Recipient Size Research Articles

Do smaller adults wait longer for liver transplantation? A comparison of the UK and the USA data

The number of patients on the UK and the USA liver transplant list is increasing. As size match is an important factor in the UK organ allocation, we studied the effect of recipient size on liver transplantation in the UK and the USA. The UK Transplant and United Network for Organ Sharing databases were used to assess difference in access to transplantation between smaller adult patients and their larger counterparts over three time periods. Subsequently, proportions of split, NHBD and living-donor transplants were analyzed. There were 1576 UK and 29,150 USA patients in our analysis. The UK small patients have been significantly disadvantaged in access to transplantation particularly in early years and in adult only transplant units. This contrasts to the USA where smaller patients have never been disadvantaged and transplantation rates are steadily increasing. Split-liver transplants are being carried out in increasing numbers in the UK but not the USA. Small adults are still less likely to be transplanted at six months in adult only units in the UK. The lack of size matched organs for smaller adults and the overall decrease in rates of transplantation in the UK may be remedied by careful consideration of allocation policy and increased use of innovative techniques.

Donor-Recipient Size Matching Influences Early But Not Late Graft Function After Pediatric En-Bloc Kidney Transplantation

Pediatric en-bloc kidney transplantation into adult recipients is an accepted technique to expand the donor pool. Concerns about adequate "nephron dosing" have traditionally favored placing these kidneys into smaller recipients. We reviewed 20 pediatric en-bloc transplants performed at our institution between 2002 and 2008. We examined the impact of donor age, donor weight, recipient sex, combined kidney length, recipient weight, recipient-to-donor weight ratio, and recipient weight gain on serum creatinine over time using regression analysis. Patient survival was 100%. Two grafts were lost early from vascular thrombosis. Of the remaining 18 recipients, all had immediate and excellent long-term function with average creatinine of 0.91+/-0.38 mg/dL at a mean follow-up of 1257+/-656 days. For 17 patients with 1 year follow-up, recipient weight, recipient-to-donor weight ratio, and recipient male sex negatively influenced renal function at 1 month. However, this relationship was lost by 1 year with increasing function in the smallest donors and largest size mismatches. Between 1 month and 1 year posttransplant, estimated creatinine clearance improved from 59+/-13 mL/min at 1 month posttransplant to 88+/-41 mL/min (P<0.015). Weight gain after transplant was associated with improved creatinine clearance, suggesting continued adaptation over time. We conclude that donor or recipient size matching up to a recipient-to-donor weight ratio of 7.5 does not significantly impact later renal function after pediatric en-bloc kidney transplantation into adults.

Acute lower limb ischemia following pediatric renal transplantation

Live donor renal transplantation remains the best treatment option for end stage renal failure in pediatric patients (1-3). Better understanding of the hemodynamics of donor-recipient size discrepancy and advances in interventional techniques with improved surgical techniques have decreased the incidence and severity of surgical complications and enhanced graft survival (1, 2). We describe a rare complication occurring intra-operatively in a pediatric renal transplant resulting in acute limb ischemia and the surgical option taken.

Splenic artery occlusion for small-for-size syndrome: Better late than never but early is the best

Splenic artery occlusion for small-for-size syndrome: Better late than never but early is the best

Conversion to termino-terminal cavo-cavostomy as a rescue technique for infrahepatic obstruction after piggyback liver transplantation

Conversion to termino-terminal cavo-cavostomy as a rescue technique for infrahepatic obstruction after piggyback liver transplantation

448: Alternative Measures of Donor:Recipient Size Matching – How Useful Are They?

448: Alternative Measures of Donor:Recipient Size Matching – How Useful Are They?

