Living Donor LT Research Articles

Liver transplantation for hepatocellular carcinoma in India: Are we ready for 2040?

Liver transplantation (LT) for hepatocellular carcinoma (HCC) has been widely researched and is well established worldwide. The cornerstone of this treatment lies in the various criteria formulated by expert consensus and experience. The variations among the criteria are staggering, and the short- and long-term out comes are controversial. To study the differences in the current practices of LT for HCC at different centers in India and discuss their clinical implications in the future. We conducted a survey of major centers in India that performed LT in December 2022. A total of 23 responses were received. The centers were classified as high- and low-volume, and the current trend of care for patients und ergoing LT for HCC was noted. Of the 23 centers, 35% were high volume center (> 500 Liver transplants) while 52% were high-volume centers that performed more than 50 transplants/year. Approximately 39% of centers had performed > 50 LT for HCC while the percent distribution for HCC in LT patients was 5%-15% in approximately 73% of the patients. Barring a few, most centers were divided equally between University of California, San Francisco (UCSF) and center-specific criteria when choosing patients with HCC for LT, and most (65%) did not have separate transplant criteria for deceased donor LT and living donor LT (LDLT). Most centers (56%) preferred surgical resection over LT for a Child A cirrhosis patient with a resectable 4 cm HCC lesion. Positron-emission tomography-computed tomography (CT) was the modality of choice for metastatic workup in the majority of centers (74%). Downstaging was the preferred option for over 90% of the centers and included transarterial chemoembolization, transarterial radioembolization, stereotactic body radiotherapy and atezolizumab/bevacizumab with varied indications. The alpha-fetoprotein (AFP) cut-off was used by 74% of centers to decide on transplantation as well as to downstage tumors, even if they met the criteria. The criteria for successful downstaging varied, but most centers conformed to the UCSF or their center-specific criteria for LT, along with the AFP cutoff values. The wait time for LT from down staging was at least 4-6 wk in all centers. Contrast-enhanced CT was the preferred imaging modality for post-LT surveillance in 52% of the centers. Approximately 65% of the centers preferred to start everolimus between 1 and 3 months post-LT. The current predicted 5-year survival rate of HCC patients in India is less than 15%. The aim of transplantation is to achieve at least a 60% 5-year disease free survival rate, which will provide relief to the prediction of an HCC surge over the next 20 years. The current worldwide criteria (Milan/UCSF) may have a higher 5-year survival (> 70%); however, the majority of patients still do not fit these criteria and are dependent on other suboptimal modes of treatment, with much lower survival rates. To make predictions for 2040, we must prepare to arm ourselves with less stringent selection criteria to widen the pool of patients who may undergo transplantation and have a chance of a better outcome. With more advanced technology and better donor outcomes, LDLT will provide a cutting edge in the fight against liver cancer over the next two decades.

Living donor liver transplant in acute on chronic liver failure grade 3: Who not to transplant

Background and AimLiver transplantation(LT)offers definitive treatment for acute on chronic liver failure(ACLF) patients. This study was done to analyze and compare the outcomes of living donor LT(LDLT) in patients with ACLF versus Chronic liver disease(CLD) and within the grades of ACLF. Factors affecting mortality in patients with ACLF and ACLF grade3 (ACLF3) following LDLT were also derived. MethodsRecords of adult LDLT between 1/2/2017 and 30/9/2021 were analyzed. ACLF was classified based on EASL-CLIF definition. Post-transplant outcomes of ACLF were compared with CLD and within ACLF grades. Post LDLT mortality predictors were identified in ACLF and ACLF3 patients. ResultsOut of 853 patients who had LT in that period; 704 patients with CLD and 103 with ACLF [of which 54 (52.42%) had ACLF3] underwent LDLT. The one month and one-year post LDLT mortality was 8.81% and 9.80% in CLD; 19.42% and 31.06% in ACLF; and 25.92% and 38.89% in ACLF3 respectively. On log regression analysis, use of grafts from older donors and pre-operative respiratory failure in recipients was associated with poor survival in ACLF, while respiratory failure was a predictor of poor survival in ACLF3 following LDLT. ConclusionOutcomes following LDLT are poorer in ACLF as compared to after CLD. Higher donor age and preoperative respiratory failure with PF Ratio<200 were associated with poor survival post LDLT in ACLF and ACLF3.

