Reduced-size Liver Transplantation Research Articles

A Novel Strategy for Preventing Posttransplant Large-For-Size Syndrome in Adult Liver Transplant Recipients: A Pilot Study.

There are two causes of graft compression in the large-for-size syndrome (LFSS). One is a shortage of intra-abdominal space for the liver graft, and the other is the size discrepancy between the anteroposterior dimensions of the liver graft and the lower right hemithorax of the recipient. The former could be treated using delayed fascial closure or mesh closure, but the latter may only be treated by reduction of the right liver graft to increase space. Given that split liver transplantation has strict requirements regarding donor and recipient selections, reduced-size liver transplantation, in most cases, may be the only solution. However, surgical strategies for the reduction of the right liver graft for adult liver transplantations are relatively unfamiliar. Herein, we introduce a novel strategy of HuaXi-ex vivo right posterior sectionectomy while preserving the right hepatic vein in the graft to prevent LFSS and propose its initial indications.

Deceleration of Liver Regeneration by Knockdown of Heme Oxygenase-1 is Associated With Impairment of Liver Injury Recovery After Reduced-Size Liver Transplantation in Rats

AimIt has been reported that heme oxygenase-1 (HO-1) is upregulated during hepatocyte proliferation. Herein, we used a half-size liver transplantation (HSLT) model to study the impact of HO-1 on liver grafts proliferation. To the best of our knowledge, this is the first time that HO-1 has been characterized as a regulator of liver graft regeneration. Materials and MethodsSaline and tin protoporphyrin (SnPP, a HO-1 competitive inhibitor) were separately administered in vehicle and SnPP group before rats HSLT. Plasma samples were collected at 0, 1, 3, and 5 days after HSLT for liver function analysis. Liver tissues were obtained at 0, 1, 3, and 5 days after HSLT for analyses of histologic, apoptosis, and proliferation index by immunohistochemical, enzyme-linked immunosorbent assay, quantitative real-time polymerase chain reaction, and Western blotting. ResultsHO-1 level was upregulated by the treatment of HSLT along with accelerated liver proliferation, which was reversed by SnPP. The reduced regeneration by SnPP lead to higher Suzuki’s scores, alanine aminotransferase, and aspartate aminotransferase levels. The interleukin-6 levels, p-Stat3/t-Stat3, c-myc, and c-jun were decreased in the SnPP group than the vehicle group. ConclusionsOur findings suggest that inhibition of HO-1 mitigates liver regeneration in part by downregulation of an interleukin-6/Stat3 axis. Targeted specific pharmacologic induction of HO-1 may be applicable in clinical practice.

AntagomiR-199a Enhances the Liver Protective Effect of Hypoxia-Preconditioned BM-MSCs in a Rat Model of Reduced-Size Liver Transplantation.

Reduced-size liver transplantation (LT) was invented to overcome the shortage of donor livers; however, it has proven to be more susceptible to ischemia-reperfusion injury. Bone marrow-derived mesenchymal stem cell infusion has been shown to be protective following LT. Optimization of MSC infusion has been performed, among which hypoxia preconditioning and miRNA modulation have shown promise. MiR-199a inhibition was reported to induce angioneogenesis; however, whether mir-199a inhibition enhances the protective effect of Bone marrow-derived mesenchymal stem cells in LT remains unknown. In this study, we combined antagomiR-199a with hypoxia-preconditioned MSC (H-MSC) infusion to discuss their effect and mechanism in a rat model of reduced-size LT. A reduced-size LT model was constructed and H-MSCs were intraportally injected during operation. AgomiR-199a and antagomir-199a were injected through the caudal vein once a day after LT. The level of apoptosis and proinflammatory cytokines were measured. An anti-vascular endothelial growth factor (VEGF) antibody was injected to further explore the underlying mechanism. AntagomiR-199a plus H-MSC not only significantly decreased ALT and AST 72 h after LT but also ameliorated the level of apoptosis and inhibited inflammatory reactions. On the contrary, agomir-199a reduced the protective effect of the H-MSC infusion. In terms of mechanism, the liver protective effect of miR-199a inhibition was abolished by treatment with a VEGF-neutralizing antibody. AntagomiR-199a enhanced the protective effect of H-MSCs infusion via activation of the hypoxia induction factor 1α/VEGF axis.

