Treatment Of Severe Liver Disease Research Articles

Advances in Cell Therapy for Liver Regeneration

With the development of translational medicine, cell therapy has been applied in clinical practice, especially in the regenerative treatment of severe liver diseases. This article introduces the origin, development, and prospects of cell therapy from the aspects of liver disease treatment, history, current status, and clinical application feasibility of cell therapy. The article also points out the existing problems in the translational medical research of cell therapy. To achieve a favorable development in cell therapy, more fundamental and clinical are warranted.

Customized normothermic machine perfusion decreases ischemia-reperfusion injury compared with static cold storage in a porcine model of liver transplantation.

Liver transplantation has been demonstrated to be the best treatment for several liver diseases, while grafts are limited. This has caused an increase in waiting lists, making it necessary to find ways to expand the number of organs available for transplantation. Normothermic perfusion (NMP) of liver grafts has been established as an alternative to static cold storage (SCS), but only a small number of perfusion machines are commercially available. Using a customized ex situ machine perfusion, we compared the results between ex situ NMP and SCS preservation in a porcine liver transplant model. During NMP, lactate concentrations were 80% lower after the 3-h perfusion period, compared with SCS. Bile production had a 2.5-fold increase during the NMP period. After transplantation, aspartate transaminase (AST) and alanine transaminase (ALT) levels were 35% less in the NMP group, compared to the SCS group. In pathologic analyses of grafts after transplant, tissue oxidation did not change between groups, but the ischemia-reperfusion injury score was lower in the NMP group. NMP reduced hepatocellular damage and ischemia-reperfusion injury when compared to SCS using a customized perfusion machine. This could be an alternative for low-income countries to include machine perfusion in their therapeutic options.

New Indications for Liver Transplantation.

Liver transplantation (LT) is an important therapeutic option for the treatment of several liver diseases. Modern LT is characterized by remarkable improvements in post-transplant patient survival, graft survival, and quality of life. Thanks to these great improvements, indications for LT are expanding. Nowadays, clinical conditions historically considered exclusion criteria for LT, have been considered new indications for LT, showing survival advantages for patients. In this review, we provide an updated overview of the principal newer indications for LT, with particular attention to alcoholic hepatitis, acute-on-chronic liver failure (ACLF), cholangiocarcinoma and colorectal cancer metastases.

An Extracellular Matrix-based Culture System for Generation of Human Pluripotent Stem Cell Derived-hepatocytes.

Liver disease (hepatic disease) adversely affects the normal function of the liver and causes liver problems. Drug-induced liver injury (DILI) can be predicted by primary human hepatocytes. However, the sources of hepatocytes for large-scale drug toxicity screening are limited. To solve this problem, pluripotent stem cells (PSCs), mesenchymal stem cells (MSCs), and hepatic stem cells (HSCs) have emerged as attractive cell sources for cell-based therapies. Human PSCs, including embryonic stem cells (ESCs) and induced pluripotent stem cells (iPSCs) have the ability to undergo self-renewal and differentiate into lineages of ectoderm, mesoderm, and endoderm. Human PSC can be used for the generation of hepatocytes to facilitate the development of novel drugs for the treatment of severe liver diseases. The therapeutic potential of PSC-derived hepatocytes for liver failure have been identified to enhance the development of chemically defined and xenogenic- free 3D culture methods. To date, several hepatic differentiation strategies and various extracellular matrix (ECM) components have been employed to produce hepatocytes or hepatic-like cells (HLCs) in vitro. In this review, we focused on the potential of Matrigel, collagen type 1, Ro- Gel, and laminin as ECM on the differentiation and function of hESC- and hiPSC-derived hepatocytes. The hepatic differentiation of human ESCs and iPSCs would offer an ideal tool for cell therapy and liver diseases.

Influencing factors of severe liver disease complicated with toxic shock

Patients with severe liver disease are prone to bacterial and fungal infections, and then develop toxic shock. The onset of the disease may be insidious, but the disease progresses rapidly with a high fatality rate. Current research results show that special conditions such as translocation of intestinal flora and immune paralysis in patients with severe liver disease are susceptible factors for infection and toxic shock. Furthermore, it is currently recognized that the treatment of severe liver disease complicated with toxic shock must be treated with antibiotics and maintenance of hemodynamic stability. Other treatments, such as hydrocortisone and strict glycemic control, are quite controversial and may not necessarily reduce mortality. Herein, we summarize the epidemiology, susceptibility factors; diagnosis and management strategies of severe liver disease complicated with toxic shock, highlighting the characteristics of toxic shock under the background of severe liver disease, so as to detect, prevent and treat septic shock in patients with severe liver disease as early as possible to reduce the fatality rate.

