Time Of Living Donor Liver Transplantation Research Articles

Outcomes of 6000 living donor liver transplantation procedures: a pioneering experience at ASAN Medical Center.

Living donor liver transplantation (LDLT) has emerged as a favorable alternative to deceased donor liver transplantation, significantly reducing waitlist mortality, particularly in Asian countries with very low deceased organ donation rates. Asan Medical Center (AMC) in South Korea has pioneered innovative LDLT surgical techniques and become established as an extremely high-volume center for LDLT. This retrospective study analyzed 6000 consecutive LDLT procedures, including 510 dual-graft procedures, performed at AMC between December 1994 and January 2021. Of these, 312 LDLT procedures were performed in children aged < 18years. In adult recipients, liver cirrhosis (LC) related to viral hepatitis was the most common indication, occurring in 69.8% of cases. Biliary atresia (46.8%) was the most common indication for pediatric LDLT. This study demonstrated outstanding long-term outcomes, with patient survival rates at 1, 5, 10, and 20years of 92.7%, 85.9%, 82.1%, and 70.9%, respectively, in LDLT group for adults aged 50 and under at the time of LDLT, and 92.9%, 89.0%, 88.1%, and 81.9%, respectively, in the pediatric group. The in-hospital mortality rate of adult recipients was 3.8% (n = 214/5688). This study demonstrates the importance of refined surgical techniques, selection of grafts tailored to the recipient, and comprehensive multidisciplinary perioperative patient care in expanding the scope of LDLT and improving recipient outcomes.

Healthcare utilization and outcomes of living donor liver transplantation for patients with APASL-defined acute-on-chronic liver failure.

Liver transplantation (LT) is associated with excellent survival in patients with acute-on-chronic liver failure (ACLF). There is a lack of data assessing the healthcare utilization and outcomes of patients with APASL-defined ACLF undergoing living donor liver transplantation (LDLT). Our aim was to assess pre-LT healthcare utilization and post-LT outcomes in such patients. Patients with ACLF who underwent LDLT at our center between 1st April 2019 and 1st October 2021 were included. Seventy-three ACLF patients willing to undergo LDLT were listed; eighteen patients died within 30days. Fifty-five patients underwent LDLT (age:38.05 ± 14.76years; alcohol:52.7%; males:81.8%). Most were in grade II ACLF (87.3%) at the time of LDLT (APASL ACLF Research Consortium [AARC] score: 9.05 ± 1; MELD NA: 28.15 ± 4.13). Survival rate was 72.73%; mean follow-up period of 925.21days; 58.2% (32/55) developed complications during the first year post-LT; 45% (25/55) and 12.7% (7/55) developed infections within and after 3months. Pre-LT, each patient required a median of 2 (1-4) admissions for 17 (4-45) days. Fifty-six percent (31/55) of patients underwent plasma exchange pre-LDLT. A median amount of Rs. 8,25,090 (INR 26,000-43,58,154) was spent to stabilize the patient (who were sicker and waited longer to undergo LDLT); though post-LT survival benefit was not observed. LDLT was associated with 73% survival and, thus, is a viable option in those with APASL-defined ACLF. There was a pre-LT high healthcare resource utilization of plasma exchange, with the intention of optimization, while survival benefit has not been demonstrated.

Preoperative prediction score of hepatocellular carcinoma recurrence in living donor liver transplantation: Validation of SNAPP score developed at Asan Medical Center

Preoperative prediction score of hepatocellular carcinoma recurrence in living donor liver transplantation: Validation of SNAPP score developed at Asan Medical Center

Surgical Procedures of Portal Vein Reconstruction for Recipients With Portal Vein Thrombosis in Adult-to-Adult Living Donor Liver Transplantation