The role of HO-1/BMMSCs in rat reduced-size liver transplantation

Objective To explore the effect and mechanism of heme oxygenase-1 (HO-1) gene modified bone marrow mesenchymal stem cells (BMMSCs) on rat reduced-size liver transplantation. Methods 50 male Brown Norway (BN) rats were used to prepare BMMSCs. Male Lewis and BN rats were 75, respectively. BN rats were randomly divided into model group (n=25), stem cell group (n=25) and combined group (n=25). Acute rejection models following 50% reduced-size transplantaton were established in rats using two-cuff technique, 1 ml of normal saline, BMMSCs suspension, or HO-1/BMMSCs suspension were injected immediately after surgery. Rats were executed at an instant, 3rd, 7th and 14th day after surgery to identify BMMSCs and HO-1/adenovirus infection efficiency. Evaluated hepatic pathology by HE staining. Liver function indexes were detected. Portal vein pressure on 7th day after surgery was detected. The levels of endothelin-1 (ET-1) and nitric oxide (NO) in serum were detected using ELISA. The expressions of ET-1 in liver were detected by immunohistochemistry staining and Western blotting. Results High purity BMMSCs were obtained and HO-1/BMMSCs were successfully infected. Compared with model group, liver tissue injury and rejection were alleviated in stem cell group and combined group, liver function was improved, and the combined group was superior to stem cell group. The portal vein pressure in model group, stem cell group, and combined group were 21.3±0.2 mmHg, 11.2±0.2 mmHg, and 10.1±0.1 mmHg, respectively. The portal vein pressure in three groups showed a decreasing trend, difference was statistically significant (P<0.05). On the 3rd, 7th and 14th day after surgery, compared with model group, the expression levels of ET-1 and NO in the stem cell group and the combined group were decreased, and the combined group was significantly lower than stem cell group (P<0.05). Conclusion HO-1/BMMSCs improved liver function and portal vein pressure after reduced-size liver transplantation in rats, and may play a protective role by regulating ET-1/NO expression. Key words: Heme oxygenase-1; Mesenchymal stromal cells; Liver transplantation; Rat; Portal pressure

Normothermic Machine Perfusion Protects Against Liver Ischemia-Reperfusion Injury During Reduced-Size Liver Transplantation in Pigs.

BackgroundNormothermic machine perfusion (NMP) preservation is superior to cold preservation during reduced-size liver transplantation (RSLT) in pigs. However, the mechanism of this protective effect has not been explained. We aimed to compare the effects of NMP preservation with that of cold preservation (CS) in protecting against ischemia-reperfusion injury (IRI) during RSLT in pigs.Material/MethodsTwenty-four healthy Bama miniature pigs were randomized into 2 groups: 1) the NMP group in which donor livers harvested without warm ischemia time and cardiac activity were connected to the NMP system to reduce liver size under normothermic conditions, and 2) the CS group in which donor livers harvested without warm ischemia time and cardiac activity were perfused using the University of Wisconsin (UW) solution and then preserved in the 0–4°C UW solution to reduce liver size under cold conditions. Livers were then transplanted without veno-venous bypass. Amounts of bile secretion for the NMP groups were recorded hourly. The serological indices were measured. Expressions of cytochrome C, caspase 3, and NF-κB p65 in liver tissue were observed.ResultsThe levels of bile secretions were gradually diminished from 16.50±2.66 mL/h before splitting to 6.35±1.24 mL/h after splitting. With the exception of TNF-α on postoperative day 2, overall, levels of TNF-α, IL-1, IL-6, and MDA were significantly lower in the NMP group versus CS group for all 5 days postoperatively. Finally, cytochrome C, caspase 3, and NF-κB p65 expressions were all significantly suppressed in the NMP group as compared with the CS group.ConclusionsMP preservation is superior to cold preservation in protecting against liver IRI during RSLT in pigs.

Thrombosis prophylaxis in pediatric liver transplantation: A systematic review.

AIMTo review current literature of thrombosis prophylaxis in pediatric liver transplantation (PLT) as thrombosis remains a critical complication.METHODSStudies were identified by electronic search of MEDLINE, EMBASE and Cochrane Library (CENTRAL) databases until March 2018. The search was supplemented by manually reviewing the references of included studies and the references of the main published systematic reviews on thrombosis and PLT. We excluded from this review case report, small case series, commentaries, conference abstracts, papers which describing less than 10 pediatric liver transplants/year and articles published before 1990. Two reviewers performed study selection independently, with disagreements solved through discussion and by the opinion of a third reviewer when necessary.RESULTSNine retrospective studies were included in this review. The overall quality of studies was poor. A pooled analysis of results from studies was not possible due to the retrospective design and heterogeneity of included studies. We found an incidence of portal vein thrombosis (PVT) ranging from 2% to 10% in pediatric living donor liver transplantation (LDLT) and from 4% to 33% in pediatric deceased donor liver transplantation (DDLT). Hepatic artery thrombosis (HAT) was observed mostly in mixed LDLT and DDLT pediatric population with an incidence ranging from 0% to 29%. In most of the studies Doppler ultrasonography was used as a first line diagnostic screening for thrombosis. Four different surgical techniques for portal vein anastomosis were reported with similar efficacy in terms of PVT reduction. Reduced size liver transplant was associated with a low risk of both PVT (incidence 4%) and HAT (incidence 0%, P < 0.05). Similarly, aortic arterial anastomosis without graft interposition and microsurgical hepatic arterial reconstruction were associated with a significant reduced HAT incidence (6% and 0%, respectively). According to our inclusion and exclusion criteria, we did not find eligible studies that evaluated pharmacological prevention of thrombosis.CONCLUSIONPoor quality retrospective studies show the use of tailored surgical strategies might be useful to reduce HAT and PVT after PLT; prospective studies are urgently needed.