NAFLD: A pretransplant and post-transplant conundrum.

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Demographics, aetiology and outcome of paediatric acute liver failure in Singapore.

The aetiology of paediatric acute liver failure (PALF) varies widely according to age, and geographic and socioeconomic factors. This study aimed to examine the epidemiology, aetiology and outcome of PALF in Singapore at a single centre. A retrospective review was performed of patients aged 0-18 years who were diagnosed with PALF from 2007 to 2019. PALF was defined by: absence of chronic liver disease; biochemical evidence of acute liver injury; and coagulopathy, non-correctible by vitamin K, defined as prothrombin time (PT) ≥20 seconds or international normalised ratio (INR) ≥2.0 regardless of hepatic encephalopathy (HE) or PT ≥15 seconds or INR ≥1.5 in the presence of HE. 34 patients were included. Median age at diagnosis was 10 months (range 7 days to 156 months). The top three causes of PALF were indeterminate (41.2%), metabolic (26.5%) and infectious (26.5%) aetiologies. A metabolic disorder was the most frequent aetiology in infants <12 months (38.9%), whereas an indeterminate cause was the most common in children >12 months (50%). No cases of viral hepatitis A or B presenting with PALF were detected. Overall spontaneous recovery rate (survival without liver transplantation [LT]) was 38.2%, and overall mortality rate was 47.1%. Six patients underwent living-donor LT, and the post-transplant survival at one year was 83.3%. The aetiologic spectrum of PALF in Singapore is similar to that in developed Western countries, with indeterminate aetiology accounting for the majority. PALF is associated with poor overall survival; hence, timely LT for suitable candidates is critical to improve survival outcomes.

Impact of COVID-19 on Liver Transplantation in Hong Kong and Singapore: A Modelling Study.

BackgroundLiver transplantation (LT) activities during the COVID-19 pandemic have been curtailed in many countries. The impact of various policies restricting LT on outcomes of potential LT candidates is unclear.MethodsWe studied all patients on the nationwide LT waitlists in Hong Kong and Singapore between January 2016 and May 2020. We used continuous time Markov chains to model the effects of different scenarios and varying durations of disruption on LT candidates.FindingsWith complete cessation of LT, the projected 1-year overall survival (OS) decreased by 3•6%, 10•51% and 19•21% for a 1-, 3- and 6-month disruption respectively versus no limitation to LT, while 2-year OS decreased by 4•1%, 12•55%, and 23•43% respectively. When only urgent (acute-on-chronic liver failure [ACLF] or acute liver failure) LT was allowed, the projected 1-year OS decreased by a similar proportion: 3•1%, 8•41% and 15•20% respectively. When deceased donor LT (DDLT) and urgent living donor LT (LDLT) were allowed, 1-year projected OS decreased by 1•2%, 5•1% and 8•85% for a 1-, 3- and 6-month disruption respectively. OS was similar when only DDLT was allowed. Complete cessation of LT activities for 3-months resulted in an increased projected incidence of ACLF and hepatocellular carcinoma (HCC) dropout at 1-year by 49•1% and 107•96% respectively. When only urgent LT was allowed, HCC dropout and ACLF incidence were comparable to the rates seen in the scenario of complete LT cessation.InterpretationA short and wide-ranging disruption to LT results in better outcomes compared with a longer duration of partial restrictions.FundingNone to disclose.

Living donor liver transplantation for small infants aged less than 6 months: The experience of a single institute