A Comparison of Right and Left Lobectomies for Living Donor Liver Transplantation: An Anesthesiologist’s Point of View

Because of the shortage of cadaveric donor organs, living donor liver transplantation (LDLT) has become an established therapy modality for end-stage liver disease. Based on recipient size, both right and left liver lobe grafts have been used successfully in LDLT. The aim of this study was to compare the risk of intraoperative complications and transfusion requirements between right and left lobe donors. We reviewed the charts of 54 right lobe (Group RL), 29 left lobe (Group LL), and 31 left lateral segment (Group LLS) donors who underwent lobectomy from January 2003 through January 2007. We recorded patient demographics, perioperative laboratory values, intraoperative fluid and transfusion requirements, intraoperative hemodynamic parameters, and complications. Demographic features and preoperative laboratory values were similar for the 3 groups, except for age (Group RL, 37.3 ± 8.7; Group LL, 36.0 ± 9.3; Group LLS, 31.7 ± 9.4; P = .02). There were no significant differences in mean liver volumes among the groups ( P > .05). Respective graft volumes were 803.1 ± 139.2 mL, 438.0 ± 122.7 mL, and 308.2 ± 76.6 mL for Groups RL, LL, and LLS, respectively ( P < .001). More patients in Group LLS required heterologous blood transfusion than did those in the other groups ( P = .01). The incidence of intraoperative hypotension was similar for all groups ( P > .05). Group RL had a significantly higher rate of intraoperative hypothermia than the other groups ( P = .01). There were no intraoperative respiratory complications or cardiac events. These results indicated that both right and left donor lobectomies for LDLT were safe procedures with acceptable rates of minor intraoperative complications.

The Evolution of Nonimmune Histological Injury and Its Clinical Relevance in Adult-Sized Kidney Grafts in Pediatric Recipients

To describe the evolution, risk factors and impact of nonimmune histological injury after pediatric kidney transplantation, we analyzed 245 renal allograft protocol biopsies taken regularly from the time of transplantation to 2 years thereafter in 81 consecutive rejection-free pediatric recipients of an adult-sized kidney. Isometric tubular vacuolization was present early after transplantation was not progressive, and was associated with higher tacrolimus pre-dose trough levels. Chronic tubulo-interstitial damage and tubular microcalcifications were already noted at 3 months, were progressive and had a greater association with small recipient size, male donor gender, higher donor age and female recipient gender, but not with tacrolimus exposure. Renal function assessment showed that older recipients had a significant increase in absolute glomerular filtration rate with time after transplantation, which differed from small recipients who showed no increase. It is concluded that progressive, functionally relevant, nonimmune injury is detected early after adult-sized kidney transplantation in pediatric recipients. Renal graft ischemia associated with the donor-recipient size discrepancy appears to be a greater risk factor for this chronic histological injury, suggesting that the exploration of additional therapeutic approaches to increase allograft perfusion could further extend the graft survival benefit of adult-sized kidneys transplanted into small children.

Temporary silastic mesh closure for adult liver transplantation: A safe alternative for the difficult abdomen