Protection of recombinant human erythropoietin toward rats with reducedsize liver transplantation for fatty liver

Objective: This paper aims to discuss the protection of recombinant human erythropoietin (r-HuEPO) toward rats with reduced-size liver transplantation for fatty livers. Methods: A total of 48 SD male rats were selected and fed with a high-fat diet to develop fatty liver. Later, the rats were divided into sham-operated, blank control (reduced sized liver transplantation +normal saline), positive control (reduced sized liver transplantation+VES), and study (reduced sized liver transplantation+r-HuEPO) groups, with 12 rats for each group. At 1 and 3 d of intervention, 6 rats from each group were sacrificed to test total bilirubin (TB), alanine aminotransferase (ALT), and aspartic transaminase (AST) levels in serum. Liver transplantation tissues were collected to test cell apoptosis and contents of tumor necrosis factor (TNF)-α, superoxide dismutase (SOD), and malondialdehyde (MDA). The pathomorphism of liver transplantation tissues was observed 3 d after intervention. Results: Except for SOCD content, the TB, ALT, and AST levels in serum, as well as TNF-α and MDA contents of the blank control and sham-operated groups at 3 d, are significantly higher than those at 1 d (p<0.05). By contrast, the indices of the research group and positive control group at day 3 are significantly lower than those at day 1 (p<0.05), whereas the SOD content at day 3 is markedly higher than that at day 1 (p<0.05). Significant inter-group differences (p<0.05) were observed. Cell apoptosis values in the positive control, blank control, and sham-operated groups at day 3 were notably higher than that at day 1 (p<0.05), but cell apoptosis in the research team at day 3 was similar to that at day 1 (p>0.05). Significant inter-group differences (p<0.05) were observed. Several small fat droplets can be observed in the research team, whereas hepatic sinusoids and hepatic lobules were clear and accompanied with certain necrosis of liver cells. Conclusion: Through reduced-sized liver transplantation, r-HuEPO can significantly protect the liver functions of rats with fatty liver, relieve liver damage, and inhibit cell apoptosis, which may be related to the decreased TNF-α and MDA contents and increased SOD activity.

Protective effects of heme oxygenase-1-transduced bone marrow-derived mesenchymal stem cells on reduced-size liver transplantation: Role of autophagy regulated by the ERK/mTOR signaling pathway

Autophagy is a critical lysosomal pathway that degrades cytoplasmic components to maintain cell homeostasis and provide substrates for energy metabolism. A study revealed that heme oxygenase-1 (HO-1)-transduced bone marrow-derived mesenchymal stem cells (BM-MSCs) could protect 50% reduced-size liver transplantation (RSLT) in a rat model. However, the mechanisms remain mostly unknown. The aim of the present study was to explore the effects and related mechanism of autophagy on the protection conferred by HO-1-transduced BM-MSCs (HO-1/BM-MSCs) on 50% RSLT in a rat model. The authors established an acute rejection model following 50% RSLT in rats, with recipients divided into three groups receiving treatment with BM-MSCs, HO-1/BM-MSCs or normal saline (NS) injected through the dorsal penile vein. Transplanted liver tissues at 0, 1, 3, 5, 7, 10 and 14 days following transplantation were acquired for further analysis. The results indicated that the expression of autophagy-related proteins LC3 and Beclin-1 increased, the levels of ERK and p-ERK increased, and the levels of mammalian target of rapamycin (mTOR) and p-mTOR decreased in the HO-1/BM-MSCs. These observations indicated that autophagy is involved in the protective effects of HO-1/BM-MSCs on liver grafts following RSLT, possibly via upregulation of autophagy-related proteins through the ERK/mTOR signaling pathway.