AAV8 Gene Therapy for Crigler-Najjar Syndrome in Macaques Elicited Transgene T Cell Responses That Are Resident to the Liver

Systemic delivery of adeno-associated viral (AAV) vectors has been evaluated for the treatment of several liver diseases, including homozygous familial hypercholesterolemia, ornithine transcarbamylase deficiency, and hemophilia. Here, we evaluated this approach for the treatment of Crigler-Najjar syndrome. We administered wild-type rhesus macaques with 1.0 × 1013 or 2.5 × 1013 genome copies/kg of an AAV serotype 8 vector expressing a codon-optimized version of human uridine diphosphate glucuronosyl transferase 1A1 (UGT1A1) from a liver-specific promoter. We extensively studied vector biodistribution, transgene expression, and immune responses following vector administration. All rhesus macaques survived until their scheduled necropsy at day 56 and showed no clinical abnormalities during the course of the study. Macaques administered with either vector dose developed a T cell response to the AAV capsid and/or transgene. We mapped the immunodominant epitope in the human UGT1A1 sequence, and we found no correlation between peripheral and tissue-resident lymphocyte responses. Upon further investigation, we characterized CD107a+, granzyme B+, CD4+, and CD8+ transgene-specific cellular responses that were restricted to tissue-resident T cells. This study highlights the importance of studying immune responses at the vector transduction site and the limited usefulness of blood as a surrogate to evaluate tissue-restricted T cell responses.

Evaluation of different routes of administration and biodistribution of human amnion epithelial cells in mice

Placenta is a non-controversial and promising source of cells for the treatment of several liver diseases. We previously reported that transplanted human amnion epithelial cells (hAECs) differentiate into hepatocyte-like cells, resulting in correction of mouse models of metabolic liver disease or acute hepatic failure. As part of preclinical safety studies, we investigated the distribution of hAECs using two routes of administration to efficiently deliver hAECs to the liver. Optical imaging is commonly used because it can provide fast, high-throughput, whole-body imaging, thus DiR-labeled hAECs were injected into immunodeficient mice, via the spleen or the tail vein. The cell distribution was monitored using an in vivo imaging system over the next 24 h. After splenic injection, the DiR signal was detected in liver and spleen at 1, 3 and 24 h post-transplant. The distribution was confirmed by analysis of human DNA content at 24 h post-transplant and human-specific cytokeratin 8/18 staining. Tail vein infusion resulted in cell engraftment mainly in the lungs, with minimal detection in the liver. Delivery of cells to the portal vein, via the spleen, resulted in efficient delivery of hAECs to the liver, with minimal, off-target distribution to lungs or other organs.

Stem Cell Therapies for Treatment of Liver Disease

Cell therapy is an emerging form of treatment for several liver diseases, but is limited by the availability of donor livers. Stem cells hold promise as an alternative to the use of primary hepatocytes. We performed an exhaustive review of the literature, with a focus on the latest studies involving the use of stem cells for the treatment of liver disease. Stem cells can be harvested from a number of sources, or can be generated from somatic cells to create induced pluripotent stem cells (iPSCs). Different cell lines have been used experimentally to support liver function and treat inherited metabolic disorders, acute liver failure, cirrhosis, liver cancer, and small-for-size liver transplantations. Cell-based therapeutics may involve gene therapy, cell transplantation, bioartificial liver devices, or bioengineered organs. Research in this field is still very active. Stem cell therapy may, in the future, be used as a bridge to either liver transplantation or endogenous liver regeneration, but efficient differentiation and production protocols must be developed and safety must be demonstrated before it can be applied to clinical practice.