BackgroundPortal vein (PV) reconstruction is an important surgical skill for living donor liver transplantation (LDLT), especially for patients with portal vein thrombosis (PVT). However, this technique remains a critical problem in LDLT because of technical demands and requirements for appropriate venous graft harvesting. This study aimed to evaluate the surgical procedure used for PV reconstruction and outcomes in LDLT recipients with PVT. MethodsBetween March 2002 and December 2018, 128 adult LDLTs were performed. Fourteen recipients (10.8%) had PVT at the time of LDLT, classified as grade I in 2, grade II in 5, grade III in 6, and grade IV in 1, according to the Yerdel classification. We retrospectively analyzed the surgical procedure and postoperative complications associated with PV reconstruction of recipients with PVT. ResultsSurgical treatments for 14 recipients with PVT were as follows: thrombectomies in 2 recipients, replacement of interpositional venous grafts using the internal jugular vein (IJV) in 3 recipients and the external iliac vein (EIV) in 6 recipients, mesoportal jump grafts using the IJV in 1 recipient and the IJV + EIV in 1 recipient, and renoportal anastomosis using the EIV in 1 recipient. Among interpositional venous grafts, 5 venous grafts (IJV: 2, EIV: 3) passed the dorsal side of the pancreas without using the jump graft. Postoperative complications associated with PV anastomosis occurred in 1 of 14 (7.1%) recipients, who developed anastomosis bleeding caused by coagulation disorders at 27 days after LDLT, without any strictures of PV anastomoses. The overall survival rate at 5 years posttransplant was not statistically different between recipients with and without PVT (50.0% vs 65.0%, P = .163). ConclusionOur techniques of PV reconstruction, using the appropriate venous grafts and route, are feasible, resulting in a prognosis comparable to that of recipients without PVT.

The outcome of living donor liver transplant recipients with recent episodes of spontaneous bacterial peritonitis.

spontaneous bacterial peritonitis (SBP) is a common complication in patients with cirrhosis and is associated with a high mortality rate. Only a few reports have analyzed the impact of treated SBP that occurs in the immediate pre-operative period on outcome after a living donor liver transplantation (LDLT). The results of whether post-transplant patients are dependent on pre-transplant infections are still debatable and unclear. Therefore, this study examined the outcomes of LDLT recipients with recent episodes of SBP and LDLT recipients without prior episodes of SBP. the records of 62 LDLT recipients who underwent LDLT were retrospectively reviewed. Twenty-four (36 %) recipients had at least one episode of SBP before LDLT. However, active SBP was not present in any of the recipients at the time of LDLT. Both recipient groups were compared in terms of demographic profile, perioperative and postoperative variables and outcomes. higher pre-operative Child-Turcotte-Pugh (CTP) score (mean [SD] 11.77 [1.37] vs 10.5 [1.22], p < 0.001) and prior history of renal dysfunction (mean serum creatinine [SD] 1.715 [1.08] vs 1.02 [0.479] mg/dl, p = 0.002) were more commonly associated with the SBP group as compared to the non-SBP group. However, there was no statistically significant difference between the two groups in terms of the following variables: previous diabetes mellitus (3 [12.5 %] vs 6 [15.8 %]), pre-operative model for end-stage liver disease (MELD) score (median [IQR] 21 [10-37] vs 22 [9-39]), operative time (mean [SD] 789.57 [153.49] vs 800.86 [138.69] min), total number of blood transfusion (median [IQR] 10 [2-19] vs 8 [1-18]), hospital stay (median 21 vs 20 days), re-exploration (4 [16.6 %] vs 2 [5.3 %]), postoperative sepsis (8 [33 %] vs 5 [13 %]) and 30-day mortality (3 [12.5 %] vs 2 [5.3 %]). the presence of previous episodes of pre-operative SBP in LDLT recipients does not result in adverse post-operative short-term outcomes.

Optimal Biliary Drainage for Patients With Biliary Anastomotic Strictures After Right Lobe Living Donor Liver Transplantation.