Adipose-derived mesenchymal stem cells promote liver regeneration and suppress rejection in small-for-size liver allograft

Adipose-derived mesenchymal stem cells (ADSCs) possess a liver regeneration capacity and immunosuppressive activity and hold promise in autologous cell-based technology. This study aimed to determine whether autologous ADSCs can improve outcomes in the rat reduced size liver transplantation model. Allogeneic 50% orthotopic liver transplantation followed by administration of autologous ADSCs delivered into the portal vein system was conducted in LEW donor rats and BN recipient rats with phosphate buffered solution (PBS) infusion used as the control. Liver grafts and recipient serum were obtained. We assessed histopathology, regeneration, apoptosis, serum liver enzymes, serum cytokines, and circulating regulatory T cells (Tregs) on postoperative day (POD) 7 and 14. It was found that ADSCs significantly reduced acute rejection and improved the allograft's survival times (median, 24days). Liver function, as assessed by the levels of alanine aminotransferase, aspartate aminotransferase, total bilirubin, as well as liver apoptosis was significantly alleviated in the ADSC group compared with the control group. In addition, ADSC therapy markedly promoted the expression of PCNA in the allograft. Furthermore, levels of interleukin (IL)-10 and transforming growth factor (TGF)-β1 were significantly elevated, whereas those of IL-2 and IL-17 levels were significantly reduced in the ADSC group when compared to the control group. Moreover, flow cytometry analysis revealed that peripheral Tregs had been significantly increased by the infusion of ADSCs. These results demonstrate that implanted autologous ADSCs improve allogeneic reduced size liver allograft outcomes by attenuating acute rejection and reducing inflammatory responses, as well as enhancing liver regeneration.

Effects of heme oxygenase-1-modified bone marrow mesenchymal stem cells on microcirculation and energy metabolism following liver transplantation.

AIMTo investigate the effects of heme oxygenase-1 (HO-1)-modified bone marrow mesenchymal stem cells (BMMSCs) on the microcirculation and energy metabolism of hepatic sinusoids following reduced-size liver transplantation (RLT) in a rat model.METHODSBMMSCs were isolated and cultured in vitro using an adherent method, and then transduced with HO-1-bearing recombinant adenovirus to construct HO-1/BMMSCs. A rat acute rejection model following 50% RLT was established using a two-cuff technique. Recipients were divided into three groups based on the treatment received: normal saline (NS), BMMSCs and HO-1/BMMSCs. Liver function was examined at six time points. The levels of endothelin-1 (ET-1), endothelial nitric-oxide synthase (eNOS), inducible nitric-oxide synthase (iNOS), nitric oxide (NO), and hyaluronic acid (HA) were detected using an enzyme-linked immunosorbent assay. The portal vein pressure (PVP) was detected by Power Lab ML880. The expressions of ET-1, iNOS, eNOS, and von Willebrand factor (vWF) protein in the transplanted liver were detected using immunohistochemistry and Western blotting. ATPase in the transplanted liver was detected by chemical colorimetry, and the ultrastructural changes were observed under a transmission electron microscope.RESULTSHO-1/BMMSCs could alleviate the pathological changes and rejection activity index of the transplanted liver, and improve the liver function of rats following 50% RLT, with statistically significant differences compared with those of the NS group and BMMSCs group (P < 0.05). In term of the microcirculation of hepatic sinusoids: The PVP on POD7 decreased significantly in the HO-1/BMMSCs and BMMSCs groups compared with that of the NS group (P < 0.01); HO-1/BMMSCs could inhibit the expressions of ET-1 and iNOS, increase the expressions of eNOS and inhibit amounts of NO production, and maintain the equilibrium of ET-1/NO (P < 0.05); and HO-1/BMMSCs increased the expression of vWF in hepatic sinusoidal endothelial cells (SECs), and promoted the degradation of HA, compared with those of the NS group and BMMSCs group (P < 0.05). In term of the energy metabolism of the transplanted liver, HO-1/BMMSCs repaired the damaged mitochondria, and improved the activity of mitochondrial aspartate aminotransferase (ASTm) and ATPase, compared with the other two groups (P <0.05).CONCLUSIONHO-1/BMMSCs can improve the microcirculation of hepatic sinusoids significantly, and recover the energy metabolism of damaged hepatocytes in rats following RLT, thus protecting the transplanted liver.

Immunomodulatory effects of bone marrow mesenchymal stem cells overexpressing heme oxygenase-1: Protective effects on acute rejection following reduced-size liver transplantation in a rat model

Here we explore the T-lymphocyte suppressive and immunomodulatory effects of bone marrow mesenchymal stem cells (BMMSCs) overexpressing heme oxygenase-1 (HO-1) on acute rejection following reduced-size liver transplantation (RLT) in a rat model. The proliferation activity, cell cycle progression, secretion of proinflammatory cytokines, expression of CD25 and CD71 in lymphocytes, and activity of NK cells were found to be significantly lowered, and the proportion of regulatory T cells (Tregs) was found to be increased relative to BMMSCs when Adv-HO-1/BMMSCs were co-cultured with Con A ex vivo; secretion of anti-inflammatory cytokines was significantly higher. When treated with saline, BMMSCs or Adv-HO-1/BMMSCs, post-transplantation rats receiving Adv-HO-1/BMMSCs showed better median survival time, lower rejection activity index, higher anti-inflammatory cytokine levels, lower proinflammatory cytokine levels, more peripheral Tregs, and lower natural killer cell viability. These results suggest that HO-1 enhanced and prolonged the effects of BMMSCs on acute rejection following RLT, with immunomodulatory effects in which adaptive and innate immunity, as well as paracrine signaling, may play important roles.

