Related Donor Liver Transplantation Research Articles

Liver transplantation in ornithine transcarbamylase deficiency: A retrospective multicentre cohort study

Ornithine transcarbamylase deficiency (OTCD) is an X-linked defect of ureagenesis and the most common urea cycle disorder. Patients present with hyperammonemia causing neurological symptoms, which can lead to coma and death. Liver transplantation (LT) is the only curative therapy, but has several limitations including organ shortage, significant morbidity and requirement of lifelong immunosuppression. This study aims to identify the characteristics and outcomes of patients who underwent LT for OTCD.We conducted a retrospective study for OTCD patients from 5 UK centres receiving LT in 3 transplantation centres between 2010 and 2022. Patients' demographics, family history, initial presentation, age at LT, graft type and pre- and post-LT clinical, metabolic, and neurocognitive profile were collected from medical records.A total of 20 OTCD patients (11 males, 9 females) were enrolled in this study. 6/20 had neonatal and 14/20 late-onset presentation. 2/20 patients had positive family history for OTCD and one of them was diagnosed antenatally and received prospective treatment. All patients were managed with standard of care based on protein-restricted diet, ammonia scavengers and supplementation with arginine and/or citrulline before LT. 15/20 patients had neurodevelopmental problems before LT. The indication for LT was presence (or family history) of recurrent metabolic decompensations occurring despite standard medical therapy leading to neurodisability and quality of life impairment. Median age at LT was 10.5 months (6–24) and 66 months (35–156) in neonatal and late onset patients, respectively. 15/20 patients had deceased donor LT (DDLT) and 5/20 had living related donor LT (LDLT). Overall survival was 95% with one patient dying 6 h after LT. 13/20 had complications after LT and 2/20 patients required re-transplantation. All patients discontinued dietary restriction and ammonia scavengers after LT and remained metabolically stable. Patients who had neurodevelopmental problems before LT persisted to have difficulties after LT. 1/5 patients who was reported to have normal neurodevelopment before LT developed behavioural problems after LT, while the remaining 4 maintained their abilities without any reported issues.LT was found to be effective in correcting the metabolic defect, eliminates the risk of hyperammonemia and prolongs patients' survival.

Family-based consent and motivation for familial organ donation in Bangladesh: An empirical exploration.

The government of Bangladesh approved the human organ transplantation law in 1999 and updated it in 2018. This legislation approved both living-related donor and posthumous organ transplantation. The law only allows family members to legally donate organs to their relatives. The main focus of this study was to explore how Bangladeshis make donation decisions on familial organs for transplantation. My ethnographic fieldwork with forty participants (physicians and nurses, a healthcare administrator, organ donors, recipients, and their relatives) disclosed that the organ donation decision was family-based. An assessment of the relationship between religion, culture, and biomedicine leads to the conclusion that deciding on donating organs to relatives is primarily family-based and is perceived to be steeped in Islamic ethical principles and religious cultural tradition. The family-based consent and motivation for donor-recipient pair organ transplantation strengthen an altruistic environment for the family and act as the moral and legal authority that ensures ethical healthcare outcomes for Bangladeshis.

More than four decades of graft survival in pediatric kidney transplant recipients.