Right lobe (RL) living donor liver transplantation (LDLT) usually includes 2 bile duct anastomosis sites, namely, the right anterior and the right posterior segmental ducts. This study aimed to evaluate the optimal treatment for biliary strictures following RL LDLT with respect to unilateral or bilateral drainage techniques. From January 2005 to December 2017, 883 patients at Seoul National University Hospital underwent RL LDLT. Of these, 110 patients were enrolled who had 2 duct-to-duct anastomosis sites and who were considered at risk of developing biliary anastomotic strictures. Unilateral or bilateral biliary drainage during the follow-up period was identified by endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous transhepatic biliary drainage (PTBD). The clinical success, complication, and 180-day mortality rates were compared between the unilateral and bilateral biliary drainage groups according to the initial ERCP findings. The mean age at the time of LDLT was 54.2±8.2 years. The median time from LDLT to initial biliary anastomotic strictures was 177 (interquartile range, 18-1085) days. At the initial ERCP, unilateral drainage was performed in 55 (50.0%) patients, and bilateral drainage was performed in 11 (10.0%) patients. Of the patients who underwent unilateral drainage, 35 (63.6%) patients required conversion to bilateral drainage during follow-up. Overall, 71 (64.5%) patients required bilateral drainage more than once, whereas only 27 (24.5%) patients reached a resolution with unilateral biliary drainage. In this study, most patients required bilateral biliary drainage more than once during follow-up. An active attempt should be made to drain bilaterally in patients with biliary anastomotic strictures following RL LDLT.

Outcomes of extrahepatic recurrence after adult living donor liver transplantation for hepatocellular carcinoma

Introduction: A few studies have been reported on extrahepatic metastasis after living donor liver transplantation (LDLT) for hepatocellular carcinoma (HCC). We investigated the clinical outcomes of patients with extrahepatic recurrence (EHR) of HCC after LDLT. Method: We retrospectively reviewed 353 patients who underwent LDLT for HCC from March 2005 to December 2015. Clinicopathological data of patients with EHR were analyzed for overall survival (OS) rate and prognostic factors. Result: During a median follow-up of 25.3 months, a total of 71 patients (71.7%) presented EHR as an initial recurrence. The sites of EHR were lung (n=33), bone (n=10), lymph nodes (n=8), adrenal gland (n=2), and others (n=18). Forty-six patients (64.7%) underwent curative resection for EHR. The 1, 3, 5-year overall survival rate from the time of LDLT in patients with resection for EHR were 90.8%, 59%, and 40.9%, while those in patients without resection for EHR were 56%, 4.7%, and 0% (p <0.05). In multivariate analysis of risk factor for OS, resection for EHR (hazard ratio [HR], 0.254; 95% confidence interval [CI] 0.131–0.495, p = 0.001), interval time from LDLT to EHR (HR 0.950; 95% CI 0.919–0.982, p = 0.002), Alpha-fetoprotein (AFP) ≤200 ng/ml at the diagnosis of EHR (HR 0.323; 95% CI 0.169–0.620, p = 0.001), and the absence of portal vein invasion of HCC in explant liver (HR 0.328; 95% CI 0.171–0.630, p = 0.001) were favorable factors. Conclusion: Resection for EHR after LDLT can be performed in selected patients with a favorable outcome. The longer interval time from LDLT to HER, a lower AFP at EHR, and the HCC without portal vein invasion in explant liver were favorable factors for OS of patients with EHR.

Percutaneous Transhepatic Portal Vein Angioplasty for Portal Vein Stricture after Living Donor Liver Transplantation

