Donor Liver Grafts Research Articles

Strategies for a successful hepatic artery anastomosis in liver transplantation: A review of 51 cases

Hepatic artery reconstruction is a critical aspect of liver transplantation. The microsurgeon faces several challenges when reconstructing the hepatic artery-the donor hepatic artery stalk is short and often a poor match for the usually hypertrophic recipient vessels. Previous inflammation impedes vessel dissection, and recipient vessels have a tendency to delaminate with manipulation. We review 51 consecutive liver transplantations to highlight these problems and propose strategies for a successful reconstruction of the hepatic artery. A prospective study involving all adult patients undergoing liver transplantation at the Singapore General Hospital from January 2015 to December 2018 was undertaken. All hepatic artery anastomoses were performed by 2 microsurgeons at 10x magnification. Patients were started on a standard immunosuppressive regimen. Postoperative ultrasound scans on days 1, 3, 5, 7, 9 and 14 were used to confirm arterial patency. There were 51 patients who underwent liver transplantation during the study period. Of this number, 31 patients received deceased donor grafts and 20 received living donor grafts. A total of 61 anastomoses were performed (5 dual anastomosis, 4 radial artery interposition grafts) with 1 case of hepatic artery thrombosis that was successfully salvaged. The mean (range) postoperative resistive index and hepatic artery peak systolic velocity were 0.69 (0.68-0.69) and 1.0m/s (0.88-1.10m/s), respectively. Hepatic artery thrombosis after liver transplantation is poorly tolerated. The challenges of hepatic artery reconstruction in liver transplantation are related to vessel quality and length. The use of microsurgical technique, appropriate recipient vessel selection, minimisation of vessel manipulation with modified instruments, variation in anastomosis techniques, and use of radial artery interpositional grafts are useful strategies to maximise the chances of success.

Liver transplantation for benign liver tumors.

Benign liver tumors are common lesions that are usually asymptomatic and are often found incidentally due to recent advances in imaging techniques and their widespread use. Although most of these tumors can be managed conservatively or treated by surgical resection, liver transplantation (LT) is the only treatment option in selected patients. LT is usually indicated in patients that present with life-threatening complications, when the lesions are diffuse in the hepatic parenchyma or when malignant transformation cannot be ruled out. However, due to the significant postoperative morbidity of the procedure, scarcity of available donor liver grafts, and the benign course of the disease, the indications for LT are still not standardized. Hepatic adenoma and adenomatosis, hepatic hemangioma, and hepatic epithelioid hemangioendothelioma are among the most common benign liver tumors treated by LT. This article reviews the role of LT in patients with benign liver tumors. The indications for LT and long-term outcomes of LT are presented.

Middle hepatic vein incorporation in live donor liver graft transplantation; implication and safety

Background: In this study, we have used the middle hepatic vein with the right lobe, and we studied the venous outflow dynamics immediately after transplant retrospectively meanwhile we studied the impact of the graft function on donor functionality and overall donor safety. 
 Method: Between October 2017 to October 2020, we performed 40 adult to adult live donor liver transplants at Zheen International Hospital (Erbil, Kurdistan Region). Postoperative Doppler ultrasound was performed for recipients and donors immediately after surgery and then daily until discharge. 
 Results: The donor age (28.5 ± 6.9) year, male/ female 19/ 21, intensive care unit stay (1.2 ± 0.43), floor stay (5.2 ± 1.4) days, their portal vein velocity (43.5 ± 18.4 ml/sec), hepatic artery resistive index (0.6 ± 0.09) and triphasic/ continuous venous outflow 30/10, their postoperative day one and at the discharge total serum bilirubin were (2.8 ± 1.8) and (2 ± 1.4), their postoperative day one and at the discharge international normalization ratio were (1.7 ± 0.5) and (1.2 ± 0.2) respectively. The recipient age (48.5 ± 11.3), male/female 27/13, intensive care unit stay (4.75 ± 3.9), floor stay (7.7 ± 3.7) days, portal vein velocity (63.96 ± 24.65 ml/sec), hepatic artery peak systolic velocity (74.76 ± 32.85) hepatic artery resistive index (0.7 ± 0.15), and triphasic/continuous venous outflow 27/13. 
 Conclusions: Middle hepatic vein incorporation in live donor liver graft is safe with a favorable outcome for recipient and donor, doppler US is one the important tool for evaluation and follow up of donor and recipient for detection of vascular complications and assessment of venous outflow and graft function. In addition, early discharge of the donor is a reasonable option. 

