.60). Early LT is a life-saving treatment for AH patients that do not respond to medical therapy. The chance of alcohol relapse after LT is not increased in selected patients.

Using 99mTc-DTPA galactosyl human serum albumin liver scintigraphy as a prognostic indicator in jaundice-free patients with biliary atresia

BackgroundWe evaluated the clinical significance of follow-up data, including 99mTc-DTPA galactosyl human serum albumin (99mTc-GSA) liver scintigraphy data, as prognostic indicators for jaundice-free patients with biliary atresia (BA). MethodsOf 87 patients who underwent Kasai portoenterostomy (KP) between 1991 and 2012, 45 jaundice-free patients aged 1–2 years underwent 99mTc-GSA scintigraphy and were classified into 2 groups: those who survived with a native liver (Group A, n = 34) and those who required liver transplantation (LTx) (Group B, n = 11). We compared 99mTc-GSA scintigraphy data (HH15, LHL15, and HH15/LHL15 [H/L15]) and liver function test (LFT) results between the groups. The patients underwent a second 99mTc-GSA scintigraphy at approximately 5 years of age. ResultsAll patients survived. HH15, H/L15, total bilirubin, direct bilirubin, gamma-glutamyl transpeptidase, and alanine transaminase levels were higher in Group B than in Group A (p<0.05). Total and direct bilirubin levels were associated with H/L15 (p<0.05). There were no significant changes in results between the first and second 99mTc-GSA scintigraphy in Group A. ConclusionsMid- and long-term prognoses may be predicted using 99mTc-GSA scintigraphy data and LFTs in patients aged 1–2 years. We recommend regular monitoring of postoperative data following KP, even in jaundice-free patients. Level of evidenceIII.

Salvage liver transplantation or repeat hepatectomy for recurrent hepatocellular carcinoma: an intent-to-treat analysis

The salvage liver transplantation (LT) strategy was conceived for initially resectable and transplantable hepatocellular carcinoma (HCC) to obviate upfront transplantation, with salvage LT in the case of recurrence. The aim of this study was to perform an intention-to-treat analysis of overall survival (OS) comparing these 2 strategies for initially resectable and transplantable recurrent HCC. From 1994 to 2011, 391 patients with HCC who underwent salvage LT (n = 77) or a second resection (n = 314) were analyzed. Of 77 patients in the salvage LT group, 21 presented with resectable and transplantable recurrent HCC and 18 underwent transplantation. Of 314 patients in the second resection group, 81 presented with resectable and transplantable recurrent HCC and 81 underwent a second resection. The 5-year intention-to-treat OS rates, calculated from the time of primary hepatectomy, were comparable between the 2 strategies (72% for salvage transplantation versus 77% for second resection; P = 0.57). In patients who completed the salvage LT or second resection procedure, the 5-year OS rates, calculated from the time of the second surgery, were comparable between the 2 strategies (71% versus 71%; P = 0.99). The 5-year disease-free survival (DFS) rates were 72% following transplantation and 18% following the second resection (P < 0.001). Similar results were observed after propensity score matching. In conclusion, although the 5-year OS rates were similar in the salvage LT and second resection groups, the salvage LT strategy still achieves better DFS. Second resection for recurrent HCC might be considered to be the best alternative option to LT in the current organ shortage.

Liver Transplantation in the Treatment of Unresectable Hepatocellular Carcinoma in the Absence of Liver Cirrhosis

Aim. The aim of the study is to determine the effectiveness of liver transplantation (LT) in the treatment of unresectable hepatocellular carcinoma (HCC) occurred in normal liver.Material and methods. 6 patients with unresectable HCC underwent orthotopic liver transplantation (OLT). The long-term OLT results were compared with survival results of liver resection in patients with late stage HCC.Results. Hepatocellular carcinoma is one of the most common types of cancer, which occurs mainly in patients with liver cirrhosis and chronic viral hepatitis. Only about 10 % of HCC develops in non-cirrhotic liver among young and somatically healthy patients. 1-, 3-, 5-year recurrence-free and overall survival in LT group was significantly better than in the control group.Conclusion. LT is indicated for patients with unresectable HCC in non-cirrhotic liver and its extrahepatic localization. A large tumor size and macrovascular invasion should not be a contraindication for LT in such patients.

Hereditary amyloidosis related to transthyretin V30M: disease progression in treated and untreated patients.