PurposeLiver transplantation (LT) for small infants < 6 months old is rare but becoming common as perioperative care improves. In Taiwan, living donor LT (LDLT) has expanded indications but is rarely performed for this age group because of unfavorable outcomes in the literature. We evaluated LDLT outcomes of patients <6 months old. MethodsWe identified infants < 6 months old undergoing LDLT between 2004 and 2019 at our hospital. Variables related to recipients, donors, surgeries, and outcomes were analyzed. ResultsNine patients were identified. Indications for LT were biliary atresia (n = 2), Alagille syndrome (n = 1), protein C deficiency (n = 1), and acute liver failure (n = 5), including two patients with neonatal hemochromatosis, one with herpes simplex hepatitis, one with giant cell hepatitis with autoimmune hemolytic anemia, and one with hemophagocytic lymphohistiocytosis. Median age and weight at LT were 129 days and 4.8 kg, respectively. Graft types included left lateral segment (LLS, n = 4), hyper-reduced LLS (n = 4), and monosegment (n = 1). The median graft-to-recipient weight ratio was 4%. The median follow-up period was 14 months (range, 8 days to 127 months) with two mortalities, and two patients were totally weaned off immunosuppressants. Adjuvant therapies were required for patients with giant cell hepatitis and hemophagocytosis. Preoperative reconstructive imaging for estimating graft thickness facilitated surgical planning. ConclusionAlthough LDLT is difficult to perform for small infants, outcomes are favorable and mainly dependent on underlying causes in addition to technical innovations.

Comparative study of the safety and efficacy of SMOFlipid vs non SMOFlipid as TPN for liver transplantation

BackgroundLiver transplantation (LT) is one of the widely recognised and leading treatments for end-stage liver disease. Nutrition impacts its success. Total parenteral nutrition (TPN) is usually prescribed for patients recommended prolonged fasting after LT. The supplement of SMOFlipid (soybean oil, MCT oil, olive oil, and fish oil) is easily metabolised to produce energy, and it possesses anti-inflammatory effects; however, SMOFlipid emulsion use raises concerns regarding coagulopathy after LT. This study investigated the postoperative correlation between SMOFlipid and coagulation in LT. Materials and methodsThe medical records of 54 recipients of living donor LT between January 2012 and June 2015 were retrospectively reviewed. Patients with pretransplant platelet count <40,000/μL and >40,000/μL were assigned to the non-SMOFlipid (n = 23) group and the SMOFlipid (n = 31) group, respectively. ResultsThe coagulation and nutrition profile of patients improved significantly after TPN support. No significant difference was observed in the coagulation profile between SMOFlipid and non-SMOFlipid groups. Although the SMOFlipid group exhibited a higher platelet count than the non-SMOFlipid group on day 7 (P < 0.001), no significant differences were observed in the platelet count on 14 and 30 days after TPN support between the 2 groups. ConclusionTPN using SMOFlipid after LT is a good strategy for improving nutritional status without increasing the risks of bleeding and coagulation in patients intolerant of early enteral nutrition. Moreover, SMOFlipid use may not cause coagulopathy up to 14 days after LT. Overall, SMOFlipid provides nutritional benefits without increasing the risk of bleeding.

Neurological complications after living-donor liver transplantation in children

AimLiver transplantation (LT) has been used as a definitive management for children with end-stage liver disease or acute liver failure. Living-donor LT (LDLT) has been a common type of LT performed in Asian countries, including Japan, where deceased donors are rarely available. However, the neurological complications (NCs) associated with LDLT remain unknown. The purpose of this study was to clarify the characteristics of NCs in children after LDLT. MethodsThis study is a retrospective observational study carried out at a tertiary children’s hospital in Japan. We studied children who had undergone LDLT between January 2001 and January 2020. ResultsWe examined 602 cases of LT, of which 559 were LDLT cases (92.9%). NCs after LT were present in 21 cases (3.8%). The most common neurological symptoms were seizure (n = 17), whereas disturbance of consciousness without seizure was observed in four cases. The frequency of NCs for each of the indications was 12.2% for fulminant hepatic failure, 6.5% for metabolic liver disease, and 0.7% for cholestatic liver disease. InterpretationWe report the characteristics of NCs after LDLT in children. The frequency of NCs after LT was high in cases of fulminant hepatic failure and metabolic diseases, who might have had neurological symptoms or impaired consciousness before LT.

Efficacy of Living Donor Liver Transplantation in Patients with Methylmalonic Acidemia.