Application of plasmapheresis combined with hemofiltration in the treatment of severe liver disease in middle and late pregnancy

To investigate the application and security of plasmapheresis combined with hemofiltration in the treatment of severe liver disease in middle and late pregnancy. Clinical data of 29 patients of middle and late pregnancy with severe liver disease from March 2009 to November 2013 in the Third Affiliated Hospital of Sun Yat-sen University was analyzed retrospectively. According to the therapeutic schedule, patients were divided into control group (n=16, 18-29 years old, median age of 24 years old) and treatment group (n=13, 21-28 years old, median age of 25 years old). The informed consents of all patients were obtained and the ethical committee approval was received. The control group was given the treatment of resisting infection, protecting liver, reducing jaundice, supplying albumin and globulin, infusing blood coagulation and so on. The treatment group was given plasmapheresis and hemofiltration on the basis of the above-mentioned treatment. The differences of major clinical indicators such as MELD scores, APACHEII scores, total bilirubin (TB), albumin (ALB), prothrombin time activity (PTA) , fasting blood glucose (FPG), serum creatinine (Scr) of peripheral venous blood and arterial lactic acid (Lac) in patients of two groups were observed 6 hours before and 1, 3, 5 days after the treatment. The major clinical indicators in patients of two groups were compared by t test and the clinical efficient were compared by χ² test. There were no statistical differences of the clinical indicators between the two groups 6 hours before the treatment (all P>0.05). The MELD scores, APACHEII scores, TB, ALB, PTA, FPG, Scr, Lac were (25 ± 6) scores, (22 ± 5) scores, (197 ± 69) µmol/L, (30 ± 7) g/L, (55 ± 24)%, (5.7 ± 2.4) mmol/L, (111 ± 42) µmol/L, (2.3 ± 0.6) mmol/L in treatment group 1 day after treatment, and were (33 ± 8) scores, (30 ± 7) scores, (299 ± 113) µmol/L, (24 ± 6) g/L, (33 ± 11)%, (3.7 ± 1.7) mmol/L, (165 ± 82) µmol/L, (4.4 ± 1.5) mmol/L in control group, which improved significantly in the treated group compared to those in the control group. There was also significant improvement in those posttreatment d3, and 5 lab findings in the treatment group (P<0.05). The effective rate was higher in the treatment group (92%, 12/13) than the control group (56%, 9/16) (χ² =4.215, P<0.05). Kaplan-Meier analysis showed the combined treatment could significantly improve the 42 d survival rate in postpartum patients with liver function failure. One patient had transitional hypotension after plasma infusion and hemofiltration in the treatment group, but the blood pressure returned to normal 1 h after small dose of vasoconstrictor. The therapeutic effect of plasmapheresis combined with hemofiltration on the treatment of severe liver disease in middle and late pregnancy is safe and effective, and it could improve the clinical outcomes and survival rate.

Morin hydrate attenuates the acrylamide-induced imbalance in antioxidant enzymes in a murine model.

Liver diseases are among the most serious health issues nowadays. Hepatocellular carcinoma, one of the most lethal types of cancer worldwide, can be caused by chemically-induced oxidative stress. In the present study, we aimed to evaluate the protective effects of morin hydrate (MH) against acrylamide (AA)-induced hepatotoxicity in male ICR mice. The mice were randomly allocated into 4 groups [the control, the group subcutaneously injected with AA alone (50 mg/kg body weight), the group subcutaneously injected with AA (50 mg/kg body weight) and MH (5 mg/kg body weight) and the group subcutaneously injected with AA (50 mg/kg body weight) and MH (15 mg/kg body weight) for 5 consecutive days]. Histopathological evaluations were performed and the levels of serum hepatic enzymes were analyzed to determine initial liver injury, and the mice in the AA-treated groups were compared with the mice receiving no treatment and with the mice administered MH in combination with AA. Furthermore, oxidative stress, hepatic inflammation and the levels of DNA damage-related markers were evaluated to determine the extent of liver damage induced by AA within a short-term period. The subcutaneous administration of AA induced severe hepatic injury, and combined treatment with AA and MH resulted in a significant improvement in all evaluated parameters. This recovery was most obvious in the group receiving AA and 15 mg/kg body weight dose of MH. The findings of our study demonstrated that MH protected mice from severe hepatic injury induced by AA. Moreover, MH is a natural polyphenolic compound, and thus it has potential for use in the treatment of severe liver diseases, in place of many synthetic drugs.

