Urgent Orthotopic Liver Transplantation Research Articles

The role of EEG and neuroimaging in the diagnosis of non-convulsive status epilepticus in Subacute Encephalopathy with Seizures in Alcoholics (SESA syndrome): a case report and overview of the literature.

Epileptic seizures are frequently associated with liver dysfunction and alcoholism. Subacute encephalopathy with seizures in chronic alcoholics (SESA) is an underrecognized condition with peculiar clinical, EEG and neuroradiological features.We report the case of a 58-year-old man with previous alcohol use disorder (AUD) and acute-on chronic liver failure on alcohol-related cirrhosis, referred for urgent Orthotopic Liver Transplantation evaluation. The patient presented with delirium, aphasia and progressive deterioration of consciousness leading to intensive care unit admission. EEG showed slow activity with superimposed lateralized periodic discharges (LPDs) over the left temporo-occipital regions and ictal discharges with focal motor phenomena, consistent with focal status epilepticus. Antiseizure treatment with lacosamide and levetiracetam was administered with progressive improvement of consciousness.Brain MRI disclosed T2/FLAIR areas of hyperintensity in the left pulvinar and T2/FLAIR hyperintensity with corresponding DWI hyperintensity in the left hippocampal cortex, suggestive of post/peri-ictal excitotoxic changes with anatomical correspondence to focal LPDs distribution. SWI demonstrated decreased prominence of cortical veins in the left temporo-occipital region consistent with increased venous blood oxygenation in compensatory hyperperfusion.In conclusion, SESA should be suspected in the differential diagnosis of patients with AUD presenting with focal neurological deficits, seizures and focal EEG abnormalities. In this context, EEG and brain MRI represent useful tools with both diagnostic and prognostic value.

S2505 Aspergillus Fumigatus Vertebral Osteomyelitis With Intracardiac and Renal Aspergillomas in a Liver Transplant Recipient: A Clinical Vignette

INTRODUCTION: Immunosuppressed patients are at risk of fungal infections associated with high morbidity and mortality. Invasive aspergillosis (IA) leading to vertebral osteomyelitis, intracardiac and renal aspergillomas in the post-transplant setting is a rare infectious complication. CASE DESCRIPTION/METHODS: A 64-year-old former prison nurse, with a history of alcohol dependence and COPD, presented to our university medical center with fulminant hepatitis A requiring urgent orthotopic liver transplantation (OLT). Intra-operatively, she was noted to have focal ischemic colitis of the cecum and proximal ascending colon with mucosal necrosis, necessitating a right hemicolectomy and primary ileocolostomy. She received induction immunosuppression with basiliximab, followed by maintenance tacrolimus and mycophenolate mofetil. Post-operatively, she received antimicrobial and antifungal prophylaxis and was discharged to a rehab unit on post-op day 11. Her post-OLT course was further complicated by failure to thrive and de novo cytomegalovirus (CMV) viremia at 2 months (CMV D+/R−). > 90 days post OLT she developed fevers and lower back pain. MRI of the spine demonstrated lumbar discitis/osteomyelitis and abdominal CT scan showed a right renal nodule. Biopsies of the L-spine and right kidney revealed septated fungi and tissue cultures were positive for Aspergillus fumigatus. Immunosuppression was stopped and she was treated with amphotericin B, but later switched to isavuconazole and anidulafungin. Despite aggressive medical therapy, she continued to deteriorate clinically, and a TEE and CT chest revealed multi-chamber intracardiac and left ventricular free wall involvement by IA that had progressed. The prognosis was felt to be extremely poor, and she later died in hospice, 5 months post-OLT. DISCUSSION: IA has been recognized as one of the most highly lethal opportunistic fungal infections in organ transplant recipients. In this unique case, late-onset IA (>90 days post-OLT) manifested with vertebral, intracardiac, and renal involvement. Her risk factors included immunosuppression, hemodialysis, and CMV infection. Early initial treatment of IA involves immunosuppression minimization and systemic antifungal therapy using a combination of an azole with or without echinocandin. Surgical resection of an aspergilloma may be indicated prior to starting medical therapy. However, despite aggressive therapy, there is generally <35% survival from IA in this high-risk population.Figure 1.: CT chest showing intracardiac masses in the left atrium (white arrow; left image). CT abdomen showing a right renal nodule that was biopsied (white arrow; right image).