Early in the history of kidney transplantation, short-term graft survival was low. Yet some have had excellent long-term survival. Herein, we describe characteristics of pediatric recipients with > 40years of graft survival currently alive with a functioning first graft. We reviewed all pediatric (age < 18years) kidney transplants performed at the University of Minnesota between January 1, 1970, and December 31, 1979 (n = 148), to identify all recipients currently alive with a functioning first graft. Data are presented as medians with interquartile ranges (IQR) and proportions. We identified 10 recipients with > 40-year graft survival (median follow-up: 45.0years (IQR: 43.1, 48.1)). The median age at transplant was 13.8years (IQR: 5.1, 16.3). All recipients were white; half were male. Of the 10, 4 had glomerulonephritis, 2 had congenital anomalies of the kidney and the urinary tract, 2 had congenital nephrotic syndrome, 1 had Alport syndrome, and 1 had cystic kidney disease as kidney failure cause. Nine patients received a living-related donor transplant, and 1 patient received a deceased-donor transplant. The median estimated glomerular filtration rate at 20years post-transplant was 79.9 (IQR: 72.3, 98.4); at 30years, 67.7 (IQR: 63.2, 91.8); and at 40years, 80.3ml/min/1.73 m2 (IQR: 73.7, 86.0). None developed rejection, 5 developed hypertension, 2 developed dyslipidemia, 1 developed diabetes, and 7 patients developed malignancy (4 skin cancer, 2 breast cancer, and 1 post-transplant lymphoproliferative disease). Pediatric kidney transplant recipients may achieve > 4 decades of graft survival. Cancer is a common complication warranting vigilant screening.

WTP3.13 Management of early complications of liver transplantation from a living related donor

Abstract Aim The aim of this study is to highlight the importance of the development of adequate surgical technique, the proper selection of donors, the preparation of recipients and the introduction of new molecules of Immunosuppressants in improving liver transplant (LT) outcomes. The study also shows that early complications, occurring within the first 3 months, are responsible for two-thirds of deaths. Methods All LT candidates were assessed for contraindications to immunosuppressants, social and psychiatric assessment, and operative and infectious risk assessment. Patients who received LT were followed according to a rigorous pre-established protocol that allowed the detection of early postoperative complications and surgical revision in some cases. Results Post-operative surgical complications occurred in 04 patients who required immediaterevision surgery for hemoperitoneum, portal thrombosis that required unblockage of the TP, thrombosis of the hepatic artery requiring new arterial anastomosis and liver resection, and one patient developed an infectious complication (MAT). Three patients experienced complications related to immunosuppressants. One patient required renal dialysis. Two patients developed biliary stenosis; treated endoscopically in one patient, and biliary repair after failure of endoscopic treatment in another. Conclusion Hemorrhage, primary graft non-function, multiple organ failure and infection, acute rejection and surgical complications dominate post-LT follow-up. Immunosuppressive treatments are responsible for a significant morbidity rate. Early detection of complications and their immediate management reducing morbidity and mortality. The living related donor LT program remains an option in our country due to the impossibility of LT as part of an ODB.

Effect of transdermal immunomodulation on liver regeneration

Introduction. The use of immunomodulators to regulate reparative processes in affected organs and tissues remains a pressing issue. Of greatest interest is liver regeneration after extended hepatic resection (EHR) in donors in right lobe living related donor liver transplantation. We propose a transdermal therapeutic system (TTS) with an immunomodulator to enhance the natural process of liver tissue regeneration. Objective: to study the effect of transdermal administration of immunomodulator sodium aminodihydrophthalazinedione on early recovery processes in the liver after EHR in in vivo experiments.Materials and methods. Sodium aminodihydrophthalazinedione was used as an active substance in TTS in the form of powder for preparation of intramuscular injection solution (Galavit®, SELVIM LLC). An experimental EHR model was performed on 22 male Wistar rats weighing 350–380 g. After HER, all animals were divided into two groups. Group 1 (n = 10) consisted of untreated animals. In group 2 (n = 12), TTS was applied immediately after liver resection. The experiment lasted for 48 hours; the TTS was changed once after 24 hours from the beginning of application.Results. In either group, there was no significant difference in the weight of liver remnant gain and in biochemical blood parameters at 48 hours after EHR. Assessment of the mitotic index (MI) of hepatocytes 48 hours after EHR revealed a significant increase in MI in both groups in comparison with the baseline (before liver resection) equal to 0.14 ± 0.07‰. The MI in group 1 and group 2 animals was 12.70 ± 4.9‰ and 17.43 ± 4.90‰, respectively (p ≤ 0.05).Conclusion. Studies on the regenerative activity of sodium aminodihydrophthalazinedione TTS on an experimental EHR model in rats showed that this drug form had a pronounced stimulating effect on the mitotic activity of liver cells.