PurposeDespite aggressive medical and nutritional management, patients with methylmalonic acidemia (MMA) often suffer from multi-organ damage. Early deceased donor liver transplantation (DDLT) has emerged as an intervention to prevent disease progression. We investigated the efficacy of living donor LT (LDLT) with a potential carrier of MMA and a small volume of graft in patients with MMA as an alternative to DDLT.MethodsOf five patients (three male, two female; median age 5.7 years; range, 1.3–13.7 years), four underwent carrier LDLT, while one underwent non-carrier auxiliary LDLT. All patients received pre- and post-LT continuous renal replacement therapy and were provided with minimal restriction diet according to serum MMA level after LT. MMA levels in the serum and urine, the incidence of metabolic crisis, and clinical findings before and after LT were compared.ResultsThe survival rate was 100% during 2.2 years of follow up period after LT. In all five cases, MMA titer in the serum after transplantation decreased with less restrictive diet. Metabolic crisis was not observed during the follow-up period. In addition, no patient showed progression of severe renal impairment requiring hemodialysis. Progression of delayed cognitive development was not observed. Social functioning with improved neuropsychiatric development was observed.ConclusionThis study showed that LDLT achieved improved quality of life with less restrictive diet, therefore it could be a feasible alternative option to DDLT for the treatment of patients with MMA, even with an auxiliary LT.

LIVER TRANSPLANTATION AT BASKENT UNIVERSITY

Background: The only potentially lifesaving intervention for acute liver failure or end-stage liver disease is liver transplant. All over the world, the common indications for liver transplant include hepatitis B, hepatitis C, alcoholic cirrhosis, and hepatocellular carcinoma. However, some more unusual liver diseases, such as liver-based metabolic abnormalities and tumor metastasis, can be treated with liver transplant. The aim of this study was to evaluate the outcomes of liver transplant at our center. Methods: The liver transplantation program at Baskent University began in December 1988. After this transplantation the first LDLT in children in Turkey, the Middle and Near East, and Europe was performed in March 1990, the first LDLT in adult in the World was performed in April 1990, first combined liver-kidney transplantation was performed in the World in May 1992 at Baskent University. We retrospectively analyzed the results of 672 patients who underwent liver transplant from 1988 to October 2020 at our liver transplant center in Turkey. Results: Four hundred fifty-eight of the patients were living donor LT, 214 of them were deceased donor LT. Thee-hundred and eleven (46.2%) of the patients were pediatric, 361 (53,8%) of them were adult. The most common etyology for pediatric liver transplantation was biliary atresia (20%) and, hepatitis B (57%) for adult liver transplantation. In the pediatric group, 5-year surviv al rates of patients was 90%, and 10-year survival rates of patients was 81%, in the adult group, the 5-year survival rate was 79.3% and the 10-year survival rate was 74%. Conclusions: In our center, we perform living-donor liver transplants more than deceased-donor liver transplant because of the paucity of organ donation. Considering acceptable postoperative complications, liver transplant is a lifesaving treatment for liver failure. Careful evaluation of recipients before transplant plays a critical step in curative treatment.

Immunosuppressant therapeutic drug monitoring and trough level stabilisation after paediatric liver or kidney transplantation.

Immunosuppressive therapy must be guided by therapeutic drug monitoring (TDM) in paediatric liver (LT) and kidney transplantation (KT) patients to prevent under- and overdosing, which have clinical consequences. The purpose of our study was to analyse TDM results in our institutions and evaluate factors associated with blood level stabilisation after LT and KT. Blood levels of immunosuppressants were measured by immunoassay analysis. We compared blood level stabilisation between LT and KT, and evaluated associated factors in a retrospective study in two Swiss university hospitals. Forty-six patients (27 LT [median age 1.0 y], 19 KT [15.1 y]) were included. During the first month after transplantation, 32.8% (LT) and 41.2% (KT) of tacrolimus, and 22.1% (KT) of ciclosporin trough levels (measured before the next dose) were within target. In KT, trough levels stabilised earlier for tacrolimus than for ciclosporin (p = 0.02). Intensive care and hospital discharge occurred earlier in KT patients (p &lt;0.001). Living-donor LT was associated with an earlier intensive care discharge compared with deceased donor (5.5 vs 11 days, p = 0.02). Primary metabolic disease and graft/recipient weight-ratio &ge;0.03 was associated with earlier tacrolimus level stabilisation (14 vs 18 days, p = 0.01 and 15 vs 22 days, p = 0.05, respectively). In KT, recipient age (&ge;15.1 years) and weight (&ge;39.4 kg) were associated with an earlier trough level stabilisation (both 13 days vs not reached, p &lt;0.001), and age with earlier hospital discharge (10 vs 14 days, p = 0.02). Immunosuppressant trough levels were often outside the target range in the first month after LT and KT. Organ-specific factors were associated with trough stabilisation.