Protective role of normothermic machine perfusion during reduced-size liver transplantation in pigs.

The purpose of this study is to explore whether normothermic machine perfusion (NMP) preservation is superior to cold preservation during reduced-size liver transplantation (RSLT) in pigs. Twenty-four healthy Ba-Ma mini pigs were used (aged >13 months; weight 25-35 kg; regardless of sex). The animals were randomized into 2 groups. In group A (NMP), donor livers were harvested without warm ischemia time and heartbeats and then were connected to the NMP system to reduce the livers' size under the normothermic condition. In group B (University of Wisconsin [UW] solution), donor livers were harvested without warm ischemia time and heartbeats after being perfused by UW solution and were then preserved in 0°C-4°C UW solution to reduce the livers' size under cold conditions. After that, liver transplantation without venovenous bypass was performed. General RSLT information of the pigs from the 2 groups was recorded; the serological indices were measured; and routine pathological examination of liver tissue was observed. A significant difference was observed in the intraoperative bleeding between the 2 groups (P < 0.05), whereas no significant difference was found in the other indices (all P > 0.05). Significant differences of alanine aminotransferase levels, aspartate aminotransferase levels, and lactate dehydrogenase levels between the 2 groups were observed between postoperative days 3 and 5 (P < 0.05). Significant differences of lactic acid levels between the 2 groups were observed between postoperative days 2 and 5 (P < 0.05). Compared with the cold preservation group, the liver tissues of the NMP preservation group only rarely experienced liver cell necrosis and maintained integrities in the hepatic sinusoid spaces and endothelial cells. In conclusion, NMP preservation is superior to cold preservation during RSLT in pigs. Liver Transplantation 22 968-978 2016 AASLD.

SENGSTAKEN-BLAKEMORE tube can prevent whole liver twisting the right hepatic fossa improving venous outflow post-orthotopic liver transplantation

Introduction: Reduced-size liver transplantation in combination with an unusual situation poses an increased risk for venous outflow obstruction. Reduced-size liver transplantation using ex-vivo graft reduction or splitting has become standard procedure in children, with some of these cases described in literature after the successful management use of Sengstaken-Blakemore, although used in orthotopic whole liver transplantation (OLT) has never been described. The aim was to report the successful management of acute venous obstruction after OLT by using a Sengstaken-Blakemore tube within the hepatic fossa in a 51-year-old male patient. Case Report: A 51-year old male patient with hepatitis C cirrhosis and alcoholism, C Child-Pugh, 24 MELD score was submitted to OLT by using the piggy-back technique. The donor and recipient body-weight ratio was 1.38 (65/90kg). The liver recipient weight was 1,152g and the donor liver was 992g. After reperfusion time, the patient showed a venous outflow obstruction in supra-hepatic anastomosis with total resolution after clockwise rotation of the graft, but reduced venous outflow was observed after liver twist to the right hepatic fossa and mean arterial blood pressure (MAP) was reduced to 30 mmHg . After five attempts, a Sengstaken-Blakemore tube was inserted into the right subphrenic space and the gastric and oesophageal balloons were inflated to maintain the graft at the midline position with normalization of the MAP and venous outflow. Although data on hemodynamic measurements were maintained during the ICU period, a Doppler ultrasonography (DUS) was carried out daily to ensure that venous outflow was maintained. On 4th day, the gastric balloon was deflated; after 2 hours the oesophageal balloon was deflated and no systemic abnormality was detected. The Sengstaken-Blakemore tube with deflated balloons was removed on 5th day using slight traction. Later, DUS was carried out after it was shown that venous outflow was maintained and the liver was fixed in a hemodynamically correct position without interfering in the mechanical outflow. The patient was discharged, and he is in good condition. Conclusion: The Sengstaken -Blakemore tube is a good tool to improve liver venous outflow due to mechanical problems such as twist of the right hepatic fossa and preventing re-operations.