Background Liver transplantations have been widely performed with good outcome for patients with end-stage liver disease. However, complications associated with vascular reconstruction might result to graft liver failure and negatively impact on the outcome. These complications more frequently occur using a reduced-size graft such as a living donor because of an intrinsic short pedicle or a size mismatch of the graft vessel. Percutaneous transhepatic portal vein angioplasty (PTPA) is an alternative except for a surgical revision for the treatment of portal vein stricture. The aim of this study is to evaluate efficacy of PTPA for portal vein stricture after living donor liver transplantation (LDLT). Patients and Methods We have performed 303 LDLTs since June 1990 and experienced 35 cases (11.6%) of portal vein complications. Out of them, 11 recipients who underwent PTPA for portal vein stricture that occurred after LDLT were included in this study. The diagnosis of portal vein stricture was obtained based on the findings of contrast-enhanced CT and/or magnetic resonance imaging, in addition to symptoms arising from portal hypertension. PTPA was performed using the ultra-sonography-guided percutaneous transhepatic method. We inserted a catheter into a portal vein and placed a balloon catheter into the anastomotic stricture. After measuring the portal vein pressure, we dilated the stricture using balloons, starting from small diameter and then extending step by step till vanishing a notch, without inserting a vascular stent. We retrospectively evaluated the outcome and complications associated with this procedure. Results Eleven recipients aged from 5 months to 49 years old (median 18 years old) at the time of LDLT, had obtained a diagnosis of portal vein stricture median 3.4 years after LDLT. Portal vein pressure decreased and symptoms arising from portal hypertension improved via PTPAs in all recipients excluding one required stenting and another underwent revision of anastomosis after PTPA. Vascular patency was maintained during the follow-up period ranging from 1 month to 22.3 years (median 7.9 years) after PTPA. Complication associated with PTPA occurred in one recipient with portal vein thrombus (grade II); no recipients had complications over grade III in the Clavien-Dindo classification. All recipients are still alive except one dying of chronic rejection. The 10 and 20 year patient survival rates in 11 recipients were comparative to those in 268 recipients without portal complications (90% each vs 93.2% and 86.7%, p>0.1). Conclusion PTPA for portal vein stricture after LDLT was effective because of safety and long vascular patency.

A simplified protocol using rituximab and immunoglobulin for ABO-incompatible low-titre living donor liver transplantation.

No consensus has been reached regarding optimal treatment strategies for ABO-incompatible (ABO-I) living donor liver transplantation (LDLT). We introduce a simplified protocol using rituximab and intravenous immunoglobulin (IVIG). Data were analysed on adult patients who underwent ABO-I LDLT of which protocol added rituximab (300mg/m2 ) before surgery and IVIG (0.8g/kg) on post-operative days 1 and 4 to the conventional immunosuppressive regimen used in ABO-compatible (ABO-C) LDLT, without plasmapheresis, splenectomy or graft local infusion. The outcomes were compared with those of ABO-C LDLT by 1:2 propensity score-matched analysis. Consecutive 43 ABO-I LDLT patients were identified between 2014 and 2016. Before desensitization, the median isoagglutinin titre was 1:8 (range, 1:2-1:64). The titre was reduced to 4 (range, 0-16) at the time of LDLT. None showed a rebound rise of isoagglutinin titres. No antibody-mediated rejection occurred. Biliary stricture was the most common complication with an incidence of 30.2%. A comparator group of 86 ABO-C LDLT patients were selected. There was no statistical difference in the overall complication rate including acute cellular rejection, biliary complications and infection between ABO-I and ABO-C groups. The 3-year cumulative patient survival rates in the ABO-I and ABO-C groups were 82.4% and 85.9% respectively (P=.115). A simplified protocol using rituximab and IVIG for ABO-I LDLT was safe and effective in achieving sufficient desensitization and comparable outcomes in patients with the titre no higher than 1:64.

Effect of Recipient Age at Liver Transplantation on Prevalence of Post-Transplant Donor-Specific HLA Antibody.

BACKGROUND Post-transplant donor-specific HLA antibodies (DSA) may have a detrimental effect on long-term outcomes of organ transplantation. The aim of this study was to specifically evaluate the effect of recipient age on the prevalence of DSA over a long-term follow-up after living donor liver transplantation (LDLT). MATERIAL AND METHODS A retrospective analysis of DSA evaluations was performed in 50 pediatric patients with HLA data available. Patients were divided into 2 groups based on their age at the time of LDLT: younger (Y) group, age <3 years; older (O) group, age ≥3 years. DSA evaluation was performed using Luminex single-antigen bead assays, with a mean fluorescence intensity ≥1000 used as a cut-off for positive results. RESULTS There were no between-group differences in terms of sex, ABO incompatibility or acute rejection. Only one of our 50 patients tested positive for class I DSA. Significantly more patients tested positive for HLA-DR DSA in group Y (40.6%) than in group O (11.1%; p=0.02). Recipients <3 years of age at the time of LDLT may be at a higher risk of testing positive for class II DSA. CONCLUSIONS These findings can inform the implementation of cost-effective screening of post-transplant DSA in pediatric LDLT recipients.