Secondary non-resectable liver tumors: A single-center living-donor and deceased-donor liver transplantation case series

BackgroundDuring the last decades, deceased-donor liver transplantation (DDLT) has gained a place in the therapeutic algorithm of well-selected patients harbouring non-resectable secondary liver tumors. Living-donor LT (LDLT) might represent a valuable means to further expand this indication for LT. MethodsBetween 1985 and 2016, twenty-two adults were transplanted because of neuroendocrine (n = 18, 82%) and colorectal metastases (n = 4, 18%); 50% received DDLT and 50% LDLT. In LDLT, 4 (36%) right and 7 (64%) left grafts were used; the median graft-to-recipient-weight ratios (GRWR) were 1.03% (IQR 0.86%-1.30%) and 0.59% (IQR 0.51%-0.91%), respectively. Median post-LT follow-up was 64 months (IQR 17–107) in the DDLT group and 40 months (IQR 35–116) in the LDLT group. DDLT and LDLT recipients were compared in terms of overall survival, graft survival, postoperative complications and recurrence. ResultsThe 1- and 5-year actuarial patient survivals were 82% and 55% after DDLT, 100% and 100% after LDLT, respectively (P < 0.01). One- and 5-year actuarial graft survivals were 73% and 36% after DDLT, 91% and 91% after LDLT (P < 0.01). The outcomes of right or left LDLT were comparable. Donor hepatectomy proved safe, and one donor experienced a Clavien IIIb complication. Bilirubin peak was significantly lower after left hepatectomy compared with that after right hepatectomy [1.3 (IQR 1.2–2.2) vs. 3.3 (IQR 2.3–5.2) mg/dL; P = 0.02]. ConclusionsThe more recent LDLT series compared favorably to our DDLT series in the treatment of secondary liver malignancies. The absence of portal hypertension and the use of smaller left grafts make recipient and donor surgeries safe. The safety of the procedures and lack of interference with the scarce allograft pool are expected to lead to a more frequent use of LDLT in the field of transplant oncology.

Biliary reconstruction before clamp removal to avoid portal vein thrombosis in pediatric living-donor liver transplantation using hyper-reduced left lateral segment grafts: A novel technical strategy.

LT has become the treatment of choice for children with end-stage liver disease. The scarcity of donors and the considerable mortality on waiting lists have propelled the related living-donor techniques, especially in small children. This population need smaller and good quality grafts and are usually candidates to receive a LLS from a related donor. Many times this grafts are still large and do not fit in the receptor's abdomen, so a further hyper-reduction may be required. Despite all advances in LT field, vascular complications still occur in a considerable proportion remaining as a significant cause of morbidity, graft loss, and mortality. Technical issues currently play an essential role in its genesis. The widely spread technique for biliary and vascular reconstruction in living donor LT (LDLT) nowadays implies removal of the portal vein (PV) clamp after the venous anastomosis, then the arterial reconstruction is done, followed by the biliary reconstruction. However, due to the posterior location of the LLS bile duct, for its reconstruction, a rotation of the liver is required risking a potential transient PV occlusion leading to thrombosis afterward. We describe a new technique that involves performing biliary reconstruction after the PV anastomosis and before removing the vascular clamp, thus allowing to freely rotate the liver with less risk of PV occlusion and thrombosis.

Liver transplantation: When to say yes or no? Based on a case report

BackgroundLiver transplantation (LT) is the gold standard therapy for end-stage liver diseases (ESLD) worldwide. Over the past decades, multiple strategies have been developed in order to optimize allograft/recipient outcomes and decrease patient morbidity/mortality. However, maintaining an appropriate balance between “using a limited resource” (i.e. available organs) and “reducing waitlist mortality” arises multiple ethical concerns. AimIn this report we aimed to address some ethical issues related to a case that occurred in our institution in which liver re-transplantation was performed in a patient with cirrhosis and hepatocellular carcinoma (HCC) as an emergent life-saving therapy. ConclusionsWe conclude that expanding the donor pool (e.g. living donor LT, use of extended criteria donors, donation after cardiac death, bridging therapies to delay the necessity of transplantation) is a way to compensate the growing discrepancy between donors and recipients; however, this needs to be evaluated in each individual patient in order to obtain the maximum benefit.