Primary fascial closure is often difficult after adult orthotopic liver transplantation (OLT), complicated by donor-to-recipient graft size mismatch, post-reperfusion hepatic edema, coagulopathy, or intestinal edema. Attempts at closing the abdomen under these circumstances can cause increase in intra-abdominal pressures, resulting in significant complications, including graft loss. Temporary closure with silastic mesh has been used as a viable option in children receiving transplants, but there is no experience recorded with its use in adults. A retrospective review was conducted on 200 consecutive liver transplantations performed over 42 months (October 2002 to February 2006). Records were evaluated for patient and donor demographics, perioperative factors including Model for End-Stage Liver Disease and Child-Turcotte-Pugh scores, indications for OLT, ischemic times, blood product administration, and use of temporary silastic mesh closure. Patients requiring silastic mesh were further evaluated for indication, time to primary fascial closure, duration of intubation, length of stay, graft function, and complications (infectious, vascular, biliary, and hernia development). Comparisons were made with a cohort of patients undergoing OLT over the same time period but who were closed primarily, without the use of temporary silastic mesh. Fifty-one liver transplantations (25.5%) of the 200 total transplant cohort used silastic mesh closure. Comparison of the cohorts (primary closure vs. temporary mesh) revealed that no differences existed, except the requirement of all blood products was significantly greater in the silastic mesh group (P < 0.001). Bowel edema (47.1%) and coagulopathy (37.3%) were the most common indications for mesh closure, with less frequent reasons including donor to recipient size mismatch (11.8%), hemodynamic instability, and a large preexisting fascial defect (2.0% each). The average time from transplant to final fascial closure was 3.4 days (range 2-9 days). In the silastic cohort, 41 transplants where closed primarily, 3 required the addition of synthetic mesh, and 6 had component separation and flap closure. After fascial closure, the mean time to extubation was 1 day. The median length of follow-up was 1.3 years for the silastic closure group. Long-term wound complications in the silastic closure group included 1 instance of colonic fistula, 2 incisional hernias, and 2 wound infections. The 30-day and 1-year patient survival for this group were 93.6 and 82.4%, respectively, and the graft survival for those same periods were 90.2 and 77.7%, respectively. Wound complications, rates of hepatic artery thrombosis or stricture, portal vein thrombosis or stricture, biliary complications, and allograft and patient survival were no different than those in patients undergoing initial primary closure. In adult liver transplantation with a difficult (or potentially difficult) abdomen, temporary closure with silastic mesh was found to allow for uncomplicated fascial closure in a short period of time, with rapid extubation times, excellent graft function, and minimal instances of infectious or wound complications. In circumstances where large amounts of blood products are required, where a size mismatch exists, or where bowel edema is present during adult liver transplantation, temporary closure with silastic mesh is an ideal strategy.

Optimal use of older donors and recipients in kidney transplantation

The aging donor and recipient population have led to new challenges in kidney transplantation. The purpose of this study was to review retrospectively our single center experience in deceased-donor kidney transplantation, with respect to donor and recipient age. From October 1, 2001, through February 20, 2004, we performed 144 deceased-donor kidney transplantations, which included 37 procedures (26%) in recipients > or =60 years old and 107 procedures (74%) in recipients 19 to 59 years old. The deceased-donor pool included 57 expanded criteria donors (ECD) and 87 standard criteria donors (defined as not ECD). ECD kidneys were used by matching estimated renal functional mass to recipient size (body mass index, <25 kg/m(2)), which included the use of dual kidney transplantations (n = 9). ECD kidney recipients were further selected on the basis of age >40 years and low immunologic risk. Recipients received rabbit antithymocyte globulin or alemtuzumab induction in combination with tacrolimus, mycophenolate mofetil, and steroids. The mean age differed between recipient groups (65 vs 46 years; P < .001). In recipients > or =60 years old, 23 recipients (62%) received kidney transplants from ECDs compared with 34 kidney transplants from ECDs (32%; P < .001) in recipients who were <60 years old. Patient survival was 89% in recipients who were > or =60 years old, compared with 95% in recipients who were <60 years old (P = .11), with a mean follow-up time of 27 months. Kidney graft survival rates were 84% in both recipient groups. Initial and subsequent graft function, rejection, infection, reoperation, length of stay, readmission, and resource use were similar among groups. By the matching of nephron mass with recipient size and avoiding the use of ECD kidneys in recipients with a high immunologic risk, short-term outcomes that are comparable with standard criteria donor kidneys in younger patients can be achieved with either older donors or recipients, regardless of age.