How to Use Rituximab in ABO-Incompatible Pediatric Living Donor Liver Transplantation: A Single Center Experience.

(Background) Previous studies have demonstrated the safety of ABO-incompatible living donor liver transplantation (LDLT) using preoperative plasmapheresis and rituximab. However, no reports have so far described the timing and dosage of rituximab administration for pediatric LDLT. The aim of this study is to determine the optimal dosage and timing of rituximab treatment in patients undergoing pediatric ABO-incompatible LDLT. (Methods) Between May 2001 and July 2013, 222 LDLTs were performed for 217 patients. Emergency LDLTs were excluded, because there was not adequate time to prepare these patients for ABO-incompatible LDLT. Those cases included 32 ABO-incompatible LDLTs in 31 patients, and 12 cases (11 patients) were administered rituximab. The anti-ABO antibody titers were reduced preoperatively by plasmapheresis in all cases who were administered rituximab. Rituximab was used from January 2004 for recipients over two years of age (first period; 375 mg/m2 two weeks before LDLT in two cases, second period; 50 mg/m2 two weeks before LDLT in two cases and third period: 200 mg/m2 three weeks before LDLT in eight cases). (Results) The ABO-incompatible LDLT recipient survival rate (87.1%) was significantly lower than that of the other recipients (97.3%) (p=0.008). Two patients who were administered 375 mg/m2 of rituximab died of Pneumocystis jiroveci pneumonia and hemophagocytic syndrome, respectively. One patient who was administered 50 mg/m2 of rituximab underwent re-transplantation due to antibody-mediated complications (intrahepatic biliary strictures). All eight patients who were administered 200 mg/m2 of rituximab survived. The mean CD20+ lymphocyte count was 0.1% at the time of LDLT and 5.4% six months after LDLT. (Conclusion) In the preoperative management of patients undergoing pediatric ABO-incompatible LDLT, the administration of 200 mg/m2 of rituximab three weeks before LDLT is optimally safe and effective.

Surgical resection and its relationship to survival for recurrent hepatocellular carcinoma after living donor liver transplantation.

e14602 Background: Although liver transplantation offers excellent recurrence-free survivals for treating hepatocellular carcinoma (HCC), cases with recurrent diseases usually result in miserable outcomes. In this study, the indication and efficacy of surgical resection for the recurrent diseases after living donor liver transplantation (LDLT) for HCC. Methods: A total of 153 recipients, who underwent LDLT for HCC between 1997 and 2011, were included. The endpoints analyzed were survivals from time of LDLT and from the time of recurrence. Results: Twenty-three patients had recurrence of HCC after LDLT. The mean period until the initial recurrence after LDLT and the mean duration until death after the initial recurrence were 17.1 months (n=23) and 17.4 months (n=16), respectively. A univariate analysis showed that gender (p&lt;0.01) des-gamma-carboxy prothrombin &lt;300 mAU/ml (p=0.02), interferon therapy (p=0.02), early posttransplant tumor recurrence (p&lt;0.01), and eligibility for a surgical resection (p&lt;0.01) all had a beneficial impact on survival from tumor recurrence. Other factors at LDLT including Milan criteria, tumor number, tumor size or alpha-fetoprotein had no impact on the survival after recurrence. Multivariate analysis showed eligibility for a surgical resection (odds ratio 12.3, p&lt;0.0199 and des-gamma-carboxy prothrombin &lt;300 mAU/ml (odds ratio 5.3, p=0.04) were the independent beneficial factors on survival from tumor recurrence. Surgical resection was performed in 12 patients for the initial recurrences at lung (n=5), peritoneum (n=2) lymph nodes (n=2), liver (n=1), bone (n=1) and adrenal gland. The 2-year survival rate after recurrence in the patients surgery was indicated or not indicated was 72.2% and 18.2%, respectively (p&lt;0.01). Conclusions: Surgical therapy could be useful for patients who experience a recurrence of HCC after LDLT to improve their outcome, when such treatment is available.