Successful Liver Transplantation for Kava-Associated Liver Failure: Report of 2 Cases

The use of herbal medicines dates back to 2100 BC and in the United States (US) herbal and dietary supplements (HDS) represent a 180 billion dollar market. Kava is an herbal preparation used as alternative medicine for anxiety and depression. We present two cases of fulminant hepatic failure (FHF) associated with kava ingestion. A 46 year old Caucasian female was transferred with acute liver failure and two weeks of a non-productive cough, fatigue, nausea, epigastric pain and jaundice. Laboratory studies were notable for an aspartate aminotransferase (AST) of 3830 (U/L), alanine aminotransferase (ALT) of 2385 (U/L), alkaline phosphatase (ALP) of 306 (U/L), bilirubin of 10.3 (mg/dL) and an international normalized ratio (INR) of 1.83. The culprit was thought to be daily kava use started three months prior. By hospital day three she had acute fulminant liver failure with grade four coma and underwent an urgent orthotopic liver transplantation. Explant pathology showed extensive necrosis with associated hemorrhage and bile duct proliferation. At our same facility a 60 year old African American female was referred for elevated liver function tests with one month of fatigue, decreased appetite, weakness, fevers, dark urine, clay colored stools and jaundice. She endorsed use of over the counter Botanicalm (containing kava). Laboratory studies were notable for AST 1405 (U/L), ALT 1240 (U/L), ALP 323 (U/L), bilirubin 24 (mg/dL), and INR of 2.6. Liver biopsy revealed submassive/massive necrosis and despite being started on N-acetylcysteine and prednisone she required an urgent orthotopic liver transplantation on hospital day 12. Explant pathology showed submassive necrosis and changes suggestive of early fibrosis. Over the past 50 years 21 herbs and 12 dietary supplements were reported to pose a risk for liver injury. Kava is a traditional Pacific beverage made from the roots and stems of Piper methysticum. Historically it was reserved for ingestion by priests and chiefs. The mechanism for kava induced liver injury remains elusive but generally speaking it favors a mixed pattern of injury, predilection for females, and a variable dose and latency response. Patients with liver disease comprise a unique population at particular risk from HDS. Up to 40% of people admit to not disclosing their use of HDS to their physicians and kava ingestion is just one of many that can cause fulminant liver failure. Further research is needed.2183 Figure 1. Liver biopsy Case 1

Staged biliary reconstruction after liver transplantation: A novel surgical strategy for high acuity pediatric transplant recipients

IntroductionBiliary complications after pediatric orthotopic liver transplantation remain causes of significant patient morbidity. Staged operative approach in complex hepatobiliary surgery has improved postoperative outcomes but has not been evaluated in pediatric orthotopic liver transplantation. We sought to analyze the outcomes of staged biliary reconstruction after orthotopic liver transplantation in high acuity patients. MethodsA retrospective analysis of 43 pediatric orthotopic liver transplantations at our center (January 2013 through December 2017). Median follow-up was 25 months. Variables were compared for group I: 1-stage orthotopic liver transplantation with biliary anastomosis (n = 6) versus group II: staged biliary reconstruction orthotopic liver transplantation (n = 37). ResultsComparing groups I and II, median age (7.3 vs 4.8 years), weight (27 vs 19 kg), proportion of urgent orthotopic liver transplantation (50% vs 65%), partial graft orthotopic liver transplantation (33% vs 35%), and intraoperative red blood cell transfusion volume (11 vs 21 mL/kg) were comparable. Roux-en-Y hepaticojejunostomy was performed in 67% (group I) and 49% (group II). There was no biliary complication in both groups. For groups I and II, 3-year survival rates for graft (100% vs 92%, P = .477) and patient (100% vs 97%, P = .679) were comparable. ConclusionOur study showed excellent outcomes with staged biliary reconstruction orthotopic liver transplantation in high acuity pediatric transplant recipients. This is the first report showing clinical applicability of staged biliary reconstruction orthotopic liver transplantation in children.