Use of liver grafts from cadaveric donors: Implementation impact of a local evaluation and procurement team in Mexico

Introduction and aimsCadaveric donor liver graft retrieval is complex in Mexico. The aim of the present article was to present the experience in liver graft use during the first year of work of a local evaluation and procurement team. Materials and methodsWe reviewed the organ donation report forms and allocation offer records covering the time frame of December 15, 2017 to December 15, 2018, and registered the donor characteristics, causes of organ discard, causes of declined offers, transport time, and graft and recipient survival at 30 days. ResultsThere were 17 donations and we completed the evaluation of 14. Two donors were considered ideal (14.2%) and 12 were expanded criteria donors (ECDs) (85.7%). Two grafts with steatosis were not offered (14.2%). Twelve liver grafts were offered 88 times (mean 7.6 offers per graft). The acceptance rate was 6% for public hospitals and 23.6% for private hospitals (p = 0.016). One graft was discarded during the procurement process due to steatosis. The rate of use after evaluation was 78.5% (11/14). All the grafts were procured by the local team and 9 (81.8%) were transported by commercial airline (median 240 min, range 85 min). Graft and recipient survival at 30 days was 100%. ConclusionsThe participation of a local evaluation and procurement team notably increased liver graft use with excellent results. Commercial airline transportation of the grafts to all active transplantation centers of the country resulted in cold ischemia times <6 h.

Liver Transplantation in Croatia: "David Among Goliaths".

Liver Transplantation in Croatia: "David Among Goliaths".

Long-Term Renal Transplant Outcome in Patients With Posterior Urethral Valves. Prognostic Factors Related to Bladder Dysfunction Management.

Introduction: To obtain a successful renal transplant (RT) outcome in patients with posterior urethral valves (PUV), it is necessary to accomplish an adequate bladder dysfunction treatment. Our aim was to determine prognostic factors related to bladder dysfunction management in long-term RT outcome in patients with PUV.Methods: A retrospective review of patients with PUV who received a first RT after 1985 in our institution with at least 5 years of follow-up was performed. Variables analyzed included prenatal diagnosis, age of diagnosis, initial presentation and management, bladder dysfunction treatment, other surgical treatments, pre-transplant dialysis, age of transplantation, type of donor, immunosuppression regimen, vascular and urological complications, rejections episodes, and graft survival.Results: Fifty-one patients were included in the analysis. Prenatal diagnosis was done in 37.3%. Median age of diagnosis was 0.30 (0–88) months. Initial presentation was vesicoureteral reflux (VUR) in 78% and obstructive ureterohydronefrosis in 35.3%. Initial management was valve ablation (29.4%), pyelo-ureterostomy (64.7%), and vesicostomy (5.9%). In 33.3%, a type of bladder dysfunction treatment was performed: 21.6% bladder augmentation (BA), 15.7% Mitrofanoff procedure, 17.6% anticholinergic drugs, and 27.5% clean intermittent catheterization (CIC). Pre-transplant dialysis was received by 66.7%. Transplantation was performed at 6.28 ± 5.12 years, 62.7% were cadaveric and 37.3% living-donor grafts. Acute rejection episodes were found in 23.6%. Urological complications included recurrent urinary tract infections (UTIs) (31.4%); native kidneys VUR (31.4%); graft VUR (45.1%); and ureteral obstruction (2%). Vascular complications occurred in 3.9%. Mean graft survival was 11.1 ± 6.9 years. Analyzing the prognostic factor that influenced graft survival, patients with had CIC or a Mitrofanoff procedure had a significant better long-term graft survival after 10 years of follow-up (p < 0.05), despite of the existence of more recurrent UTIs in them. A better graft survival was also found in living-donor transplants (p < 0.05). No significant differences were observed in long-term graft survival regarding native kidneys or graft VUR, BA, immunosuppression regimen, or post-transplant UTIs.Conclusion: Optimal bladder dysfunction treatment, including CIC with or without a Mitrofanoff procedure, might result in better long-term graft survival in patients with PUV. These procedures were not related to a worse RT outcome in spite of being associated with more frequent UTIs.