Activity and results of liver transplantation in Spain during 1984-2012. Analysis of the Spanish Liver Transplant Registry

Background and objectiveLiver transplantation (LT) is a proven effective treatment of severe liver disease. The aim of this paper is to analyze the results of LT in Spain during the period 1984–2012. Patients and methodWe analyze the results of the database of Spanish Liver Transplant Registry. ResultsA total of 20,288 transplants were performed in 18,568 patients. The median age of the donor and recipient increased during the analysis period: 25 years (95% confidence interval [95% CI] 18–40) and 47 years (95% CI 34–55), respectively, in the period 1984–1994 compared to 59 years (95% CI 33–65; P<.05) and 55 years (95% CI 48–61; P<.01), respectively, in the period 2010–2012. The most frequent indications were liver cirrhosis (63.18%) and hepatocellular carcinoma (19.62%). The overall patient and graft survival was respectively 85.1 and 77.8% in the first year, 72.6 and 63.5% the fifth year and 62 and 52.6% in the tenth year. First year patients and graft survival increased respectively from 77.8 and 66.3% in the period 1984–1994 to 88.5 and 83% in 2010–2012 (P<.01). Donor and recipient age, etiology of underlying disease, and hepatitis C virus serological status, were factors associated with decreased survival in univariate and multivariate analysis. ConclusionsResults of LT improved significantly over the review period, despite a progressive increase in donor and recipient age.

Actividad y resultados del trasplante hepático durante el período 1984-2012. Análisis del Registro Español de Trasplante Hepático

Background and objectiveLiver transplantation (LT) is a proven effective treatment of severe liver disease. The aim of this paper is to analyze the results of LT in Spain during the period 1984-2012. Patients and methodWe analyze the results of the database of Spanish Liver Transplant Registry. ResultsA total of 20,288 transplants were performed in 18,568 patients. The median age of the donor and recipient increased during the analysis period: 25 years (95% confidence interval [95% CI] 18-40) and 47 years (95% CI 34-55), respectively, in the period 1984-1994 compared to 59 years (95% CI 33-65; P<.05) and 55 years (95% CI 48-61; P<.01), respectively, in the period 2010-2012. The most frequent indications were liver cirrhosis (63.18%) and hepatocellular carcinoma (19.62%). The overall patient and graft survival was respectively 85.1 and 77.8% in the first year, 72.6 and 63.5% the fifth year and 62 and 52.6% in the tenth year. First year patients and graft survival increased respectively from 77.8 and 66.3% in the period 1984-1994 to 88.5 and 83% in 2010-2012 (P<.01). Donor and recipient age, etiology of underlying disease, and hepatitis C virus serological status, were factors associated with decreased survival in univariate and multivariate analysis. ConclusionsResults of LT improved significantly over the review period, despite a progressive increase in donor and recipient age.

Saikosaponin d protects against acetaminophen-induced hepatotoxicity by inhibiting NF-κB and STAT3 signaling

Overdose of acetaminophen (APAP) can cause acute liver injury that is sometimes fatal, requiring efficient pharmacological intervention. The traditional Chinese herb Bupleurum falcatum has been widely used for the treatment of several liver diseases in eastern Asian countries, and saikosaponin d (SSd) is one of its major pharmacologically-active components. However, the efficacy of Bupleurum falcatum or SSd on APAP toxicity remains unclear. C57/BL6 mice were administered SSd intraperitoneally once daily for 5days, followed by APAP challenge. Biochemical and pathological analysis revealed that mice treated with SSd were protected against APAP-induced hepatotoxicity. SSd markedly suppressed phosphorylation of nuclear factor kappa B (NF-κB) and signal transducer and activator of transcription 3 (STAT3) and reversed the APAP-induced increases in the target genes of NF-κB, such as pro-inflammatory cytokine Il6 and Ccl2, and those of STAT3, such as Socs3, Fga, Fgb and Fgg. SSd also enhanced the expression of the anti-inflammatory cytokine Il10 mRNA. Collectively, these results demonstrate that SSd protects mice from APAP-induced hepatotoxicity mainly through down-regulating NF-κB- and STAT3-mediated inflammatory signaling. This study unveils one of the possible mechanisms of hepatoprotection caused by Bupleurum falcatum and/or SSd.