Hyperleucinosis during infections in maple syrup urine disease post liver transplantation

Maple syrup urine disease (MSUD) is due to biallelic variants in one of the three genes: BCKDHA, BCKDHB, and DBT. Branched-chain alpha-ketoacid dehydrogenase complex deficiency and elevated leucine, valine, isoleucine and alloisoleucine in body fluids are the results. We report hyperleucinosis during intercurrent illnesses in six patients with MSUD post liver transplantation. Patient charts were retrospectively reviewed. Data was entered into an Excel Database. Literature was reviewed. Six patients with MSUD were included who had post liver transplantation hyperleucinosis during an intercurrent illness. Five had encephalopathy. One received hemodialysis for the management of hyperleucinosis. All patients had unrestricted diet. Additionally, there were five patients (one patient included into the current study) reported in the literature. We suggested management considerations for the follow-up of patients with MSUD post liver transplantation after the first episode of unexplained encephalopathy or signs of acute hyperleucinosis during intercurrent illness due to our clinical experience: 1) Healthy: Unrestricted diet and monitoring of leucine levels; 2) Illness: a) home illness management: increased carbohydrate intake b) illness management at hospital: intravenous dextrose, intravenous lipid and daily plasma amino acid monitoring. We report hyperleucinosis and/or encephalopathy as a rare event post liver transplantation in MSUD as a multicenter case series. Hyperleucinosis and/or encephalopathy may occur in both related and unrelated donor liver transplantation. Based on the long-term follow-up of those patients, these suggested management considerations may be revised as per the patients' needs.

Pediatric ABO-incompatible Living Related Donor Liver Transplantation: Experience from Indian Subcontinent

We present our experience with pediatric ABO-incompatible liver transplantation in India. Data of patients 64 requiring plasmapheresis. All 8 patients survived without rejection/biliary issues. Mean (range) of post-transplant hospital stay was 19.1 (13-22) d and follow-up period was 38.1 (7.1-84.4) mo. Pediatric ABO-incompatible liver transplantation can be successfully performed using plasmapheresis with optimal immune-suppression and vigilant post-op monitoring.

SCYL1 disease and liver transplantation diagnosed by reanalysis of exome sequencing and deletion/duplication analysis of SCYL1

SCYL1 disease results from biallelic pathogenic variants in SCYL1. We report two new patients with severe hepatic phenotype requiring liver transplantation. Patient charts reviewed. DNA samples and skin fibroblasts were utilized. Literature was reviewed. 13-year-old boy and 9-year-old girl siblings had acute liver insufficiency and underwent living related donor liver transplantation in infancy with no genetic diagnosis. Both had tremor, global developmental delay, and cognitive dysfunction during their follow-up in the medical genetic clinic for diagnostic investigations after their liver transplantation. Exome sequencing identified a likely pathogenic variant (c.399delC; p.Asn133Lysfs*136) in SCYL1. Deletion/duplication analysis of SCYL1 identified deletions of exons 7-8 in Patient 1. Both variants were confirmed in Patient 2 and the diagnosis of SCYL1 disease was confirmed in both patients at the age of 13 and 9 years, respectively. SCYL1 protein was not expressed in both patients' fibroblast using western blot analysis. Sixteen patients with SCYL1 disease reported in the literature. Liver phenotype (n = 16), neurological phenotype (n = 13) and skeletal phenotype (n = 11) were present. Both siblings required liver transplantation in infancy and had variable phenotypes. Exome sequencing may miss the diagnosis and phenotyping of patients can help to diagnose patients.

The association of living donor source with patient and graft survival among kidney transplant recipients in the ERA-EDTA Registry - a retrospective study.