Metabolic Demand and Renal Mass Supply Affecting the Early Graft Function After Living Donor Kidney Transplantation

Metabolic demand and renal mass supply affecting the early graft function after living donor kidney transplantation. Background Graft mass has been demonstrated to be a determinant of outcome after kidney transplantation. An insufficient nephron might fail to meet the metabolic demands of the recipient and lead to hyperfiltration. Methods The study population was restricted to live donor transplants demonstrating immediate function that had neither ischemic injury, episodes of rejection, nor any complications that resulted in a functional decrease of the graft. The donated kidney was weighed just after cold flush, and the recipient's serum creatinine (Scr) was measured on a daily basis postoperatively. When the recipient's Scr reached the baseline, the recipient's 24-hour urine was collected for the amount of proteinuria (Upr), creatinine excretion (Ucr), and creatinine clearance (Ccr) calculation. As the parameters of the metabolic demands of donor and recipient, body weight, height, body surface area, lean body weight, and body mass index were noted. Pearson correlation and linear regression were carried out. Results The graft function, as measured by Scr, Ucr, and Upr, was not directly correlated with the graft weight but rather correlated with the ratios of graft weight to the parameters of recipient's metabolic demands. As recipient size increased, the metabolic demand has increased. The parameters of recipient's metabolic demands were directly correlated with Scr and Ucr, rather than with Upr. Conclusion During living donor and recipient matching, both the potential sizes of the donated kidney and the recipient should be considered in terms of the early graft function after transplantation.

Immediate Extubation of Children Following Liver Transplantation Is Safe and May Be Beneficial

Immediate tracheal extubation of selected adult patients after orthotopic liver transplant (OLT) is common practice. We hypothesized that selected children may be safely extubated immediately after OLT and avoid potentially deleterious effects of artificial ventilation and sedation. After June 2002, we chose immediate extubation unless a specific contraindication was identified. Charts of all children undergoing OLT between June 2002 and February 2005 were reviewed to audit safety and outcome of this approach. Comparative data were obtained for children undergoing first elective OLT at other UK centers. Forty-six cadaveric liver transplants were performed in 40 patients: 26 of 34 (76%) elective transplants and 4 of 12 (33%) urgent transplants were extubated immediately after surgery. Eight of 14 (57%) children weighing less than 10 kg were successfully extubated. One child required reintubation after developing transfusion-related acute lung injury. There were no other events compromising patient or graft. Small recipient size, split/reduced grafts, preexisting respiratory disease, retransplantation, and acute liver failure did not individually preclude successful immediate extubation. After elective OLT, the mean duration of intensive care stay was significantly shorter in the extubated group than in those who were ventilated (2.5 vs. 6.1 days, P<0.01). All children receiving a liver transplant at other UK centers in 2003 were ventilated postoperatively. However, the median duration of intensive care stay (2 days) was the same as in our series. Immediate extubation of selected children after OLT is safe. It may enhance patient recovery, benefit graft physiology, and reduce intensive care requirement.

Size-dependent mating and gender choice in a simultaneous hermaphrodite, Bulla gouldiana

Simultaneous hermaphrodites are predicted to optimally divide resources between male and female function, which can result in both size-dependent mating behaviors and conflict between potential mates. Predicted strategies include size-assortative mating, conditional exchange of gametes, and mating patterns where relative size affects investment in each sexual role. This study investigated the effect of body size on the mating strategies of a hermaphroditic opisthobranch, Bulla gouldiana. Although individuals were spatially aggregated in the field with high levels of movement and size variation, there was little evidence for predictions. Laboratory experiments, however, revealed complicated effects of mass on the probability and duration of mating, as well as gender choice. Pairs were more likely to mate if they included at least one large animal, with the larger animal typically inseminating the smaller. When both individuals were large, they were more likely to each mate in both sexual roles by switching roles once. Although B. gouldiana did not usually alternate between sexual roles multiple times within mating events, paired individuals behaved similarly (neither or both mating as sperm donors) more often than expected by chance. This suggests some level of reciprocity, which is unlikely to be conditional given rates of unilateral mating. When the larger member of the mating pair inseminated the smaller, the duration of insemination increased with the size of the smaller sperm recipient. Copulations lasted longer in pairs that switched sexual roles than in those that did not switch roles. This study suggests that variation in body size can lead to size-dependent mating patterns, but only some of the patterns in B. gouldiana support theoretical predictions. We review other studies that have addressed similar issues, providing inconsistent mating patterns in sperm-storing hermaphrodites.