Application of Induced Pluripotent Stem Cells in Liver Diseases.

Tens of millions of patients are affected by liver disease worldwide. Many of these patients can benefit from therapy involving hepatocyte transplantation. Liver transplantation is presently the only proven treatment for many medically refractory liver diseases including end-stage liver failure and inherited metabolic liver disease. However, the shortage in transplantable livers prevents over 40% of listed patients per year from receiving a liver transplant; many of these patients die before receiving an organ offer or become too sick to transplant. Therefore, new therapies are needed to supplement whole-organ liver transplantation and reduce mortality on waiting lists worldwide. Furthermore, the remarkable regenerative capacity of hepatocytes in vivo is exemplified by the increasing number of innovative cell-based therapies and animal models of human liver disorders. Induced pluripotent stem cells (iPSCs) have similar properties to those of embryonic stem cells (ESCs) but bypass the ethical concerns of embryo destruction. Therefore, generation of hepatocyte-like cells (HLCs) using iPSC technology may be beneficial for the treatment of severe liver diseases, screening of drug toxicities, basic research of several hepatocytic disorders, and liver transplantation. Here we briefly summarize the growing number of potential applications of iPSCs for treatment of liver disease.

Allogenic hepatocyte transplantation in immunomodulated Lewis rats with acute liver insufficiency following hepatectomy.

Orthotropic Liver transplantation (OLT) is a conventional management for end-stage acute or chronic liver insufficiency, but the shortage of donor organs continues to be the restrictive factor throughout the world. Hepatocyte transplantation (HCTx) might be the promising treatment for several liver diseases and can be used as a "bridge" to OLT. Hepatocytes transplantation can protect and even save human lives, its' applicability remains limited by the large deficiency of liver organs and hepatocytes (HC), and cellular loss after engraftment. Host elimination of grafted cells is called Early Graft Dysfunction. This study was developed for an efficient protocol of HCT. Several conditions have been met in order to achieve a high yield of harvested viable HC, overcome the detached-cell apoptosis, attenuation of innate immune reaction against transplanted cells and a receptive cell environment. HC were isolated from Lewis rats (n = 8) weighing 250 gm, by the 2 step collagen a seper fusion technique, and bone marrow cells (BMCs) were obtained from the rats tibia and femur by centrifugation in a buffer solution. The mean viability of harvested HC and BMCs were 90% and 95% respectively. To minimize the rejection of HC, Lewis rat recipients (n = 14) weighing 250 gm, were irradiated with 6 Gy and received 0.1 mg of anti-aisle GMI antiserum intravenously as immunosuppressive drug. The isolated HC were intra-splenically transplanted and 10(7) bone marrow cells were injected in a penile vein into the recipients on the third day. Simultaneously, 70% hepatectomy and ligation of common bile duct were done. Thirty days later; the grafted spleen had areas with external appearance of a normal liver in ten out of 14 surviving rats (71%). Hematoxlin and eosin (H & E) staining of sections from these fragments showed sinusoids and portal areas, an evidence of successful hepatocyte engraftment and bile canaliculea formation. Large number of HC clusters of 15 to 20 cells and 2 to 4 distended small bile canaliculea were seen per 50 HC. The intrasplenic route for transplanting freshly isolated HC in an immune-compromised animal model was found to give good results regarding cell engraftment and tissue formation.

An In Vitro Expansion System for Generation of Human iPS Cell-Derived Hepatic Progenitor-Like Cells Exhibiting a Bipotent Differentiation Potential