Clinical outcomes in liver transplantation from donation after cardiac death

Objective To investigate the clinical outcomes in liver transplantation from donation after cardiac death (DCD) . Methods The clinical data of 52 patients with end stage liver disease who received liver transplantation from DCD donors (the age of 21 pediatric recipients <18 years, and the age of 31 adult recipients≥18 years) at the Tianjin First Central Hospital from December 2008 to July 2013 were retrospectively analyzed. The intraoperative, postoperative and prognosis data were analyzed. All patients were regularly followed up in the Transplantation Follow-up Center after discharge till July 31 , 2014. The measurement data with normal distribution were presented as±s. The comparison between groups was evaluated with the repeated measures ANOVA. The cumulative survival rate was done by the Kaplan-Meier method. Results Among the 21 pediatric recipients, 16 received classic orthotopical liver transplantation and 5 received reduced-size liver transplantation from adult donors. The weight of 21 DCD livers, graft to recipient weight ratio (GRWR) , warm ischemia time, cold ischemia time, anhepatic phase, volume of intravenous infusion, operation time and volume of intraoperative blood loss were (338±34) g, 1. 9%±0. 7% , (16±6) minutes, (86±36) minutes, (43±10) minutes, (816±662) mL, (7. 1 ± 1. 5) hours and (329±214) mL, respectively. No peritoneal effusion, acute cellular rejection (ACR) , portal vein thrombosis (PVT) and biliary complications occurred in the pediatric recipients. The duration of hospital stay was (41±23) days. The level of hemoglobin (Hb) and albumin (Alb) to reach the normal level from pre-operation to postoperative day 14 were (101±19) g/ L to (128±23) g/ L and (34±7) g/L to (44±7) g/ L, respectively, with significant differences (F =3.943 , 7.340, P <0.05) . The level of total bilirubin (TBil) , aspartate transaminase (AST) and alanine transaminase (ALT) gradual reducing to the normal level from preoperation to postoperative day 14 were (307±69) μmol/ L to (34±17) μmol/ L, (88±34) U/ L to (36±17) U/ L and (154±51) U/ L to (46±18) U/ L, respectively, with significant differences (F =142.200, 17.060, 31.750, P <0.05) . Thirtyone adult recipients received classic orthotopical liver transplantation form adult donors. The weight of 21 DCD livers, GRWR, warm ischemia time, cold ischemia time, anhepatic phase, volume of intravenous infusion, operation time and volume of blood loss were (1 104 ± 43) g, 1. 7% ± 0. 4%, (16 ± 4) minutes, (89 ± 43) minutes, (47±9) minutes, (2 515±1 803) mL, (7. 9 ± 1.8) hours and (1 208 ± 548) mL, respectively. The complications occurred in 14 adult recipients, including peritoneal effusion in 8 recipients, ACR in 3 recipients, PVT in 2 recipients and biliary complications in 1 recipient. The duration of hospital stay was (44±22) days. The level of Alb to reach the normal level from pre-operation to postoperative day 14 were (31±5) g/ L to (40±5) g/ L, with a significant difference (F =14.930, P <0.05) . The level of TBil, AST and ALT gradual reducing to the nearly normal level from pre-operation to postoperative day 14 were (182 ± 55) μmol/ L to (62 ± 22) μmol/ L, (286 ± 93) U/ L to (79±47) U/ L and (349±111) U/ L to (76±28) U/ L, respectively, with significant differences (F = 34.350, 71.070, 82.680, P <0.05) . All the 52 recipients were followed up for a median time of 544 days (range, 196-1 953 days) , with 1-year survival rate of 90.38%. During the follow-up, 1 pediatric recipient died of pulmonary infection and 1 of massive hemorrhage, and 1 adult recipient died of pulmonary infection, 1 of primary graft dysfunction and 1 of massive hemorrhage. Conclusion Liver transplantation from DCD is a feasible treatment for end-stage liver diseases, with a good short-term clinical outcomes. Key words: End stage liver disease; Donation after cardiac death; Liver transplantation; Short-term outcomes; Clinical analysis

Anatomical and Surgical Basis for Adult Living Donor Liver Transplantation with the Right Liver Lobe

Abstract Liver transplantation is now a standard procedure for the treatment of end stage liver diseases. Since 1968 until 2012, a number of 113,627 liver transplantations were performed in Europe, in 28 countries and 153 institutions. Despite these impressive figures the waiting list is growing every year. Transplant surgeons were preoccupied to find new ways to increase the donor pool. Among them: reduced size liver transplantation, split liver technique and more recently living donor liver transplantation. At first in the early `90, living donor liver transplantation was used for pediatric patients because the left lateral hepatic segments were harvested. This graft is too small for the metabolic demands of an adult patient. So the next step was the harvesting of the right liver lobe from the donor and transplantation to adult patients. Living donor liver transplantation has gained fast a wide acceptance but there are a few issues to discuss. The main concern is about the donor safety which is a healthy person undergoing major surgery with potential risks. Also the surgical technique evolved due to a better understanding of the anatomy and physiology of the liver and the right liver graft. We discuss here the anatomical and surgical basis for living donor liver transplantation with the right liver lobe.