Acute on Chronic Liver Failure and Urgent Orthotopic Liver Transplantation in an Adult with Alagille Syndrome

Alagille syndrome is an autosomal dominant syndrome marked by a paucity of interlobular bile ducts with cholestasis, and whose features can include butterfly vertebrae, dysmorphic facies, cardiac and ocular anomalies. Most patients are symptomatic during childhood. As adult patients may require elective liver transplant for cirrhosis and intractable pruritus, liver failure is uncommon in these patients. We present a case of liver failure in an adult with Alagille syndrome. A 32-year-old man with known Alagille syndrome was admitted to the hospital with progressive jaundice and RUQ pain. At that time his MELD was 24 and he was referred for liver transplant evaluation. A month later, he was admitted for hematemesis and hepatic encephalopathy. He had a complicated hospital course with worsening encephalopathy, hepatorenal syndrome (requiring dialysis), and septic shock due to Streptococcus viridans requiring pressors. His peak MELD score during this hospitalization was 42(total bilirubin 47.5, Cr 5, INR 2.0). A CDC high risk liver became available and he underwent an orthotopic liver transplant. This was complicated by bacterial peritonitis from an infected hematoma. However, he recovered well after treatment of his peritonitis, and LFTs were normal one month post-transplant. Allagile syndrome occurs in 1 in 70,000 live births from a JAG1 or NOTCH2 mutation. They have paucity or stenotic bile ducts with progressive cholestasis in 95%, and cirrhosis in more than 20% of cases. Initial treatment includes ursodeoxycholic acid, cholestyramine, fat soluble vitamins and nutrition support. However, 21-31% patients will require liver transplant for severe xanthomatosis, intractable pruritus, and portal hypertension. Most liver transplants are done in the pediatric group. Only 9.7% patients had their first liver transplant beyond 18 years old, and are done electively for cirrhosis and intractable pruritus. Only a few cases were reported due to acute liver failure requiring an urgent transplant, similar to our patient. Alagille syndrome patients may require liver transplantation, usually during childhood. In some cases, transplant may be required in adulthood due to liver cirrhosis and intractable pruritis, and is mostly elective. Liver failure is uncommon in these patients.

Hepatocyte transplantation attenuates the course of acute liver failure induced by thioacetamide in Lewis rats.

Acute liver failure (ALF) is a clinical syndrome resulting from widespread damage of hepatocytes, with extremely high mortality rate. Urgent orthotopic liver transplantation was shown to be the most effective therapy for ALF but this treatment option is limited by scarcity of donor organs. Therefore, hepatocyte transplantation (Tx) has emerged as a new therapeutical measure for ALF, however, the first clinical applications proved unsatisfactory. Apparently, extensive preclinical studies are needed. Our aim was to examine if hepatocytes isolated from transgenic "firefly luciferase" Lewis rats into the recipient liver would attenuate the course of thioacetamide (TAA)-induced ALF in Lewis rats. Untreated Lewis rats after TAA administration showed a profound decrease in survival rate; no animal survived 54 h. The rats showed marked increases in plasma alanine aminotransferase (ALT) and aspartate aminotransferase (AST) activities, in plasma level of bilirubin and ammonia (NH(3)), and in a significant decrease in plasma albumin. Hepatocyte Tx attenuated the course of TAA-induced ALF Lewis rats which was reflected by improved survival rate and reduced degree of liver injury showing as lowering of elevated plasma ALT, AST, NH(3) and bilirubin levels and increasing plasma albumin. In addition, bioluminescence imaging analyses have shown that in the TAA-damaged livers the transplanted hepatocyte were fully viable throughout the experiment. In conclusion, the results show that hepatocyte Tx into the liver can attenuate the course of TAA-induced ALF in Lewis rats. This information should be considered in attempts to develop new therapeutic approaches to the treatment of ALF.