Hereditary amyloidosis related to transthyretin V30M (hATTR V30M) is a progressive length-dependent sensorimotor axonal neuropathy. We aimed to compare the disease progression of treated [liver transplantation (LT) or tafamidis] versus untreated patients with hATTR V30M. A total of 81 patients with hATTR V30M were included: 27 untreated, 25 treated with LT and 29 undergoing tafamidis treatment. Neuropathy was assessed at baseline, 12, 24 and 36months after study entry. We evaluated disease stage, modified polyneuropathy disability (mPND) score and a composite neurophysiological score comprised of sensory and motor conduction parameters. The effect of treatment on disease progression was analysed using linear mixed-effects modelling. At baseline, patients from the untreated group were older (P<0.01) and those in the LT group had longer disease duration than those in the tafamidis group (P<0.05). Gender, mPND and motor scores at study entry were equal in the three groups; however, the untreated group had lower sensory scores compared with the tafamidis group (P<0.01). During the 3-year follow-up period, progression to stage II of the disease was seen only in the untreated group. The progression on mPND, sensory and motor scores was significantly higher in the untreated patients. When treated groups were compared, the LT group had lower rates of composite neurophysiological score progression. However, the sensory score outcome was similar between tafamidis responders and LT patients. Both LT and tafamidis therapy modified the natural history of hATTR V30M by reducing neuropathy progression.

Comparison of Induction and Maintenance Immunosuppression Regimens in Intestinal and Multivisceral Transplant

Aim Induction and maintenance immunosuppression regimens in intestinal transplant widely vary among centers. The aim of this study was to investigate an association between immunosuppression regimens and transplant outcomes. Methods We examined the patients who underwent primary intestinal/multivisceral transplant between January 1, 2001 and March 31, 2017 by using the United Network Organ Sharing registry. Intestine transplant without liver graft group and intestine and liver transplant group were separately analyzed. Patients were categorized based on immunosuppression regimens. Induction regimen groups included none, anti-thymocyte globulin (ATG) with or without rituximab, basiliximab, and alemtuzumab. Additional maintenance agent groups included none, mycophenolic acid, and sirolimus/everlolimus (mTOR-i). Graft and patient survival, death associated with infection, and incidence of acute rejection were evaluated using Cox and logistic multivariable analyses. Risks were adjusted for recipient age/ethnicity/functional status, donor age, and ischemia time. Results A total of 1676 patients were eligible for this study (intestine without liver [n=780], intestine with liver [n=896]). In the intestine without liver group, alemtuzumab (hazard ratio [HR]=0.56, P=0.012) and mTOR-i (HR=0.62, P=0.026) showed significantly better graft survival, compared with ATG+rituximab and no additional maintenance agent, respectively. In the intestine with liver group, there was no induction regimen superior to others regarding graft/patient survival, whereas a risk of death associated with infection was lowest in the ATG+rituximab group and highest in the alemtuzumab group (HR=3.324, P=0.034). The mTOR-i group showed significantly better graft outcome in intestine and liver transplant (HR=0.476, P=0.003 [Ref. no additional maintenance agent]).A risk of acute rejection was significantly higher in the groups of ATG alone or almtuzumab, compared with the ATG+rituximab group, regardless of a graft type.Conclusion Our results suggested that alemtuzumab induction with mTOR-i as an additional maintenance agent seemed appropriate in intestinal transplant without liver graft, and that ATG+rituximab induction with mTOR-i may be better option in intestinal transplant with liver graft.

Health-Related Quality of Life Comparisons After Radical Therapy for Early-Stage Hepatocellular Carcinoma

BackgroundFor cancer patients, health-related quality of life (HRQoL) is as important as other key outcomes, such as overall survival and tumor-free survival. Liver transplantation (LT), resection, and radiofrequency ablation (RFA) are 3 radical therapies for hepatocellular carcinoma (HCC) that result in similar survival. The main objective of this study was to assess and compare long-term HRQoL scores for patients with early-stage (tumor diameter ≤3 cm) HCC after LT, resection, or RFA. MethodsA total of 128 HCC patients with a single tumor ≤3 cm and who agreed to undergo LT, resection, or RFA were included in the present analysis. Postoperative HRQoL was evaluated by using the Medical Outcomes Study 36-Item Short Form Health Survey questionnaire. The 3 groups were compared at the 6-month and 3-year time points. ResultsThe 3 groups showed comparable 3-year HCC recurrence rates (P > .05). Compared with the LT and resection groups, the RFA group had significantly higher scores for bodily pain, general health, and vitality 6 months after surgery (all P values < .05). Moreover, at 3 years after surgery, the RFA group had higher scores for bodily pain and vitality than the other 2 groups (P < .05) and a higher general health score than the resection group. Other aspects of HRQoL were comparable among the 3 groups at both time points. ConclusionsDue to its comparable HCC recurrence rate and superior long-term HRQoL scores relative to other radical therapies, RFA may be the first-choice treatment for solitary early-stage HCC.