Interleukin-6 Mediates Angiotensinogen Gene Expression during Liver Regeneration

BackgroundAngiotensinogen is the precursor of angiotensin II, which is associated with ischemia-reperfusion injury. Angiotensin II reduces liver regeneration after hepatectomy and causes dysfunction and failure of reduced-size liver transplants. However, the regulation of angiotensinogen during liver regeneration is still unclear.AimsTo investigate the regulation of angiotensinogen during liver regeneration for preventing angiotensin II-related ischemia-reperfusion injury during liver regeneration.MethodsA mouse in vitro partial hepatectomy animal model was used to evaluate the expression of interleukin-6 (IL-6) and angiotensinogen during liver regeneration. Serum IL-6 and angiotensinogen were detected by enzyme immunoassay (EIA). Angiotensinogen mRNA was detected by RT-PCR. Tissue levels of angiotensinogen protein were detected by Western blot analysis. Primary cultures of mouse hepatocytes were used to investigate IL-6-induced angiotensinogen. Chemical inhibitors were used to perturb signal transduction pathways. Synthetic double-stranded oligodeoxynucleotides (ODNs) were used as ‘decoy’ cis-elements to investigate transcription. Ki 67 staining and quantification were used to verify liver regeneration.ResultsIn the in vivo model, the levels of serum IL-6 and angiotensinogen correlated. In the in vitro model, IL-6 transcriptionally regulated angiotensinogen expression. Additionally, IL-6 mediated angiotensinogen expression through the Janus kinase (JAK)/signal transducer and activator of transcription 3 (STAT3) and JAK/p38 signaling. Decoy ODN analyses revealed that STAT3 and nuclear factor-kB (NF-kB) also played critical roles in the transcriptional regulation of angiotensinogen by IL-6. IL-6-mediated signaling, JAK2, STAT3 and p38 inhibitors reduced angiotensinogen expression in the partially hepatectomized mice.ConclusionDuring liver regeneration, IL-6-enhanced angiotensinogen expression is dependent on the JAK/STAT3 and JAK/p38/NF-kB signaling pathways. Interruption of the molecular mechanisms of angiotensinogen regulation may be applied as the basis of therapeutic strategies for preventing angiotensin II-related ischemia-reperfusion injury during liver regeneration.

Role of mesenchymal stem cells in partial liver transplantation

First performed in 1963 [1], liver transplantation has developed in its clinical application and is now considered the only therapeutic option for patients with end-stage chronic liver disease and severe acute liver failure [2]. Despite its proven benefits to patient care, a shortage of donor organs has limited the expansion of hepatic transplantation into more widespread application. In an attempt to increase the availability and utilization of viable donor organs, innovative techniques of reduced-size liver transplantation (RSLT), living donor liver transplantation, and split liver transplantation have been developed to maximize donor organ use [3].

Mesenchymal stem cell–conditioned medium reduces liver injury and enhances regeneration in reduced-size rat liver transplantation

BackgroundMesenchymal stem cell (MSC) therapy can prevent parenchymal cell loss and promotes tissue repair through the action of trophic, secreted molecules. In this study, we investigated whether MSC-conditioned medium (MSC-CM) could protect hepatocytes and sinusoidal endothelial cells (SECs) and stimulate their regeneration in 50% reduced-size liver transplantation (RSLT). Materials and methodsRats were randomly divided into three groups: sham-operated group, MSC-CM group (rats with 50% RSLT receiving MSC-CM infusion), and medium group (rats with 50% RSLT receiving medium therapy). Graft function, proinflammatory cytokines, incidence of apoptosis, proliferation of hepatocytes and SECs, and the expression of vascular endothelial growth factor and matrix metallopeptidase 9 were assessed in this study. ResultsSystemic infusion of MSC-CM prevented the release of liver injury biomarkers and provided a significant survival benefit. Furthermore, MSC-CM therapy resulted in reduction of apoptosis of hepatocytes and SECs. The number of proliferating hepatocytes and SECs increased 1.2- and 1.6-fold, respectively, accompanied by a decrease in the expression levels of several proinflammatory cytokines and a noticeable decrease in infiltration of neutrophils and activation of Kupffer cells. Also, increased expression of vascular endothelial growth factor and matrix metallopeptidase 9 in the grafts was observed after MSC-CM therapy. ConclusionsThese data suggest that MSC-CM therapy in RSLT provides trophic support to the injured liver by inhibiting SEC and hepatocellular death and stimulating their regeneration.