The Predictive Ability of the Glasgow Prognostic Score and Variants in Both Deceased Donor and Living Donor Liver Transplantation for Hepatocellular Cancer

AimLiver transplantation (LT) is the most promising treatment method in hepatocellular cancer (HCC). Due to the shortage of organ donors and the possible risks associated with living donation, the selection of patients for LT is critical. The aim of this study is to investigate the predictive ability of the Glasgow Prognostic Score (GPS), modified GPS (mGPS), and hepatic GPS (hGPS) on prognoses in a patient group who underwent deceased donor LT (DDLT) or living-donor LT (LDLT) for HCC. Patients and MethodsThis study includes 62 DDLT and 55 LDLT patients who underwent LT for HCC between 1998 and 2016 in a single center. The study endpoints were recurrence, 0- to 1-year mortality, 0- to 3-year mortality, mortality, and overall survival (OS). ResultsThe median follow-up time was 70.24 ± 48.47 months. GPS and hGPS positivity were found to be prognostic indicators of 0- to 3-year mortality and overall mortality in DDLT (P = .012, P = .006; P = .044 and P = .022 respectively). In the LDLT group, GPS was found to be effective in predicting 0- to 1-year and 0- to 3-year mortality (P = .045, P = .022 respectively); GPS and hGPS were also found to be effective in predicting overall mortality (P = .001 and P = .046 respectively). The OS was significantly longer in the GPS 0 group and hGPS 0 group compared to the GPS 1-2 and hGPS 1-2 group in both DDLT and LDLT. ConclusionThe findings of this study and the literature indicate that using GPS and hGPS is appropriate in selecting patients with HCC who are candidates for LT.

Living donor liver transplantation for alcoholic liver disease; does abstinence correlate with recidivism?

Introduction: The traditional “6 months rule” for ALD is becoming debatable with recent evidences showing comparable outcomes without a pre-fixed abstinence period. Method: Abstinence of minimum 3 months being the standard, was made flexible in selected cases where patients' clinical condition with good social support merited early Liver Transplant. Outcomes of all spectrums of ALDs undergoing LT between “June 2011 to September 2017" were analyzed. Recidivism was defined as any alcohol intake after LT and was compared between three groups (A up to 3 months, B 4 to 6 months and C > 6 months). Results: Out of total 159 ALD patients, 148 underwent Living donor LT ad 11 had diseased donor LT. The mean MELD Na was 24 and 65 patients (40.8%) had score > 25. Amongst living donors, 97(65%) were female family members. The median abstinence period was 8 months (range 1 to 84) with 64(43.2%) patients had < 6 months and 23(15.5%) had < 3 months of sobriety. Out of 148 patients, 9 (6.08%) had recidivism, out of which 5(55.5%) died within 6 months. The recidivism rates were 2(8.7%) in Group A, 3(7.3%) in B and 4(4.8%) in C (p value 0.72).The overall survival was significantly lesser in the recidivism group compared to those who didn't resume to alcohol (44.5% vs 89.8%, p = 0.004). Conclusion: Abstinence didn't predict recidivism, provided a promising social support along with strong commitment from patient. Specifically in LDLT settings, abstinence can be made more flexible to benefit patients with high MELD.

Pretransplant trends in α-fetoprotein levels as a predictor of recurrence after living donor liver transplantation for unresectable hepatoblastoma: A single-institution experience.