Hepatoblasts, hepatic stem/progenitor cells in liver development, have a high proliferative potential and the ability to differentiate into both hepatocytes and cholangiocytes. In regenerative medicine and drug screening for the treatment of severe liver diseases, human induced pluripotent stem (iPS) cell-derived mature functional hepatocytes are considered to be a potentially good cell source. However, induction of proliferation of these cells is difficult ex vivo. To circumvent this problem, we generated hepatic progenitor-like cells from human iPS cells using serial cytokine treatments in vitro. Highly proliferative hepatic progenitor-like cells were purified by fluorescence-activated cell sorting using antibodies against CD13 and CD133 that are known cell surface markers of hepatic stem/progenitor cells in fetal and adult mouse livers. When the purified CD13highCD133+ cells were cultured at a low density with feeder cells in the presence of suitable growth factors and signaling inhibitors (ALK inhibitor A-83-01 and ROCK inhibitor Y-27632), individual cells gave rise to relatively large colonies. These colonies consisted of two types of cells expressing hepatocytic marker genes (hepatocyte nuclear factor 4α and α-fetoprotein) and a cholangiocytic marker gene (cytokeratin 7), and continued to proliferate over long periods of time. In a spheroid formation assay, these cells were found to express genes required for mature liver function, such as cytochrome P450 enzymes, and secrete albumin. When these cells were cultured in a suitable extracellular matrix gel, they eventually formed a cholangiocytic cyst-like structure with epithelial polarity, suggesting that human iPS cell-derived hepatic progenitor-like cells have a bipotent differentiation ability. Collectively these data indicate that this novel procedure using an in vitro expansion system is useful for not only liver regeneration but also for the determination of molecular mechanisms that regulate liver development.

Review of hepatocyte transplantation

Hepatocyte transplantation is a promising treatment for several liver diseases and can also be used as a "bridge" to liver transplantation in cases of liver failure. Although the first animal experiments with this technique began in 1967, it was first applied in humans only in 1992. Unfortunately, unequivocal evidence of transplanted human hepatocyte function has been obtained in only one patient with Crigler-Najjar syndrome type I and, even then, the amount of bilirubin-UDP-glucuronosyltransferase enzyme activity derived from the transplanted cells was not sufficient to eliminate the patient's eventual need for organ transplantation. A literature review was carried out using MEDLINE and library searches. This review considers the following: (1) alternatives or bridges to orthotopic liver transplantation (OLT); (2) solutions to the shortage of organs-the shortage of organ donors has impeded the development of human hepatocyte transplantation, and immortalized hepatocytes in particular could provide an unlimited supply of transplantable cells in a nearly future; (3) future directions. We review these efforts along with hepatocyte transplantation over the last 13 years.

Repopulation of Athymic Mouse Liver by Cryopreserved Early Human Fetal Hepatoblasts

Transplantation of hepatocytes is a promising alternative to liver transplantation for the treatment of severe liver diseases. However, this approach is hampered by the shortage of donor organs and intrinsic limitations of adult hepatocytes. To investigate whether most of the hurdles faced with adult hepatocytes could be surmounted by the use of human fetal hepatoblasts, we have developed a method to isolate, transduce, and cryopreserve hepatoblasts from human livers at an early stage of development (11-13 weeks of gestation). Cells were characterized in vitro for expression of specific markers, and in vivo for their proliferation and differentiation potential after transplantation into athymic mice. Most of the cells (80-90%) harbored a bipotent phenotype, expressing cytokeratins 8/18, albumin, and CK19. They proliferated spontaneously in culture and were efficiently transduced by a beta-galactosidase-expressing retrovirus (90%). After transplantation, cryopreserved cells engrafted into the liver of athymic mice and proliferated, resulting in up to 10% repopulation. Engrafted cells expressed markers of differentiated adult hepatocytes including albumin, alpha1-antitrypsin, cytochrome P450 3A4, and alpha-glutathione-S-transferase. When retrovirally transduced before transplantation they expressed the transgene in vivo. In summary, early human fetal hepatoblasts engraft, proliferate, and mature in athymic mouse liver, without conditioning the donor.