Donor Cause of Death and Mid-Term Survival in Lung Transplantation

The influence of donor cause of death (DCD) on survival after lung transplantation (LTx) is uncertain. This was investigated using data from a national prospective cohort study of adult single and bilateral LTx undertaken between July 1995 and June 2002. DCD was categorized a priori into vascular and tumor (V), traumatic (T), hypoxic brain damage (H) and infective (I) causes. All T donor deaths were the result of blunt trauma. Risk factors for early (30 days), late (30 days to 5 years) and overall (5 years) mortality were identified using Cox regression analysis. Of 580 eligible transplants, DCDs were classified as V (n = 372), T (n = 153), H (n = 38) and I (n = 17). V donors were older (median 42 years) than the others (medians < 27 years) (p < 0.001). T donors were more likely to be of male gender (p < 0.001). Two hundred fifty-nine patients died within 5 years of surgery. The median follow-up time of survivors was 37 months. Unadjusted 5-year Kaplan-Meier survival rates did not vary with DCD (p = 0.6). Cox analysis identified donor age group, recipient diagnosis, pre-operative recipient ventilation, donor-recipient size mismatch, donor-recipient blood group variance, cytomegalovirus (CMV) mismatch and recipient creatinine clearance as predictors of mortality. After adjustment for these risk factors, DCD was not identified as a predictor of early (p = 0.2), late (p = 0.5) or overall mortality (p = 0.4) in LTx recipients. We found that DCD did not affect mid-term survival after LTx.

Metabolic demand and renal mass supply affecting the early graft function after living donor kidney transplantation

Graft mass has been demonstrated to be a determinant of outcome after kidney transplantation. An insufficient nephron might fail to meet the metabolic demands of the recipient and lead to hyperfiltration. The study population was restricted to live donor transplants demonstrating immediate function that had neither ischemic injury, episodes of rejection, nor any complications that resulted in a functional decrease of the graft. The donated kidney was weighed just after cold flush, and the recipient's serum creatinine (Scr) was measured on a daily basis postoperatively. When the recipient's Scr reached the baseline, the recipient's 24-hour urine was collected for the amount of proteinuria (Upr), creatinine excretion (Ucr), and creatinine clearance (Ccr) calculation. As the parameters of the metabolic demands of donor and recipient, body weight, height, body surface area, lean body weight, and body mass index were noted. Pearson correlation and linear regression were carried out. The graft function, as measured by Scr, Ucr, and Upr, was not directly correlated with the graft weight but rather correlated with the ratios of graft weight to the parameters of recipient's metabolic demands. As recipient size increased, the metabolic demand has increased. The parameters of recipient's metabolic demands were directly correlated with Scr and Ucr, rather than with Upr. During living donor and recipient matching, both the potential sizes of the donated kidney and the recipient should be considered in terms of the early graft function after transplantation.