Number of cholangitis episodes as a prognostic marker to predict timing of liver transplantation in biliary atresia patients after Kasai portoenterostomy

BackgroundCholangitis may affect liver failure of biliary atresia (BA) patients after Kasai portoenterostomy (KP). We examined whether the number of cholangitis episodes could be a prognostic marker for liver transplant (LT) in children with BA after Kasai portoenterostomy (KP).MethodsData for BA patients born after 1998 and undergoing KP were obtained from National Health Insurance Research Database (NHIRD), Taiwan. Patients were followed up until the end of 2011. Incidence and the number of cholangitis episodes were recorded and compared between patients based on LT status.ResultsNinety-six (26.8%) of the 366 BA patients underwent LT. More patients who underwent KP at < 60 days of age survived with their native liver (P = 0.007). The mean age at first cholangitis was 0.9 years and 0.8 years in the LT and non-LT groups, respectively (P = 0.868). The cumulative incidence of cholangitis within 2 years after KP did not differ between the groups (hazard ratio 1.2; 95% CI 0.9–1.6). However, the total number of cholangitis episodes was higher in the LT group within 2 years after KP (P < 0.001).ConclusionsCholangitis occurrence was not related to LT in the first 2 years after KP in BA patients, but the number of cholangitis episodes could be a prognostic marker for future LT.

Outcomes of Liver Transplantation Using Pediatric Deceased Donor Livers: A Single-Center Analysis of 102 Donors.

Background:The outcome of pediatric deceased donor liver transplantation (LT) has not been well studied, especially pediatric deceased donor livers used in adult transplantation. This study aimed to evaluate the efficacy of LT using pediatric deceased donor livers and compare the outcomes between pediatric-to-pediatric LT and pediatric-to-adult LT.Methods:A retrospective review of LT using pediatric deceased donor livers from June 2013 to August 2016 was performed. The patients were divided into the pediatric-to-pediatric LT group and pediatric-to-adult LT group based on the ages of the recipients. The survival and incidence of early vascular complications (VCs) were observed between the two groups. We also analyzed the risk factors of early VCs in pediatric LT and the effect of donor hypernatremia on the prognosis of recipients.Results:There were 102 cases of LT using pediatric deceased donor livers in our hospital from June 2013 to August 2016, 83 pediatric-to-pediatric LT (recipients’ age ≤13 years) and 19 pediatric-to-adult LT (recipients’ age ≥19 years). The ratio of early VC was similar in the two groups (19.3% vs. 10.6%, P = 0.514). Low body weight of recipient was an independent risk factor of early VC in pediatric LT (odds ratio: 0.856, 95% confidence interval: 0.752–0.975, P = 0.019). The 1-year cumulative survival rates of grafts and patients were 89.16% and 91.57% in pediatric-to-pediatric LT and 89.47% and 94.74% in pediatric-to-adult LT, respectively (all P > 0.05). In all cases, patients using donors with hypernatremia (serum sodium levels ≥150 mmol/L) had worse graft survival (χ2=4.330, P = 0.037).Conclusions:Pediatric-to-pediatric LT group has similar graft and patient survival rates with those of pediatric-to-adult LT group. Low body weight of recipients is an independent risk factor of early VC in pediatric LT. Patients using donors with hypernatremia have worse graft survival.

Evaluation the efficacy and safety of simultaneous splenectomy in liver transplantation patients: A meta-analysis.

Background:Simultaneous splenectomy during liver transplantation (LT) is debated. The present meta-analysis assessed the efficacy and safety of splenectomy on the outcome of LT patients.Methods:We searched PubMed, Embase, and Wanfang databases for relevant studies published until the date of July 15, 2017. Quality assessment of the included studies was performed using a modified Newcastle-Ottawa Scale judgment. The data were analyzed using RevMan5.3 software.Results:A total of 16 studies consisting of 2198 patients (892 patients received splenectomy during LT [SPLT group] and 1306 patients received LT only [LT group]) were included in the present meta-analysis. Efficacy analysis revealed that pooled hazard ratio for overall survival (OS) between 2 groups was not significantly different (hazard ratio = 1.03; 95% confidence interval [CI]: 0.71–1.50). SPLT group had less postoperative rejection (odds ratio [OR] = 0.63, 95% CI: 0.50–0.79) and small for size syndrome (OR = 0.23, 95% CI: 0.07–0.79). SPLT group had significantly lower preoperative platelet (mean difference [MD] = −17.23, 95% CI: −19.54, −14.91), but significantly higher postoperative platelet (MD = 170.45, 95% CI: 108.33–232.56). Conversely, SPLT group had significant higher preoperative portal pressure (MD = 1.54, 95% CI: 0.75–2.33) and significant lower postoperative portal pressure (MD = −1.17, 95% CI: −2.24, −0.11). Safety analysis revealed that SPLT group had significantly longer operation time (MD = 56.66, 95% CI: 35.96–77.35), more intraoperative blood loss (MD = 1.08, 95% CI: 0.25–1.91), and more intraoperative red blood cell (RBC) transfusion (MD = 3.77, 95% CI: 3.22–4.33). Furthermore, SPLT group had significantly higher incidence of postoperative hemorrhage (OR = 3.07, 95% CI: 1.92–4.91), postoperative thrombosis (OR = 3.63, 95% CI: 1.06–12.45), and perioperative infection (OR = 2.62, 95% CI: 1.76–3.90). In addition, perioperative mortality was significantly higher in the SPLT group (OR = 3.14, 95% CI: 1.31–7.52). Postoperative hospital stay did not differ significantly between 2 groups (OR = −1.75, 95% CI: −3.66–0.16).Conclusions:Splenectomy benefits LT patients in increasing platelet count. However, splenectomy is a morbid procedure as splenectomy increases operation time, intraoperative blood loss, intraoperative RBC transfusion, and postoperative complications. Splenectomy does not improve OS but increase perioperative mortality. Therefore, splenectomy should be performed only in selective patients.