Pediatric living donor liver transplantation for biliary atresia with hepatopulmonary syndrome: the gift of a second wind

Hepatopulmonary syndrome (HPS) is a progressive, deteriorating complication of end-stage liver disease (ESLD) that occurs in 13-47% of liver transplant candidates. Although LT is the only therapeutic option for HPS, it has a high morbidity and mortality, especially in patients with severe hypoxemia before transplantation, but the course of HPS after living donor liver transplantation (LDLT), especially for biliary atresia (BA) patients is not well established. The present study evaluated 122 patients who received an LDLT for BA and of these, 3 patients had HPS at the time of LDLT in a single-center series. Two patients of the HPS patients them had biliary and/or vascular complications, but they recovered uneventfully with interventional treatment. None of the patients required supplemental oxygen and had no residual cardiopulmonary abnormalities at a follow-up of more than 24 months. Although a series of three patients is too small for definitive conclusion and further investigations must be conducted, pediatric LDLT can be a favorable therapeutic option for HPS.

Pediatric living-donor liver transplantation for acute liver failure: analysis of 57 cases

We reviewed 57 pediatric patients admitted with acute liver failure to Kyoto University Hospital in Japan over a period of 15 years to compare the etiology and the long-term outcome of infants and children after living donor liver transplantation (LDLT). Patients were divided into two groups according to age at the time of liver transplantation, infants group (<1 year, n = 20), and children group (1-18 years, n = 37). The overall survival rates were 73.6%, 69.5% and 67.2% at 1, 5, and 10 years after LDLT respectively. Age of recipients at the time of LDLT had a strong impact on their outcome, Children had significantly better outcome than infants (P = 0.001). Surgical complications were comparable between both groups. Infants had higher rates of acute cellular rejection (ACR), which was associated with features of hepatitis in many cases. Refractory ACR was the leading cause of death in eight out of 12 infants, while it resulted in loss of one child only. Cox's proportional hazard regression model was used to examine potential risk factors for graft loss and it shows that age <1 year was associated with high risk of graft loss [hazard ratio (HR) = 11.393; CI = 1.961-76.1763] (P < 0.05). In conclusion, Infants had poorer prognosis than children and refractory ACR was the leading cause of death. Using additional immunosuppressant for cases with severe and atypical rejections is recommended.

Salvage cystic duct anastomosis using a magnetic compression technique for incomplete bile duct reconstruction in living donor liver transplantation

In living donor liver transplantation (LDLT), bile duct reconstruction is often technically demanding due to the frequently anomalous anatomy of the bile duct, as well as the high incidence of biliary complications. A bile duct branch may also be accidentally left without anastomosis at the time of LDLT and found to be obstructed after surgery. Surgical revision for such cases is sometimes not feasible because of the invasiveness of the procedure. We report a case in which a bile duct branch was intentionally left without anastomosis and was later successfully anastomosed to the cystic duct stump using a magnetic compression anastomosis (MCA) technique. A combination of the MCA technique and cystic duct anastomosis is life-saving in certain situations and should be considered as the treatment of choice.