Diagnostic accuracy of Doppler ultrasound for detecting hepatic artery stenosis after liver transplantation

To evaluate the diagnostic accuracy of Doppler ultrasound (DUS) in detecting hepatic artery stenosis (HAS) after liver transplantation using computed tomography angiography (CTA) as the reference standard. This study included data from January 2005 to November 2017, where DUS of the hepatic artery of living and deceased donor liver grafts were compared with the reference standard, CTA. DUS parameters, such as intrahepatic artery (IHA) peak systolic velocity (PSV), resistive index (RI), systolic acceleration time (SAT); and extrahepatic artery (EHA) PSV were taken. The optimum cut-off was estimated using area under the receiver operating characteristic curve (AUC). Multivariable logistic regression analysis was developed to predict HAS. Ninety-nine liver transplant cases were retrieved, 50 met the inclusion criteria where nine patients had significant HAS. HAS patients had a significantly low IHAPSV with a cut-off of 35.1 cm/s (sensitivity 53.8%, specificity 78.4%, AUC 0.701). IHARI had a significantly low RI with a cut-off 0.585 (sensitivity 86.7%, specificity 85.4%, AUC 0.913). The IHASAT cut-off was 0.045 seconds (sensitivity 80%, specificity 91.4%, AUC 0.857). The EHAPSV cut-off was 197.4 cm/s (sensitivity 50%, specificity 99.1%, AUC 0.648). The prediction model using DUS parameters IHARI and IHASAT demonstrated good discrimination with an AUC of 0.930 (95% CI: 0.843, 1.000; sensitivity 93.3%, specificity 88%). A prediction model using the DUS parameters IHARI and IHASAT showed good diagnostic accuracy of 88.6% for monitoring liver transplant patients. If validated externally, this DUS model could be utilised to diagnose HAS in liver transplant recipients.

Association between neutrophil\u2013lymphocyte ratio change during living donor liver transplantation and graft survival

Preoperative neutrophil–lymphocyte ratio (NLR), has shown a predictive value in living donor liver transplantation (LDLT). However, the change in the NLR during LDLT has not been fully investigated. We aimed to compare graft survival between the NLR increase and decrease during LDLT. From June 1997 to April 2019, we identified 1292 adult LDLT recipients with intraoperative NLR change. The recipients were divided according to NLR change: 103 (8.0%) in the decrease group and 1189 (92.0%) in the increase group. The primary outcome was graft failure in the first year. In addition, variables associated with NLR change during LDLT were evaluated. During 1-year follow-up, graft failure was significantly higher in the decrease group (22.3% vs. 9.1%; hazard ratio 1.87; 95% confidence interval 1.10–3.18; p = 0.02), but postoperative complications did not differ between two groups. This finding was consistent for the overall follow-up. Variables associated with NLR decrease included preoperative NLR > 4, model for end-stage liver disease score, intraoperative inotropic infusion and red blood cell transfusion, and operative duration. The least absolute shrinkage and selection operator model yielded similar results. NLR decrease during LDLT appeared to be independently associated with graft survival. Further studies are needed to confirm our findings.

Risk Factors for Endoscopic Biliary Tract Interventions Following Orthotopic Liver Transplantation: An Analysis of 10,252 Patients over 15 Years Across the United States

Introduction: Endoscopic biliary tract interventions following orthotopic liver transplantation (OLT) are being utilized more commonly now with advancements in endoscopic technique and technology. This study assesses the risk factors for endoscopic procedures following OLT. Method: Data on 10,252 OLT patients from the National Inpatient Sample database who underwent post-transplant endoscopic biliary procedures (EBP) was analyzed over a 15-year period (2001-2016). Results: 581 patients who had EBP were identified. Of these, 467 (80.4%) had ERCP, sphincterotomy and stenting. The remainder had ERCP alone. EBP and non-EBP patients had a similar demographic and comorbidity profile. The strongest risk factors for EBP post-OLT on multivariate analysis were biliary anastomotic stricture (OR 6.1), bile leak/fistula (OR 5.4), choledocholithiasis (OR 5.0), cholangitis (OR 4.2), age>60 (OR 2.1), living donor graft (OR 1.9), and emergency admission status (OR 1.1), p< 0.05. Conversely, roux-en-y hepaticojejunostomy and age< 20 were associated with fewer EBP, p< 0.05. EBP was associated with a significantly longer length of stay (98.3% stayed over 1 week), and higher risk of post-procedure biliary sepsis (23.2% vs 11.8%), graft abscess (11.4% vs 6%), acute graft rejection (46.1% vs 18.4%), and inpatient mortality (7.2% vs 5.3%), p< 0.05. Conclusions: OLT recipients who develop postoperative biliary complications (especially anastomotic strictures), older than 60, have living donor grafts and have non-elective admissions are at highest risk of undergoing EBP. Although unavoidable in many situations, EBP is associated with significantly greater morbidity and mortality post-OLT. Clinicians must be cognizant of these risks when considering EBP in OLT recipients. Clinical Profile of 10,252 Liver Transplant Patients from the NIS Database (2001-2016)