SummaryIn this study we aimed to compare patient and graft survival of kidney transplant recipients who received a kidney from a living‐related donor (LRD) or living‐unrelated donor (LUD). Adult patients in the ERA‐EDTA Registry who received their first kidney transplant in 1998–2017 were included. Ten‐year patient and graft survival were compared between LRD and LUD transplants using Cox regression analysis. In total, 14 370 patients received a kidney from a living donor. Of those, 9212 (64.1%) grafts were from a LRD, 5063 (35.2%) from a LUD and for 95 (0.7%), the donor type was unknown. Unadjusted five‐year risks of death and graft failure (including death as event) were lower for LRD transplants than for LUD grafts: 4.2% (95% confidence interval [CI]: 3.7–4.6) and 10.8% (95% CI: 10.1–11.5) versus 6.5% (95% CI: 5.7–7.4) and 12.2% (95% CI: 11.2–13.3), respectively. However, after adjusting for potential confounders, associations disappeared with hazard ratios of 0.99 (95% CI: 0.87–1.13) for patient survival and 1.03 (95% CI: 0.94–1.14) for graft survival. Unadjusted risk of death‐censored graft failure was similar, but after adjustment, it was higher for LUD transplants (1.19; 95% CI: 1.04–1.35). In conclusion, patient and graft survival of LRD and LUD kidney transplant recipients was similar, whereas death‐censored graft failure was higher in LUD. These findings confirm the importance of both living kidney donor types.

PNPLA3 L148M (rs738409) polymorphism as a risk for new onset diabetes mellitus and obesity in non-NASH/cryptogenic living related donor liver transplant recipients

BackgroundLiver transplantation is considered the main treatment for end stage liver disease and the early stages of hepatocellular carcinoma. Long-term metabolic outcomes after liver transplantation affect morbidity and mortality, and the genetic rule has not been well studied for such complications. The patatin-like phospholipase domain-containing 3 (PNPLA3) gene L148M (rs738409) polymorphism has been associated with a wide spectrum of metabolic affection, but mainly fatty liver, in the general population. Here, we demonstrate the impact of the PNPLA3 polymorphism on living related donor liver transplantation (LRDLT) recipients' new onset diabetes mellitus and obesity. MethodsGenotyping of PNPLA3 rs738409 variants was analyzed using an allele discrimination assay with real-time PCR in 158 LRDLT donors and their recipients, who had no history of diabetes mellitus or fatty liver disease before transplantation and survived >1 year after transplantation. The LRDLT recipients were assessed for the development of new onset diabetes and the risk of obesity 1 year after transplantation. ResultsRecipients' PNPLA3 genotypes were associated with the development of new onset diabetes mellitus after liver transplantation (CC genotype 18.8%, CG genotype 39.1%, GG genotype 42.2%, P = 0.000; GG genotype: odds ratio 24, (95% CI 8.1–70.5). Logistic regression for the predictors of new onset diabetes showed significant risk for recipients with the PNPLA3 CG genotype (P = 0.000, OR 5.5, 95% CI 2.4–12.7) and the GG genotype (P = 0.000, OR 32, 95% CI 9–116.7). In recipients, the GG genotype enhanced the incidence of obesity, with an odds ratio of 3.8 (95% CI 1.6–8.9). The PNPLA3 gene of variants of donors did not show any significant variations with different parameters. ConclusionThe PNPLA3 L148M (rs738409) polymorphism of recipients, not donors carries a risk for new onset diabetes and obesity in LRDLT recipients post-transplant. That means there is a peripheral effect, rather than a central effect, of genotype.

Retrospective genetic analysis illustrates the spectrum of autosomal Alport syndrome in a case of living-related donor kidney transplantation