Long-Term Outcomes for 32 Cases of Wilson’s Disease After Living-Donor Liver Transplantation

Long-term outcomes after living donor liver transplantation (LDLT) in Wilson's disease (WD) with heterozygous donors for WD gene are unknown. LDLT was performed for 32 patients with WD (15 men, 17 women; mean age 16 years; range, 6-40 years) at Kyoto University Hospital from 1992 to 2006. The mean follow-up time from LDLT was 6.7+/-4.0 years (0.04-15.0 years). Donors were mainly parents (90.6%), who were obligatory carriers of the WD mutation. The present study examined retrospectively the copper metabolism, recurrence of WD, survival rate, and neurologic outcomes after LDLT. Mean ceruloplasmin at the time of LDLT was 9.7+/-7.3 mg/dL and increased to 22.3+/-5.3 mg/dL (normal, 18-37 mg/dL). Urinary copper decreased from 2704+/-901 to 73.7+/-5.2 microg/day (normal, <50 microg/day). Serum copper improved from 72.9+/-33.9 to 81.0+/-14.9 mg/dL (normal, 78-131 mg/dL). Although six patients died and two received retransplantation, the remaining 24 remain alive without recurrence, with overall survival rates of 90.6%, 83.7%, and 79.9% at 1, 5, and 10 years, respectively. Patients with chronic liver failure had a poorer prognosis (P<0.05). Use of liver grafts from heterozygous donors has been considered safe. Good improvements in copper metabolism were obtained without evidence of recurrence in long-term follow-up. Neuropsychologic presentations of WD improved or remained unchanged. Indications for liver transplantation in patients with WD with neurologic symptoms must be considered carefully based on the stage of neurologic damage and its irreversibility.

Quality of Life and Problems Affecting Recipients More Than 10 Years After Living Donor Liver Transplantation

Background We initiated living donor liver transplantation (LDLT) in 1991, allowing us to examine issues related to long-term survival. The aim of this study was to review the long-term outcomes of LDLT in children. Patients and Methods We performed 116 LDLT from 1991 to present, including 17 recipients who survived >10 years. They were evaluated for growth, immunosuppressive therapy, complications, and quality of life (QOL). Results The average age at LDLT was 5.4 years (range, 6 months to 17 years), with a present average age of 17.2 years (range, 11–28 years). At the time of LDLT, 6 recipients had growth retardation with body weights low for age by 2 standard deviations (SD). However, 4 of 6 recipients who underwent LDLT before age of 2 years caught up, reaching average heights and body weights for their ages. Among 6 recipients who were diagnosed with acute rejections by biopsy >5 years after LDLT, 5 improved after steroid pulse therapy. One recipient with a steroid-resistant acute rejection was administered deoxyspergualin after steroids. Chronic rejection was not observed in this series. One recipient has not required immunosuppressive therapy for >4 years with a good present condition. Conclusion The majority of LDLT recipients achieved a good QOL during long-term survival; they are pursuing normal studies.

Portal vein complications after adult-to-adult living donor liver transplantation

Successful management of portal vein (PV) complications after liver transplantation is crucial to long-term success. Little information is available, however, regarding the incidence and treatment of PV complications after adult-to-adult living donor liver transplantation (LDLT). Between January 1996 and October 2006, 310 adult LDLTs were performed at our institution. PV thrombus was present in 54 patients at the time of LDLT. The incidence of PV complications, choice of therapeutic intervention, and outcomes were retrospectively analyzed. Among the 310 recipients, PV complications were identified in 28 (9%). Risk factors included smaller graft size, presence of PV thrombus at the time of LDLT, and use of jump or interposition cryo-preserved vein grafts for PV reconstruction. When divided into early (within 3 months, n = 11) and late (after 3 months, n = 17) complications, the use of vein grafts for PV reconstruction predisposed to the occurrence of late, but not early, PV complications. Portal vein thrombosis occurred more frequently in the early period (eight out of 11, 73%), whereas stenosis occurred more frequently in the later period (14 out of 17, 82%). Surgical interventions were favored in the earlier period, whereas interventional radiologic approaches were selected for later events. Overall 3- and 5-year survival rates were 81% and 77%, respectively, in patients with PV complications and 88% and 84%, respectively, in those without PV complications (P = 0.21, log-rank test). PV complications are a significant problem following LDLT with both early and late manifestations. Acceptable long-term results, however, are achievable with periodic ultrasonographic surveillance and timely conventional therapeutic interventions. The use of cryo-preserved vein grafts for reconstructing portal flow should be discouraged.