Approach for outflow reconstruction and reperfusion in LDLT with a right lobe graft

Presenter: Nicolas Goldaracena MD | University of Virginia Health System Background: Living donor liver transplantation (LDLT) emerged to overcome the organ shortage and reduce waitlist mortality. However, is a technically demanding operation that requires careful preoperative preparation, as well as a meticulous surgery. To reduce the risk of small for size syndrome, a balance between a sufficient graft size, the degree of the recipient’s portal hypertension and adequate outflow reconstruction to avoid venous congestion of the graft are mandatory. Different approaches are being utilized to perform an optimal outflow reconstruction during LDLT. However, proper graft positioning, enlarged outflow openings and reconstruction of venous outflow of all liver sectors are crucial to achieve a congestion-free graft. Methods: A video abstract is presented illustrating the approach used for venous outflow reconstruction and graft reperfusion during LDLT with a right lobe graft. Results: The living donor graft consisted of a right lobe without the middle hepatic vein (MHV). As venous outflow, the graft had a dominant right hepatic vein (RHV), an accessory segment 6/7 vein and a segment 8 vein that needed reconstruction for optimal graft venous drainage. The approach used consists of performing a total caval clamping that facilitates a wide opening of the recipient’s vena cava, as anastomosis sites, while ensuring an optimal graft positioning and orientation. Once the RHV and segment 6/7 vein are reconstructed, the outflow of the anterior sector (segment 8 vein) is temporarily clamped to be reconstructed sequentially to the MHV following graft reperfusion. Therefore, portal vein anastomosis is then performed and following the release of the caval clamps the graft is reperfused via the portal vein. Once the graft is reperfused, the anastomoses of the graft segment 8 vein to the recipient’s MHV is performed with an interposition cadaveric iliac vein that was previously anastomosed to the segment 8 vein of the graft in the backtable. Conclusion: In our opinion, total caval clamping in LDLT ensures the possibility of providing enlarged outflow openings without compromising graft positioning and orientation. Therefore, this approach allows an optimal venous outflow and a congestion free graft in LDLT. In addition, in order to shorten the total caval clamping time, sequential reconstruction of the anterior sector veins of right lobe grafts can be safely performed following reperfusion of the graft.

The ERA-EDTA Registry Annual Report 2018: a summary.

BackgroundThe European Renal Association – European Dialysis and Transplant Association (ERA-EDTA) Registry collects data on kidney replacement therapy (KRT) via national and regional renal registries in Europe and countries bordering the Mediterranean Sea. This article summarizes the 2018 ERA-EDTA Registry Annual Report, and describes the epidemiology of KRT for kidney failure in 34 countries.MethodsIndividual patient data on patients undergoing KRT in 2018 were provided by 34 national or regional renal registries and aggregated data by 17 registries. The incidence and prevalence of KRT, the kidney transplantation activity and the survival probabilities of these patients were calculated.ResultsIn 2018, the ERA-EDTA Registry covered a general population of 636 million people. Overall, the incidence of KRT for kidney failure was 129 per million population (p.m.p.), 62% of patients were men, 51% were ≥65 years of age and 20% had diabetes mellitus as cause of kidney failure. Treatment modality at the onset of KRT was haemodialysis (HD) for 84%, peritoneal dialysis (PD) for 11% and pre-emptive kidney transplantation for 5% of patients. On 31 December 2018, the prevalence of KRT was 897 p.m.p., with 57% of patients on HD, 5% on PD and 38% living with a kidney transplant. The transplant rate in 2018 was 35 p.m.p.: 68% received a kidney from a deceased donor, 30% from a living donor and for 2% the donor source was unknown. For patients commencing dialysis during 2009–13, the unadjusted 5-year survival probability was 42.6%. For patients receiving a kidney transplant within this period, the unadjusted 5-year survival probability was 86.6% for recipients of deceased donor grafts and 93.9% for recipients of living donor grafts.