269. Optimal testicular size of donor and recipient for testicular germ cell transplantation in the bovine

The maturity status of donor and recipient testis appears to be important in the efficiency of testicular germ cell transplantation. When neonatal mice were used as recipients, they show 9.4 times greater colonization and 4 times larger colony size than in the adult.1 The objective of this study in cattle was to investigate the effect of testicular maturity of donor and recipient calves on success of the testis cell transplant procedure. Testicular maturity was measured indirectly by scrotal circumference and donor testicular cells were enzymatically isolated from 8 Angus calves aged 5–7 months (scrotal circumference, SC of 18–22cm) and injected into both testes of 12 recipient calves aged 4–6 months (SC 15–21cm. Donor cells were labeled with the red fluorescent dye PKH26 then transferred into the rete testis under ultrasonographic guidance. Castration of recipients was performed 2–6 months following injection and then frozen sections were used to localize the PKH26 positive donor cells. Five sections from different 5 areas in each testis were prepared and 100 tubules were counted. In 15 of the 24 (63%) testes, PKH positive donor cells were identified. There was no correlation between colonization rate and maturity of donor animal testis for the range of testis sizes studied. Testis cells from donors of SC 18-20 cm or of SC 21-22 did not result in different number of recipient testis with positive cells (7/10 (70%) v. 8/14 (57%)) or the number of positive cells per testis (1.92 ± 0.67% v. 2.5 ± 1.01%). Recipient maturity (SC of 15–18 cm v. SC of 19–21 cm) had no effect on the colonization rate (7/11 (64%) v. 8/13 (62%)); however, there were significantly more positive cells per testis in less mature (SC of 15–18) recipients (3.18±1.21% v. 1.52 ± 0.64% P &lt; 0.05)). In summary we have demonstrated successful testicular germ cell transplantation between calves and while donor testis cell age appeared to have little effect on the efficiency of colonization, less mature testis provided more suitable conditions for colonization. (1)Shinohara T, Orwig KE, Avarbock MR and Brinster RL. (2001) Remodeling of the postnatal mouse testis is accompanied by dramatic changes in stem cell number and niche accessibility. PNAS 98(11), 6186–6191.

Penetrating keratoplasty for macular corneal dystrophy

To determine the prognosis of penetrating keratoplasty (PK) for macular corneal dystrophy (MCD). Single-center, retrospective, interventional, noncomparative case series. One hundred forty-one patients (229 eyes) with MCD. Retrospective review of the medical record of every patient who underwent primary PK for histopathologically confirmed MCD at the King Khaled Eye Specialist Hospital between January 1, 1983 and December 31, 2002 and for whom at least 12 months of follow-up is available. Visual acuity (VA), graft survival, and postoperative complications. After a mean follow-up period of 5.9+/-3.8 years (range, 1-17), the mean best-corrected VA was 20/50. At the most recent visit, 206 (90.0%) grafts were clear, and 23 (10.0%) had failed. Probabilities of graft survival were 98.1% at 1 year, 89.8% at 5 years, 82.1% at 10 years, and 74.1% at 15 years. There was a statistically significant increased likelihood of graft failure if the patient was older than 40 years at the time of surgery (P<0.00003). The differences in graft failure between patients older than 40 and those younger were not attributable to statistically significant differences in duration of follow-up, donor age, or donor endothelial cell counts. Corneal endothelial rejection episodes occurred in 47 (20.0%) grafts, but resulted in irreversible graft failure in only 8 (3.5%) eyes. Eighteen (27.3%) of 66 eyes with a recipient size of > or =7.5 mm developed a graft rejection episode, compared with 27 (16.6%) of 163 eyes with a recipient size of <7.5 mm (P = 0.04). Microbial keratitis occurred in 14 (6.1%) grafts and was more likely to occur in patients over 40 (14.0% vs. 3.0%, P = 0.01). Clinically significant recurrence was observed in 12 (5.2%) grafts, after a mean interval of 84+/-48.2 months, and was directly related to patient age (P = 0.04) and inversely related to donor graft size (P = 0.04). Good visual results and excellent graft survival can be achieved after PK for MCD. The risk of graft failure is higher in patients older than 40 years.

KIDNEY TRANSPLANTATION IN THE ELDERLY: VARIATIONS OF THE “MATCH-GAME”