Long‐term clinical outcome of living‐donor liver transplantation for primary biliary cirrhosis

We described the recurrence of primary biliary cirrhosis (PBC) after living donor liver transplantation (LDLT) (Liver Transplantation, 7, 2001: 588). However, since the follow-up period in that study was insufficiently long (median 35.5 months), we performed a long-term study to further characterize recurrence of PBC after LDLT. From 1991 to 2006, 15 patients with end-stage PBC underwent LDLT at Tokyo Women's Medical University. Of these patients, we studied 8 PBC patients (age 29 to 51 years, all females) who survived LDLT for more than 5 years. The follow-up period for these patients ranged form 68 to 120 months. Immunosuppression was maintained with tacrolimus and prednisone. Laboratory examinations performed in every patient and donor before LDLT included routine biochemical studies, antimitochondrial antibody (AMA) by immunofluorescence (IF), anti-M2 by enzyme-linked immunosorbent assay as well as antinuclear antibody (ANA) by IF, and immunoglobulin. After LDLT, the same laboratory examinations were performed in patients every 6 months. Liver biopsy was performed when patients exhibited clinical or biochemical signs of graft dysfunction. In addition, protocol biopsy was performed every 1 to 2 years after LDLT. At the time of LDLT, all patients had end-stage cholestatic liver failure. Seven patients were positive for AMAand anti-M2 while 1 patient was negative for these markers but strongly positive for ANA. Donors were blood relatives in 6 cases, and 2 donors who were not blood relatives still exhibited multiple HLA matches with the recipients. At the end of the study in May 2006, all patients were doing well. On laboratory examination, mild abnormal liver function test results were found in 4 patients: 3 were probably due to recurrence of PBC, 1 resulted from nonalcoholic steatohepatitis. Comparison of the AMA titer between before LDLT and the most recent follow-up visit showed an increase in three patients, a decrease in two patients and no change in three patients. In contrast, the ANA titer increased in five patients. Histologically, strong evidence of recurrent PBC was found in 4 patients, and findings compatible with PBC were present in 2 additional patients. Although the number of our patients is small, our findings confirm that PBC can recur at high frequency after LDLT. However, this complication has not developed to advanced stages and has not caused appreciable symptoms in our patients, all of whom have a good quality of life.

Prevention of hepatitis B virus infection from hepatitis B core antibody‐positive donor graft using hepatitis B immune globulin and lamivudine in living donor liver transplantation

Hepatic grafts from hepatitis B surface antigen-negative and anti-core antibody (HBcAb)-positive donors have been shown to transmit hepatitis B virus (HBV) infection. Recently, it has been reported that combined hepatitis B immune globulin (HBIG) and lamivudine therapy is effective in the prevention of hepatitis B recurrence after living donor liver transplantation (LDLT). In this report, we assessed the efficacy of combined HBIG and lamivudine therapy in preventing HBV transmission by graft with HBcAb-positive donors. We studied 22 patients who had undergone LDLT with allografts from HBcAb-positive living donors at Gunma University Hospital and Kyushu University Hospital. Long-term combined HBIG and lamivudine therapy were administrated to all recipients. Serum samples from the donor and recipient were tested for HBcAb, HBV DNA, and hepatitis B surface antibody. Liver biopsies from grafts were tested for HBV DNA. All recipients were HBcAb negative before LDLT. All of the donor livers were HBV DNA positive at the time of LDLT. All of the recipients had HBsAb titers greater than 300 mIU/ml 4 weeks after LDLT, and remained 100 mIU/ml thereafter. None of the recipients have become infected with HBV with a follow-up of 25-86 months. Perioperative combined HBIG and lamivudine therapy can prevent HBV infection in recipients who receive liver grafts from HBcAb-positive donors.