Acute Liver Failure in an Adult, a Rare Complication of Alagille Syndrome: Case Report and Brief Review

Alagille syndrome (AS) is an autosomal-dominant, multisystem disorder affecting the liver, heart, eyes, skeleton, and face. The manifestations are predominantly pediatric. Diagnosis is based on findings of a paucity of bile ducts on liver biopsy combined with ≥3 of 5 major clinical criteria. Orthotopic liver transplantation (OLT) is the only option for treating patients who developed liver failure, portal hypertension, severe itching, and xanthomatosis. It is difficult to establish clear criteria for OLT; indications are controversial because of the wide variety of clinical symptoms and the multisystem involvement. Generally, AS-associated liver disease is never an acute illness. We report the case of a 28-year-old woman with AS who underwent urgent OLT for acute liver failure. At 24 months posttransplant, the patient is in good clinical condition and with normal hepatic and renal function.

Updated Status of Deceased-Donor Liver Graft Allocation for High-Urgency Adult Patients in a Korean High-Volume Liver Transplantation Center

BackgroundThe number of deceased organ donors in Korea has been gradually increased to reach 8 per million population. This study intended to analyze the updated status of urgent deceased-donor liver transplantation in a Korean high-volume liver transplantation center. MethodsA retrospective study was performed with a 4-year study period from 2010 to 2013. ResultsDuring the study period, 328 adult patients were enrolled at the Asan Medical Center for urgent orthotopic liver transplantation (OLT) with Korean Network for Organ Sharing status 1 in 56 (17.1%) and status 2A in 272 (82.9%). Of them, 201 (61.3%) were allocated for OLT and 195 (58.2%) actually underwent OLT after exclusion of 6 cases of spontaneous withdrawal. In KONOS status 1, liver grafts were initially allocated to 33 (58.9%), but 6 were withdrawn owing to clinical improvement, so 27 (48.2%) actually underwent OLT. In status 2A, 168 (61.8%) underwent OLT within 2 weeks of priority waiting period. According to ABO blood groups in recipients, the allocation probability was 68% (68 of 100) in group A, 60.6% (60 of 99) in group B, 64.1% (25 of 39) in group AB, and 53.3% (48 of 90) in group O. Mean waiting period for OLT was 5.7 ± 2.1 days. ConclusionsDeceased donor incidence of ∼8 per million population contributed to meeting ∼60% of the demand for urgent deceased-donor liver transplantation in a Korean transplantation center, so further increasing deceased organ donor numbers is necessary to improve the current status of organ shortage.

Drug management in emergent liver transplantation of mitochondrial disorder carriers: review of the literature

Mitochondrial respiratory-chain disorders (MRCD) lead to progressive disabling of neurological and cellular conditions that involve muscles, brain, kidney, and liver dysfunction. Affected individuals may need surgery, including orthotopic liver transplantation (OLT). Surgery poses anesthesia challenges because of the prolonged use of anesthetic drugs and sedatives, which may inhibit oxidative phosphorylation, mimic mitochondrial cytopathic disorders, or unveil them ex novo. We conducted a multilingual PubMed search of surgical and non-surgical anesthesia reports between the years 1992 and 2008, where anesthetic drugs were used in MRCD patients, especially for those undergoing urgent OLTs. There were 51 case reports of 210 anesthesia and critical care interventions in patients with MRCD, a large part of them were children. Data pertaining to the safe usage of anesthesia and perioperative drugs were limited and conflicting. We found no article that addressed the issue of perioperative handling of urgent OLT in MRCD patients. We therefore suggest our own - although limited - experience for such occasions. There are no randomized, controlled, trial-based indications regarding safe anesthetic drugs to be used perioperatively in MRCD carriers. Consultation among geneticists, anesthesiologists, intensivists, and surgeons is essential in patients with known/suspected metabolic syndrome for planning appropriate perioperative care.