Whole liver deceased donor liver transplantation for pediatric recipients: single-center experience for 20 years.

BackgroundWe investigated the incidence and outcomes of pediatric deceased donor liver transplantation (DDLT) using whole liver grafts in a high-volume liver transplantation (LT) center.MethodsThe study was a retrospective single-center analysis of whole LT in pediatric recipients. The study period was set as 20 years between January 2000 and December 2019. We defined pediatric recipients and donors to be aged ≤18 years.ResultsDuring the study period, there were 98 cases of pediatric DDLT, and 34 patients (34.7%) received whole liver grafts. The age range of the deceased donors was 3 months to 56 years and that of pediatric recipients was 7 months to 17 years. Common primary diseases for LT were biliary atresia in 13, acute liver failure in four, Wilson disease in four, congenital portal vein agenesis in three, and genetic metabolic diseases in three. Pediatric-to-pediatric and adult-to-pediatric whole LTs were 22 (64.7%) and 12 (35.3%), respectively. A good correlation was noted between the donor and the recipient’s body weight, and the recipient’s body weight and allograft’s weight. Graft and overall patient survival rates were 91.2% and 91.2% at 1 year, 88.0% and 88.0% at 3 years, and 88.0% and 88.0% at 5 years, respectively.ConclusionsThe results of this study revealed that Korean Network for Organ Sharing (KONOS) regulations with donor-recipient body weight matching exhibited good performance. Considering the reciprocal trades of liver organs among pediatric and adult donors and recipients, it is necessary to establish a policy for pediatric donor liver grafts to pediatric recipients on a priority basis.

Whole liver deceased donor liver transplantation for pediatric recipients: single-center experience for 20 years

Background: We investigated the incidence and outcomes of pediatric deceased donor liver transplantation (DDLT) using whole liver grafts in a high-volume liver transplantation (LT) center. Methods: The study was a retrospective single-center analysis of whole LT in pediatric recipients. The study period was set as 20 years between January 2000 and December 2019. We defined pediatric recipients and donors to be aged ≤18 years. Results: During the study period, there were 98 cases of pediatric DDLT, and 34 pa tients (34.7%) received whole liver grafts. The age range of the deceased donors was 3 months to 56 years and that of pediatric recipients was 7 months to 17 years. Common primary diseases for LT were biliary atresia in 13, acute liver failure in four, Wilson dis ease in four, congenital portal vein agenesis in three, and genetic metabolic diseases in three. Pediatric-to-pediatric and adult-to-pediatric whole LTs were 22 (64.7%) and 12 (35.3%), respectively. A good correlation was noted between the donor and the re cipient’s body weight, and the recipient’s body weight and allograft’s weight. Graft and overall patient survival rates were 91.2% and 91.2% at 1 year, 88.0% and 88.0% at 3 years, and 88.0% and 88.0% at 5 years, respectively. Conclusions: The results of this study revealed that Korean Network for Organ Sharing (KONOS) regulations with donor-recipient body weight matching exhibited good perfor mance. Considering the reciprocal trades of liver organs among pediatric and adult do nors and recipients, it is necessary to establish a policy for pediatric donor liver grafts to pediatric recipients on a priority basis.

Anesthetic management in laparoscopic living donor hepatectomy, the first case-series in Thailand

Background: Laparoscopic living donor hepatectomy began early in 2020 at our institution. This surgery was the first case and a new experience in Thailand. Perioperative and anesthetic management should not only concern anesthetic and surgical com plications but also graft function, including ischemic time. In this paper, we review anesthetic considerations and perioperative management in laparoscopic living donor hepatectomy as a new experience in Thailand. Methods: All four living donors were selected and underwent elective laparoscopic living donor hepatectomy at the university hospital. Results: Differences in anesthetic considerations between laparoscopic liver resection in pathologic livers versus donor liver graft typically include heparin administration, intravenous indocyanine green, and prolong ischemic time after major vessels clamping. During the operation, only one case had subcutaneous emphysema and one other case had oliguria. There were no in traoperative hypothermia in all cases. All the patients were able to be extubated at the end of surgery inside the operation room. For postoperative pain control, two cases were given intravenous morphine patient-controlled analgesia, while the others were given continuous intravenous morphine infusion. However, emergent explore laparotomy was performed in one case to stop postoperative bleeding from the surgical site. Conclusions: The advantages of minimal invasive technique include a potential reduction in blood loss and transfusion require ment, lower incidence of intraoperative hypothermia, as well as decreased postoperative pain and opioid consumption. However, complications that must be taken into account include the effect of pneumoperitoneum, patient’s positioning, and emergent conversion to open surgery. As this surgery is largely dependent on the surgeon’s experience, operation time may be extended in some cases. As an anesthesiologist, practical and effective anesthetic management is essential to improve patient outcomes.