BackgroundKidney transplantation is the treatment of choice in end-stage renal disease due to Alport syndrome (AS). However, the chances of finding an adequate living-related donor in AS are much worse compared to non-heritable conditions. Successful cases of related living-donor transplantation mostly refer to X-linked AS but are rarely reported in genetically confirmed autosomal AS.Case presentationWe describe the outcome of an exceptional AB0-incompatible kidney donation from father to son in a family with altered COL4A3. While decision-making was based on extensive clinical donor evaluation prior to transplantation, we analyzed the underlying genetic background in retrospect and associated these findings with the phenotype in all available family members. While biallelic COL4A3 variants caused autosomal recessive AS (ARAS) in the son (recipient), heterozygous family members, including the father (donor), showed minimal renal involvement and high-frequency sensorineural hearing impairment later in life indicating mild autosomal dominant Alport syndrome (ADAS). The recipient’s successful participation in the European and World Transplant Games is a testament to the positive outcome of transplantation.ConclusionsIn summary, living-related donor transplantation may be successful in autosomal AS, provided that thorough clinical and genetic evaluation of potential donors is performed. However, unrelated kidney transplantation should be given priority upon unpredictable genetic risk. Individual genetic variant interpretation is an important component of personalized donor assessment and will help to better predict genetic risk in the future.

The Effect of Pediatric Living Donor Liver Transplantation on Neurocognitive Outcomes in Children.

BackgroundNeurocognitive dysfunction commonly occurs after solid organ transplantation and affects 15–30% of liver transplant recipients. The aim of this study was to evaluate the neurocognitive changes pre- and post-operation and the relative factors affecting those changes.Material/MethodsChildren with biliary atresia who underwent pediatric living donor-related liver transplantation before the age of 2 years were given Bayley Scale of Infant Development-II test (BSID-II), including Mental Development Index (MDI) and Psychomotor Development Index (PDI) the week before and again half a year after transplantation to assess the effect of transplantation on neurocognition. According to the test outcome, the children were divided into a normal group and an abnormal group. The association of clinical data with neurocognitive development between the 2 groups was analyzed by logistic regression analysis.ResultsThere was a certain degree of improvement in neurocognition half a year after surgery compared with preoperative. The BSID-II subscales were significantly lower than expected before and after transplantation. Preoperative blood ammonia and bilirubin levels were independent risk factors for MDI half a year after transplantation, and preoperative albumin and bilirubin levels were risk factors for PDI.ConclusionsLiver transplantation clearly improves children’s neurocognitive function. The postoperative neurocognition is closely related to pre-operation nutritional development.

Liver Transplantation After Downstagings of Ruptured Advanced Hepatocellular Carcinoma in Cirrhotic Liver: Is It Advisable? A Case Report

Spontaneous rupture of hepatocellular carcinoma (HCC), defined as T4 in TNM stage by the American Joint Committee on Cancer (eighth edition), is a serious life-threatening complication. Effective treatment remains challenging because of a high 1-month mortality, a short median survival, and the potential of peritoneal metastasis. We reported on a case that received a living related donor liver transplantation (LDLT) after successful consecutive downstaging therapies. A 63-year-old man with alcohol-related liver cirrhosis and multiple HCC developed spontaneous rupture and hemoperitoneum. He received 3 sessions of transcatheter hepatic arterial chemoembolization and target therapy with sorafenib. Computed tomography scans and magnetic resonance imaging after 11 months of treatment showed that the patient's HCCs fulfilled the Milan criteria and the University of California San Francisco criteria prior to LDLT. The perioperative course was rather smooth. After discharge, interval follow-up computed tomography studies of chest and liver and a whole-body bone scan showed no tumor recurrence or metastasis up to 20 months post-operation. Successful downstaging therapies of ruptured HCC to fulfill Milan criteria to receive liver transplantation is advisable in highly selected patients.