Optimized postconditioning algorithm protects liver graft after liver transplantation in rats

BackgroundIschemia reperfusion injury (IRI) causes postoperative complications and influences the outcome of the patients undergoing liver surgery and transplantation. Postconditioning (PostC) is a known manual conditioning to decrease the hepatic IRI. Here we aimed to optimize the applicable PostC protocols and investigate the potential protective mechanism. MethodsThirty Sprague–Dawley rats were randomly divided into 3 groups: the sham group (n = 5), standard orthotopic liver transplantation group (OLT, n = 5), PostC group (OLT followed by clamping and re-opening the portal vein for different time intervals, n = 20). PostC group was then subdivided into 4 groups according to the different time intervals: (10 s × 3, 10 s × 6, 30 s × 3, 60 s × 3, n = 5 in each subgroup). Liver function, histopathology, malondialdehyde (MDA), myeloperoxidase (MPO), expressions of p-Akt and endoplasmic reticulum stress (ERS) related genes were evaluated. ResultsCompared to the OLT group, the grafts subjected to PostC algorithm (without significant prolonging the total ischemic time) especially with short stimulus and more cycles (10 s × 6) showed significant alleviation of morphological damage and graft function. Besides, the production of reactive oxidative agents (MDA) and neutrophil infiltration (MPO) were significantly depressed by PostC algorithm. Most of ERS related genes were down-regulated by PostC (10 s × 6), especially ATF4, Casp12, hspa4, ATF6 and ELF2, while p-Akt was up-regulated. ConclusionsPostC algorithm, especially 10 s × 6 algorithm, showed to be effective against rat liver graft IRI. These protective effects may be associated with its antioxidant, inhibition of ERS and activation of p-Akt expression of reperfusion injury salvage kinase pathway.

Prediction of post-TACE necrosis of hepatocellular carcinoma usingvolumetric enhancement on MRI and volumetric oil deposition on CT, with pathological correlation.

To investigate whether volumetric enhancement on baseline MRI and volumetric oil deposition on unenhanced CT would predict HCC necrosis and response post-TACE. Of 115 retrospective HCC patients (173 lesions) who underwent cTACE, a subset of 53 HCC patients underwent liver transplant (LT). Semiautomatic volumetric segmentation of target lesions was performed on dual imaging to assess the accuracy of predicting tumour necrosis after TACE in the whole cohort and at pathology in the LT group. Predicted percentage tumour necrosis is defined as 100 % - (%baseline MRI enhancement - %CT oil deposition). Mean predicted tumour necrosis by dual imaging modalities was 61.5 % ± 31.6%; mean percentage tumour necrosis on follow-up MRI was 63.8 % ± 31.5 %. In the LT group, mean predicted tumour necrosis by dual imaging modalities was 77.6 % ± 27.2 %; mean percentage necrosis at pathology was 78.7 % ± 31.5 %. There was a strong significant correlation between predicted tumour necrosis and volumetric necrosis on MRI follow-up (r = 0.889, p<0.001) and between predicted tumour necrosis and pathological necrosis (r = 0.871, p<0.001). Volumetric pre-TACE enhancement on MRI and post-TACE oil deposition in CT may accurately predict necrosis in treated HCC lesions. • Imaging-based tumour response can assist in therapeutic decisions. • Lipiodol retention as carrier agent in cTACE is a tumour necrosis biomarker. • Predicting tumour necrosis with dual imaging potentially obviates immediate post-treatment MRI. • Predicting tumour necrosis would facilitate further therapeutic decisions in HCC post-cTACE. • Pre-TACE MRI and post-TACE CT predict necrosis in treated HCC.