Mesenchymal Stem Cells Overexpressing C-X-C Chemokine Receptor Type 4 Improve Early Liver Regeneration of Small-for-Size Liver Grafts

Mesenchymal stem cell (MSC) therapy can prevent hepatic parenchymal cell loss and promote tissue repair. However, poor MSC engraftment is one of the primary barriers to the effectiveness of cell therapy because culture-expanded MSCs progressively down-regulate C-X-C chemokine receptor type 4 (CXCR4) expression and lose their ability to migrate toward a concentration gradient of stromal cell-derived factor 1a (SDF1a). In this study, we investigated whether a CXCR4-MSC infusion could protect hepatocytes and stimulate regeneration in 50% reduced size liver transplantation (RSLT). Rats that underwent 50% RSLT were randomly divided into 3 groups: a phosphate-buffered solution group (PBS), a green fluorescent protein (GFP)-MSC group, and a CXCR4-MSC group. Rats received 1 mL of PBS with or without a resuspension of GFP-MSCs or CXCR4-MSCs. The factors secreted by MSCs, the graft function, the apoptosis and proliferation of hepatocytes, the efficacy of MSC engraftment, and the expression of SDF1α, albumin (Alb), and cytokeratin 18 (CK18) in engrafted GFP-positive MSCs were assessed. A systemic infusion of GFP-MSCs led to a reduction of the release of liver injury biomarkers and apoptosis of hepatocytes; CXCR4 overexpression did not further reduce the liver injury. However, CXCR4 overexpression enhanced MSC engraftment in liver grafts, improved the effect on the proliferation of hepatocytes, and thus provided a significant 1-week survival benefit. SDF1α expression in grafts was elevated after transplanted CXCR4-MSCs were recruited to the remnant liver. However, engrafted MSCs did not express the markers of hepatocytes, including Alb and CK18, in vivo 168 hours after transplantation. CXCR4 overexpression enhanced the mobilization and engraftment of MSCs into small-for-size liver grafts, in which these cells promoted the early regeneration of the remnant liver not by direct differentiation but perhaps by a paracrine mechanism.

Results after Adult Ex Situ Split Liver Transplantation Since 1987 and the Influence of Biliary Complications

Introduction: Some transplant centres still hesitate to use split liver grafts in adults obtained by an ex situ split either in general or for complicated or retransplant cases due to the inherently increased risks of significant biliary complications. This study investigates the frequency, the treatment and the long-term results of biliary complications after adult ex situ split liver transplantation from deceased heart-beating donors. Patients and methods: This is a single centre analysis with ongoing data collection. Included were all consecutive split liver transplants performed in adult recipients (minimum age 18 years) in our centre between the 01.12.1987 and the 31.12.2010. Excluded were all combined transplants (e.g. combined split liver and kidney transplantation) and living-related organ donor transplants as well as reduced size liver transplantation. We investigated 132 consecutive split liver transplants including 7 acute retransplants (defined as retransplantation within 30 days after the previous transplant) and 5 chronic retransplants (primary transplantation n = 119, 90.8 %; secondary transplantation n = 12, 9.2 %) in a total of 131 patients (median age: 43.8 years, range: 18-66 years; males n = 52, 39.7 %; females n = 79, 60.3 %). The post-transplant observational period ended on the 31.03.2011. Results: The overall 30-day mortality rate, the 1-year and the 3-year patient survival rates after adult ex situ split liver transplantation for all patients were 13%, 76.3% and 66.4%, respectively. The overall 1-year and 3-year graft survival rates of all transplants performed were 63.4% and 54.2%, respectively. The occurrence of any type of biliary complication had a significant influence on 1-year and 3-year graft survival (p=0.025 and p=0.020, respectively, Chi2-test). The individual types of biliary complications did not show a statistically significant influence on long-term patient or graft survival (Cox regression analysis) with central bile duct lesions leading to significantly worse patient survival as compared to all other types of biliary complications (p=0.014, Log Rank). The absence or presence of biliary complications had no statistically significant influence on long-term patient and graft survival (p>0.05; Kaplan-Meier analysis, Log Rank test). The majority of patients with biliary complications were treated surgically (57.1%, n=20). A large proportion of patients with biliary complications required interventional treatment (40%, n=14). Hepatic artery thrombosis occurred in 17 of 129 (13.2%) patients and in 4 of 34 (11.8%) patients with biliary complications following split-liver transplantation (difference not significant). Our results reveal that the era during which the split liver transplant was performed had a significant impact on patient long-term patient survival (p=0.016; Cox regression analysis; see also Figure 1) but not on transplant survival (era 1 = 01.12.1987-31.12.1991, era 2 = 01.01.1992-31.12.1994, era 3 = 01.01.1995-31.12.1998, era 4 = 01.01.1999-31.12.2003, era 5 = 01.01.2004-31.12.2007, era 6 = 01.01.2006-31.12.2010). Conclusions: This is a long-term series of adult ex situ split liver transplantation and currently one of the largest series in the world and shows that biliary complications after ex situ split liver transplantation have no significant influence on long-term patient and graft survival and that the results have improved since its invention.