P99 Aims: Introduction: The aging donor (D) and recipient (R) population has led to new challenges in kidney transplantation (KT). Controversy exists regarding the optimal approach to the elderly D or R. A number of strategies have been proposed including matching by age, medical risk, serology, HLA, size, or nephron mass. The purpose of this study was to retrospectively review our single center experience in deceased donor (DD) KT with respect to age. Methods: From 10/1/01 through 11/15/03, we performed a total of 129 DD KTs, including 33 (26%) in Rs ≥60 years and 96 (74%) in Rs 19-59 years of age. The DD pool included 51 expanded criteria donors (ECD; defined and allocated according to UNOS policy) and 78 standard criteria donors (SCD; defined as non-ECD). ECD kidneys were utilized by matching estimated renal functional mass to recipient size (BMI <25 kg/m2), including the use of dual KTs (N=8). ECD kidney Rs were further selected based on age >40 and low immunologic risk. Rs received rATG or alemtuzumab induction in combination with tacrolimus, MMF, and steroids; those ≥60 had lower tacrolimus targets and MMF doses. Results: The mean age differed significantly between R groups (65 vs 46 years, p<.001), including 7 patients >70. In Rs ≥60, 22 (67%) received KTs from ECDs compared to 29 from ECDs (30%, p<.001) in Rs <60. Other demographic and transplant characteristics were similar among groups. Patient survival is 97% in Rs ≥60 compared to 99% in Rs <60 (p=NS) with a mean follow-up of 12 months. Kidney graft survival rates are 94% in Rs ≥60 vs 89% in Rs <60, p=NS. Initial and subsequent graft function, rejection, infection, re-operations, length of stay, re-admissions, and resource utilization were similar among groups. Nine patients had opportunistic viral infections (5 CMV, 3 polyomavirus nephropathy, 1 EBV-associated PTLD), including 4 (12.5%) in Rs ≥60 compared to 5 (5%, p=NS) in Rs <60. However, all 9 cases occurred in ECD Rs (18% ECD vs 0 SCD Rs, p<.001). Conclusions: By matching nephron mass with R size and avoiding the use of ECD kidneys in high immunologic risk Rs, short-term outcomes that are comparable to SCD kidneys in younger patients can be achieved with either older Ds or Rs, regardless of age. However, the risk of viral infection is higher in ECD Rs, and long-term follow-up is needed to ultimately determine the risks and benefits of KT in this setting.

Outcome of 28 split liver grafts

Our aim is to present our experience with split liver transplantation. From 1992–2002, 14 livers were split to obtain 28 grafts that were transplanted to 12 adults and 16 children. Ex situ splitting was performed in all cases. The left graft consisted of the left lateral segment (segments II–III) in 11 cases and the left lobe in three, depending on the size of the pediatric recipient. Pediatric recipients were of mean age 3, 4 years; mean weight 13 kg; six emergency cases for fulminant hepatic failure or urgent retransplantation and seven of 10 elective cases for biliary atresia. Postoperative mortality rate was 31% (five cases), including four of six emergency cases and one elective case (10%). The main cause was multiorgan failure. Technical complications were: one arterial thrombosis, one portal vein thrombosis, and four biliary complications. Eleven patients are alive and well. Adult recipients were of mean age 53 years. The indications were hepatocellular carcinoma in six cases, liver cirrhosis of various etiologies in five, and one recurrence of hepatitis C in a graft. Two patients died during the postoperative period from sepsis after retransplantation for primary nonfunction of the split graft and multiorgan failure with sepsis. One-year actuarial survival was 84%. Conclusions The results of split liver transplantation in elective cases are similar to whole liver transplantation, whereas patient survival among emergency cases is low due to the critical condition of the patients.

Monosegmental living-donor liver transplantation for infantile hepatic hemangioendothelioma

Infantile hepatic hemangioendothelioma (IHHE) is a rare vascular tumor that presents before the age of 6 months. The patients with IHHE suffer from high-output congestive heart failure caused by major arteriovenous fisutulas in the liver, which leads to respiratory compromise and results in a high mortality rate despite medical treatments. A case of 4-month-old baby with liver failure caused by IHHE is reported. The baby received an urgent liver transplantation from a living donor. A monosegmental graft was used to mitigate graft-to- recipient size mismatching. The surgical procedure of monosegmental living donor liver transplantation also is discussed.