LIVING-DONOR LIVER TRANSPLANTATION IN BABIES LESS THAN 3 MONTHS OLD

O95* Background: Liver transplantation in infants in the first three months of life, neonates, offers treatment to a patient population in whom life expectancy without hepatic replacement is very limited. Although living-donor liver transplantation (LDLT) has become a well-recognized therapeutic option for children with end-stage liver disease, LDLT in neonates still remains a technically difficult and medically challenging procedure. An analysis of data regarding only LDLT in the first 3 months of life has not performed previously, while several reports about liver transplantation using not only living-donor but also cadaveric graft exist. Therefore, the aim of this retrospective study was to analyze the results of our experience with LDLT in children younger than 3 months of age and to explore strategy to improve survival in the recipients. Patients and Methods: Between June 1990 and December 2003, 600 children (<18 years old) underwent LDLT at our program. Of these, a total of 6 children (3 boys and 3 girls) before the age of 90 days at the time of transplant constitute the study population. Our previous reports have described medical management and surgical techniques. Left lateral segment graft (segments 2 and 3) in 3 cases, reduced-size grafts in 2 cases, and monosegment graft in 1 case were indicated. The arterial anastomosis was made in an end-to-end fashion between one of the hepatic arteries of the recipients and the donor hepatic artery under magnification by surgical microscope. Portal vein was reconstructed in end-to-end manner directly or via venous graft taken from the donor (inferior mesenteric vein). Donor hepatic vein was anastomosed to the stump of the left and the middle hepatic vein. Bile duct was anastomosed to the Roux-en Y loop in an end-to-end fashion. Posttransplant immunosuppression was based on oral FK506 combined with low-dose steroid. Results: The mean age and body weight of the 6 patients was 30 days (range, 27 to 74) and 4.1 kg (range, 3.5 to 4.8), respectively. The age distribution at the time of transplantation included the following: <1 month, 50%; 1–2 months, 33%; and 2–3 months, 17%. Four patients were intensive care unit bound at the time of transplant and 2 patients were hospitalized awaiting transplantation. Liver disease etiology included fluminant hepatic failure (5 cases) and tyrosinemia (1 case). Liver grafts were ABO-identical in 5 patients and ABO-incompatible in the rest. The maximum of the ratio of liver graft weight which was measured at the operation to the recipient body weight (GRWR) was 7.7. Incidence of acute cellular rejection occurred in 2 of 6 patients. Cytomegalovirus or Epstein-Barr virus infection was observed in 4 and 1 cases, respectively. Two patients have been completely withdrawn from immunosuppression for more than three years without any hepatic dysfunction. The patient survival of the neonates was 50%, with follow-up of 1 to 100 months. Three patients died after LDLT. These three deaths were due to sepsis in two cases and vascular occulusion in the other one. Maintenance immunosuppression was FK506-based. Acute rejection episodes occurred in two patients and was managed with intravenous steroid pulse and optimization of FK506. One patient had post-transplant lymphoproliferative disease. Currently, 3 of 6 recipients are alive with good graft function. Conclusions: This is the first report on LDLT in babies younger than 3 months old. From our experience, LDLT offers a promising option for the treatment of severe liver disease in neonates. These neonates should be referred promptly for liver transplantation as reasonable survival can be expected.

Hepatic transplantation in children under 3 months of age: A single centre's experience

Liver transplantation in neonates represents a major medical and technical challenge particularly in babies weighing less than 5 kg. The authors report the experience of 10 liver transplants in 9 babies (6 boys and 3 girls), mean age, 6 weeks (range, 2 to 11); median weight, 3.7 kg (range, 2.4 to 5). All had fulminant hepatic failure caused by neonatal haemochromatosis (n = 3) non-A non-B hepatitis (n = 3), total parenteral nutrition induced (n = 1), hepatitis B (n = 1), and hepatic haemangio-endothelioma (n = 1). One child underwent retransplantation for hepatic artery thrombosis. Immunosuppression was by Cyclosporine A-based triple therapy in all cases. All received a reduced size graft consisting of left lobe (n = 1), left lateral segment (n = 6) and monosegment III (n = 3). In nine cases the donor hepatic artery was anastomosed to an iliac artery conduit from the infrarenal aorta, and a Roux loop was used for bile duct reconstruction. Primary abdominal wound closure was possible in six patients, skin closure alone in one, and a silastic patch was used in three. Complications included infection (n = 5), bowel perforation (n = 2), diaphragmatic perforation (n = 2), bile leak (n = 1), hepatic artery thrombosis (n = 1), and portal vein thrombosis (n = 1). None of the babies experienced acute rejection. Currently five of the nine recipients are alive with good graft function at a mean follow-up of 22 months (range, 5 to 58). Of the four deaths, two were related to infection (one in combination with portal vein thrombosis), one to multiorgan failure and fluid overload, and one to early graft dysfunction and sepsis after undergoing retransplantation for hepatic artery thrombosis. From our experience liver transplantation offers a promising option for the treatment of severe liver disease in children less than 3 months old.