LT is a practical therapeutic alternative for unresectable hepatoblastoma; however, deciding when to perform LT is difficult. The aim of this study was to optimize the timing of LT for hepatoblastoma using pretransplant trends in AFP levels. Trends in pretransplant AFP levels and their influence on post-transplant outcomes were retrospectively evaluated. All patients who underwent living donor LT for hepatoblastoma in our institution since 2002 were included. Variables analyzed included history of prior tumor resection, pretransplant AFP responses to chemotherapy, metastatic disease at diagnosis, and post-transplant chemotherapy. Eight patients (seven boys and one girl; median age, 35months; range, 15months-12years) were transplanted. The overall post-transplant recurrence-free survival rate was 62.5% (5/8) with a mean follow-up of 77months. Patients with post-transplant recurrence showed a 0.573 log increase in AFP levels after the last chemotherapy session before LT. This was significantly higher than the 0.279 log decrease observed in patients without post-transplant recurrence (P=.024). Because the AFP response cannot be accurately predicted before each cycle of chemotherapy, it may be appropriate to perform LT when AFP levels do not decrease after the last cycle and before they are found to be elevated again.

The use of hepatitis B immunoglobulin with or without hepatitis B vaccine to prevent de novo hepatitis B in pediatric recipients of anti-HBc-positive livers.

Prophylactic measures are used to reduce DNHB after HBsAg-negative patients receive anti-HBc-positive liver grafts. This study investigated the incidence of DNHB and clinical outcomes in pediatric LT recipients under HBIG prophylaxis, with or without hepatitis B vaccination. Between 1995 and 2013, 51 HBsAg-negative pediatric recipients underwent living-donor LT from anti-HBc-positive donors. The median (range) age was 4 (0.1-17) years, 23 (45%) were male, and 71% were negative for both anti-HBc and anti-HBc. During a median follow-up of 12.1 (0.06-19.9) years, 13 (25.4%) developed DNHB; 7 of the 13 achieved HBsAg seroconversion after administration of LAM or ETV. Among studied patients, 20 (39%) received hepatitis B vaccination, and 2 of them (10%) developed DNHB. At last follow-up, 41% (21/51) discontinued HBIG either after successful HBV vaccination (n=17) or retransplantation with anti-HBc-negative grafts (n=4). In conclusion, pediatric LT recipients of anti-HBc-positive grafts, most of them were naïve to HBV infection, were at high risk of DNHB, and consistent monitoring for the early detection of DNHB was necessary. A combination use of post-LT vaccination is promising prophylactic strategy against DNHB.

Cost Analysis and Determinants of Living Donor Liver Transplantation in Taiwan

BackgroundLiver transplantation (LT) has become established therapy for end-stage liver disease and small-cell hepatocellular carcinoma (HCC), relying mainly on living donor LT (LDLT) in Taiwan. The cost of LDLT varies in different countries depending on the insurance system, the costs of the facility, and staff. In this study we aimed to investigate cost outcomes and determinants of LDLT in Taiwan. MethodsFrom January 2014 to December 2015, 184 LDLT patients were enrolled in a study performed at the Kaohsiung Chang Gung Memorial Hospital. Patients' transplantation costs were defined as expense from immediately after surgery to discharge during hospitalization for LDLT. Antiviral therapy and hepatitis B immunoglobulin (HBIG) for prevention of hepatitis B virus (HBV) were included, but direct-acting antiviral (DAA) therapy for hepatitis C (HCV) was excluded. ResultsThe median total, intensive care unit (ICU), and ward costs of LT were US$64,250, $43,357, and $16,138 (currency ratio 1:30), respectively. HBV significantly increased the total cost of LT, followed by postoperative reintubation and bile duct complications. ConclusionThe charges associated with anti-HBV viral therapy and HBIG increase the cost of LDLT. Disease severity of liver cirrhosis showed less importance in predicting cost. Postoperative complications such as reintubation or bile duct complications should be avoided to reduce the cost of LT.

Incidence and Outcome of Small-for-Size Liver Grafts Transplanted in Adult Recipients

Small-for-size liver transplantation (SFS-LT) carries high morbidity and mortality after transplantation. SFS-LT is usually associated with living-donor or deceased-donor split LT; however its incidence and outcome are poorly defined in adult LT recipients who receive whole grafts (WLT). In this study, we retrospectively reviewed our cohort of 3,106 deceased-donor LT in adult recipients. We found that among the 31 split LTs, 11 (35.5%) were SFS. In contrast, there only 1.08% of the whole-graft transplants (31 out of 2,868) were SFS. Although less common, SFS-WLT is associated with poorer long-term outcome of both graft and patient survivals.