17. Portoenteric Fistula Following Living Donor Liver Transplant

Background and Aims: Portal venous complications following liver transplantation are uncommon, with potential for developing immediate graft failure. While we do come across portal vein stenosis and portal vein thrombosis, portoenteric fistula following liver transplantation has not been reported so far in literature to best of our knowledge. Case summary: 55-year-old male underwent a living donor liver transplant (LDLT) for recurrent HCC. He had a history of Right hepatectomy, TACE and RFA for tumor recurrences. After a thorough work-up he received a right liver graft with MHV. During the surgery, the donor portal vein length was inadequate and a cryopreserved IVC with Iliac vein bifurcation was used as a conduit between the donor Right anterior Portal vein + Right Posterior portal vein and the recipient Main portal vein. A Roux-en-Y hepatico-jejunostomy with ductoplasty of donor hepatic ducts was done for the biliary reconstruction. Post-operatively the patient developed bile leak. A percutaneous malecot catheter was inserted into a dilated Roux limb under CT guidance to drain urbid bilious fluid from an obstructed Roux limb. Two months following his liver transplant, the patient developed malena and his Hb dropped to 5 gm% following addition of antiplatelet medication (clopidogrel). Within 24 h of this event; the patient developed massive hematochezia, hypotension and loss of consciousness. After transiently stabilizing, he underwent a CT Angiography which revealed a large contrast blush along the portal vein. The anterior sectoral portal vein could not be visualized with lack of blood supply to the anterior sector of the liver graft (Figure 1). An urgent portal vein angiography was done with a percutaneous transhepatic approach. An expandable stent was put across the portal vein (Figure 2). Inspite of being able to control the bleeding, the patient rapidly deteriorated over the next 8 h and died. Conclusions: Portal venous complications are more common with split liver and living related donor transplants (LRDT) than with deceased donor liver transplants (DDLT). Portoenteric fistula is an extremely rare and fatal complication post liver transplantation.Fig. 2Expandable stent was put across the portoenteric fistula.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The authors have none to declare.

Living-unrelated kidney donor transplantation: Legalization in exceptional circumstances?

The prevalence of end-stage renal disease (ESRD) morbidity and mortality is mounting. Kidney transplantation offers a good means of survival and improves longevity of patients with ESRD. However, not everyone is fortunate to benefit from this lifesaving renal replacement therapy due to the lack of available kidneys, one of the many reasons. It eventually expands the number of patients on waiting list of kidney transplantation. At present, deceased and living-related kidney donor transplantation models are widely used, but with limited success to keep up with the pace of burgeoning ESRD. A debate over the legalization of unrelated living kidney donor transplantation has erupted lately. This short review articles focuses on issues surrounding kidney transplantation in Pakistan and draws an informed conclusion regarding pragmatic legalization of unrelated living kidney donor transplantation in exceptional circumstances. Finally, this article also offers a food for thought for countries facing analogous picture in the field of kidney transplantation.

Treatment of early hepatic venous outflow obstruction after living donor-related liver transplantation by the insertion of expandable metallic stent

Treatment of early hepatic venous outflow obstruction after living donor-related liver transplantation by the insertion of expandable metallic stent

Disseminated histoplasmosis in pediatric kidney transplant recipients-A report of six cases and review of the literature

We report a case series of histoplasmosis in KTx patients in a children's hospital in an endemic area. All KTx cases from January 1, 2002, to August 31, 2016, were reviewed to identify those with disseminated histoplasmosis. The attack rate of histoplasmosis among our KTx patients was 6.9 per 100 cases. The median age at the time of diagnosis was 16years (11-18). Comorbidities included glomerulosclerosis (3), medullary cystic disease (1), and obstructive uropathy (2) and HIV (1). There were 5 deceased and 1 living-related donor transplants, and no patient had a history of rejection prior to histoplasmosis. Median time from transplant to histoplasmosis was 14.8months (IQR 2.2-38.3) and 33% occurred in the first year after transplant. Urine and/or serum antigens were positive in all patients. They were either treated with amphotericin B and transitioned to an azole or received azole monotherapy. Most (83%) received chronic suppression with itraconazole. No patients died and relapse occurred in 1 patient after repeat transplant. KTx patients in endemic areas are at risk for disseminated histoplasmosis. Further study is needed to determine which factors portend the need for fungal prophylaxis in this subset of patients.

Clinical and pathological phenotype of genetic causes of focal segmental glomerulosclerosis in adults.