Expanding living donor liver transplantation in the Western world: changing the paradigm

: Living donor liver transplantation (LDLT) in adults emerged in response to an effective donor organ shortage created by the critical discrepancy between donor graft supply and demand. Due to the scarcity of deceased donor liver graft in most of Asia, the utilization of LDLT has grown exponentially however, this growth has not been reproduced in North America and Europe where LDLT still remains a small percentage of total liver transplants performed. Despite a growing body of evidence demonstrating superior survival outcomes in LDLT in addition to a multitude of other advantages including shorter cold ischemia times, opportunity for pre-transplant medical optimization, and expansion of transplant eligibility, concern over donor risk and technical challenges of the procedure still pose significant hurdles to increasing rates of LDLT. Overcoming these hurdles not only requires increasing center experience and minimization of donor risk, but also a major change in mentality by the Western transplant community to embrace LDLT as a compulsory, rather than discretionary, part of liver disease surgical management. Changing the paradigm to a “LDLT-first” approach at experienced, capable centers by routinely offering an LDLT option for the majority of patients undergoing transplant evaluation will reduce an unacceptably high waitlist mortality and drastically increase patients’ access to liver transplantation.

Comparing survival, tacrolimus trough level, prevalence of biliary stenosis and studying for possible early detection of biliary stenosis in liver transplant recipients at First Central Hospital of Mongolia and various high-volume foreign centers

Background: Since 2015, First Central Hospital of Mongolia independently transplanted 62 living donor liver grafts in 60 adult and pediatric patients (domestic-group). Separately, First Central Hospital of Mongolia follows-up on 243 Mongolian post-trans plant patients from foreign clinics (foreign-group). Methods: In this study, we compared these two groups for 1-year graft and patient survival, prevalence of biliary stenosis (BS), tacrolimus oral dose and trough levels, transaminase and creatinine levels. Alkaline phosphatase (ALP) of patients with radiolog ically diagnosed and endoscopically treated BS were compared to non-stenotic patients from 1 to 12 months postoperative in a bid to correlate its change with BS later on. Results: One-year recipient and graft survival in the domestic-group was 90% and 87%, respectively. Prevalence of BS in this group was 28.5%, while in the foreign-group it was 17.2%. ALP in the BS group tended to increase from the second month on and reached statistical significance on 3rd month compared (215.7 u/L; standard error of the mean [SEM], ±36.76) to control group (108.7 u/L, SEM±19.85, P=0.039). Trough tacrolimus level at 3rd year in domestic-group was 6.3 ng/mL (standard deviation [SD], ±2.9), while in foreign-group it was 3.9 (SD±1.6) ng/mL. Daily oral tacrolimus level at 3rd year in the domestic-groups was 3.8 mg/ day, while in the foreign-group it was 2.4 mg/day. Conclusions: There was no significant difference in transaminases and creatinine between the groups. Survival of recipients depend not only the surgical technique, but also on quality of follow-up. Therefore, for the domestic-group tighter adherence to scheduled check-ups and better collection of information is required. BS that would require endoscopic intervention is likely to manifest itself with a 2xULN change in ALP as early as 3rd month. Physician-controlled immunosuppressant minimization is not only safe but also is required to avoid long-term side-effects.