Focal segmental glomerulosclerosis (FSGS) is a histologic lesion resulting from a variety of pathogenic processes that cause injury to the podocytes. Recently, mutations in more than 50 genes expressed in podocyte or glomerular basement membrane were identified as causing genetic forms of FSGS, the majority of which are characterized by onset in childhood. The prevalence of adult-onset genetic FSGS is likely to be underestimated and its clinical and histological features have not been clearly described. A small number of studies of adult-onset genetic FSGS showed that there is heterogeneity in clinical and histological findings, with a presentation ranging from sub-nephrotic proteinuria to full nephrotic syndrome. A careful evaluation of adult-onset FSGS that do not have typical features of primary or secondary FSGS (familial cases, resistance to immunosuppression and absence of evident cause of secondary FSGS) should include a genetic evaluation. Indeed, recognizing genetic forms of adult-onset FSGS is of the utmost importance, given that this diagnosis will have major implications on treatment strategies, selecting of living-related kidney donor and renal transplantation success.

Use of robotics in liver donor right hepatectomy.

Liver transplantation is the best solution for end stage liver disease, and has been widely accepted and rapidly developed in the past decades. Along with the improved outcomes of liver transplantation, living-related donor transplantation has been conducted to overcome the shortage of the deceased donor. The most important aspects of the living-related liver transplantation are donor safety and fast recovery after graft procurement. Meanwhile, the rapid progress of minimally invasive surgery (MIS) in general surgery has generated heated debate regarding the appropriateness of MIS in living-related donor graft hepatectomy. Technical innovations and instrument enhancements have been allowing recruitment of more potential candidates through smaller wounds and better surgical experience. Although MIS has been documented with safety and feasibility in complex liver surgery, the progress is slow in regard to the application of MIS in donor graft hepatectomy. Pioneer surgeons have devoted themselves to develop the pure MIS approach for the liver donor surgery, but the steep learning curve for pure MIS major hepatectomy remains a major barrier for wide adoption. The introduction of robotic system may lower the barrier for entry for practice into MIS donor hepatectomy.

Novel Use of Percutaneous Thrombosuction for Hepatic Vein Thrombosis of the Liver Graft after Liver Transplantation

Introduction: Early thrombosis of hepatic vein graft of liver graft after living related donor liver transplantation (LDLT) is a challenging problem and poses a high potential of graft failure or/and patient failure. Re-exploration faces the risk of repeated general anesthesia, adhesion and anatomical difficulty, family’s attitude, and the potential of rethrombosis. Methods: A 54-year-old woman with hepatitis B viral infection related liver cirrhosis with two hepatocellular carcinoma (cT2N0M0 stage II) received LDLT with right hepatic lobe donated by her daughter. The outflow reconstruction using an artificial vascular conduit included the V5 and V8 with end-to-side anastomosis each. Anastomosis of the conduit with right hepatic vein orifice on IVC of the recipient was performed with 4-0 prolene suture. The liver enzyme, total bilirubin and lactate elevated since the 7th day postoperation. CT study showed thrombosis of V5 and V8 with hypoenhancement of the corresponding liver parenchyma. The hepatic artery and the portal vein were patent. Results: Heparin 5000U was given intravenously. After local anesthesia, we inserted a 7-French (Fr) sheath through right femoral vein, then 7-Fr Judkins guide catheter to approach hepatic vein, wiring to distal V5 branch with 0.014" HydroST wire (COOK medical). Thrombosuction with 7-Fr Pronto V4 (Vascular Solution) to extract thrombus was repeated smoothly. Balloon catheter angiography showed good flow from V5 to IVC. The function of the graft recovered and she discharged at the end of 3rd week after transplantation. She remained well for 6 months up to now. Conclusion: Thrombosuction had been used in the treatment of deep vein thrombosis of lower limbs, pulmonary embolism, thrombosis of hemodialysis fistula or of coronary vessels. We applied it for liver graft to avoid repeated major surgery and general anesthesia. To follow up imaging studies and appropriate anticoagulant therapy are necessary for those who had an episode of graft vein thrombosis.