Korea-nationwide incidence of pediatric deceased donors and single-institutional status of liver transplantation using pediatric donor liver grafts

Korea-nationwide incidence of pediatric deceased donors and single-institutional status of liver transplantation using pediatric donor liver grafts

Kidney transplantation from living donor with monolateral renal artery fibromuscular dysplasia using a cryopreserved iliac graft for arterial reconstruction: a case report and review of the literature

BackgroundAging and mortality of patients on waiting lists for kidney transplantation have increased, as a result of the shortage of organs available all over the world. Living donor grafts represent a significant source to maintain the donor pool, and resorting successfully to allografts with arterial disease has become a necessity. The incidence of renal artery fibromuscular dysplasia (FMD) in potential living renal donors is reported to be 2–6%, and up to 4% of them present concurrent extra-renal involvement.Case presentationWe present a case of renal transplantation using a kidney from a living donor with monolateral FMD. Resection of the affected arterial segment and its subsequent replacement with a cryopreserved iliac artery graft from a deceased donor were performed. No intraoperative nor post-operative complications were reported. The allograft function promptly resumed, with satisfying creatinine clearance, and adequate patency of the vascular anastomoses was detected by Doppler ultrasounds.ConclusionLiterature lacks clear guidelines on the eligibility of potential living renal donors with asymptomatic FMD. Preliminary assessment of the FMD living donor should always rule out any extra-renal involvement. Whenever possible, resection and reconstruction of the affected arterial segment should be taken into consideration as this condition may progress after implantation.

Korea-nationwide incidence of pediatric deceased donors and single-institutional status of liver transplantation using pediatric donor liver grafts.

BackgroundThe present study intended to investigate the allocation status of pediatric deceased donor liver allografts. We analyzed the incidence of pediatric deceased donors in the Korean Network for Organ Sharing (KONOS) database and single-institutional status of liver transplantation (LT) using pediatric donors.MethodsWe assessed the nationwide incidence of pediatric donors aged ≤15 years and conducted single-center analysis of LT using pediatric donors.ResultsBetween 2010 and 2019, pediatric donors aged ≤15 years accounted for 171 out of 4,395 donors (3.9%) in the KONOS database and 31 out of 640 liver donors (4.8%) in Asan Medical Center (AMC) database. In AMC, 11 (35.5%) and 20 (64.5%) grafts were allocated to pediatric recipients aged ≤15 years and adult recipients aged ≥19 years, respectively. All nine livers from donors aged ≤5 years were implanted in pediatric recipients aged ≤5 years. From 21 donors aged ≥9 years, 16 whole liver grafts and four split extended right liver grafts were implanted in 20 adult recipients and two split left lateral section grafts were implanted in two pediatric recipients. Four split liver grafts were implanted in other institutions. The overall patient survival rates at 1, 3, and 5 years were 90.9%, 80.8%, and 80.8%, respectively in pediatric-to-pediatric LT group and 69.6%, 58.4%, and 58.4%, respectively in pediatric-to-adult LT group (P=0.21).ConclusionsMore than half of the pediatric donor livers were allocated to adult patients. Recipient criteria for allocation of liver allografts from pediatric donors need revision for children on pediatric LT waitlist.

De novo hepatocellular carcinoma in living donor liver grafts: A Japanese multicenter experience.

Direct-acting antivirals for hepatitis C virus have reduced the decompensation risk. Immunosuppressants for transplantation raise the risk of occurrence of de novo malignancies. We assessed the probabilities of and risk factors for de novo hepatocellular carcinoma (HCC) development post-living donor liver transplantation (LDLT). We retrospectively evaluated the data of developed HCC in a graft including metastatic HCC post-LDLT from 2779 adult cases collected from nine major liver transplantation centers in Japan. Of 2779 LDLT adult recipients, 34 (1.2%) developed HCCs in their grafts. Of 34, five HCCs appeared to be de novo because of a longer period to tumor detection (9.7 [6.4-15.4] years) and no HCC within the native liver of the two recipients. The donor origin of three of five de novo HCCs was confirmed using microsatellite analysis in resected tissue. Primary disease of all five was hepatitis C virus-related cirrhosis, of which two were treated with direct-acting antivirals. Four of five developed HCC de novo in the hepatitis B core antibody-positive grafts. De novo HCCs had favorable prognosis; four of five were cured with complete remission. However, recurrent HCC (n = 29) in the graft had a poorer outcome, especially in patients with neutrophil to lymphocyte ratio scores above 4 (median survival time, 262 [19-463] days). Analysis of the database from major liver transplantation institutes in Japan revealed that de novo HCCs determined by microsatellite analysis were rarely detected, but the majority were successfully treated. LDLT recipients with higher risks of de novo HCC, including those with hepatitis B core antibody-positive grafts, should be carefully followed by surveillance of the liver graft.