Successful Liver Transplantation in Antituberculosis Therapy–Induced Acute Fulminant Hepatic Failure

The antituberculosis drugs isoniazid, rifampin, and pyrazinamide expose patients to the risk of hepatotoxicity ranging from an asymptomatic increase in aminotransferase concentrations to fulminant hepatic failure. Herein, we report a case of acute fulminant hepatic failure that developed at 3 weeks after initiation of antituberculosis therapy (ATT) in a 31-year-old man with acute pulmonary tuberculosis in whom pretreatment liver function had been normal. The ATT regimen was changed to include less toxic substances, and an urgent orthotopic liver transplantation was performed successfully. Despite immunosuppression therapy with tacrolimus, mycophenolate mofetil, steroids, and antithymocyte globulin, clinical symptoms and radiologic signs of TB improved. Twelve months posttransplantation, graft function was normal. Acute TB should not be considered a contradiction to liver transplantation if effective ATT can be administered.

Live Donor Liver Transplantation for Acute Liver Failure

Acute liver failure (ALF) carries a high mortality unless urgent orthotopic liver transplantation (OLT) is performed on time. Live donors are utilized to treat this irreversible condition first in pediatric cases and then in adults. Herein, we aimed to report our experience with live donors for ALF in a country of a deceased donor organ donation rate is only 1.5 per million people. Among the 245 live donor liver transplantations (LDLT) performed from June 1999 to December 2005, 14 of them (6%) were performed for ALF in 8 pediatric and 6 adult cases. Right lobes were harvested for the adult cases whereas left lateral segments were harvested for pediatric cases, except one child transplanted with a right lobe graft. The etiology of the disease was; acute hepatitis B in four cases, hepatitis A in three cases, Wilson disease two cases, autoimmune hepatitis in two cases, and was unknown in three cases. Three-year graft and patient survival is 79% for these series. Five of the six adult patients and six of the eight pediatric cases survived after transplantation. There was not any donor mortality or major morbidity. LDLT offers a safe and effective modality of treatment for ALF for both pediatric and adult patients to overcome the problem of organ shortage especially in countries where the chance of receiving an organ from a deceased donor is low.

Successful Treatment of a Child With Fulminant Liver Failure and Coma Due to Amanita phalloides Poisoning Using Urgent Liver Transplantation

Intoxication due to eating wild mushrooms presents with a variety of signs, ranging from mild diarrhea to severe organ failure. We present the case of an 11-year-old boy with fulminant liver failure and hepatic coma due to Amanita phalloides poisoning treated with an urgent pediatric orthotopic liver transplantation. Successful treatment of patients with fulminant liver failure and hepatic coma caused by Amanita phalloides poisoning is possible using urgent orthotopic liver transplantation when conservative medical treatment modalities are ineffective.

Fulminant hepatic failure

The rare but potentially devastating clinical syndrome of fulminant hepatic failure has as its components severe encephalopathy and finally cerebral edema, hemodynamic instability, renal failure, coagulopathy, profound metabolic disturbances and a particular susceptibility to bacterial and fungal infection. Despite advances in medical management, fulminant hepatic failure in its most severe form carries a high mortality rate unless urgent orthotopic liver transplantation is carried out. However, availability of cadaveric donor organs is limited and, due to the rapidly progressive clinical course in many cases, a substantial proportion of patients will die or develop contraindications to transplantation before the procedure can be performed. Consequently, recent interest has centred on living donor transplantation and the possibility of providing temporary liver support, either through auxiliary partial organ transplantation, extracorporeal perfusion or transplantation of hepatocytes, to allow time for either a liver graft to become available or native liver regeneration, on which spontaneous survival ultimately depends, to occur.

Pathologic analysis of right-lobe graft failure in adult-to-adult live donor liver transplantation.

Live donor adult liver transplantation (LDALT) utilizing right-lobe grafts is now acceptable as an alternative to cadaveric orthotopic liver transplantation (OLT). However, some LDALTs fail and require urgent OLT or result in recipient death. Our aim was to determine the basis of LDALT failure. Liver specimens from 49 LDALT recipients were evaluated and the findings correlated with clinical outcome. Ten patients (20.4%) had either early (< or = 1 month) or late (> 1 month) graft failure. Eight early failures, 7 of which occurred among our first 25 cases, were due to extensive liver parenchymal necrosis as a result of hepatic artery thrombosis (n=3), portal vein thrombosis (n=1), hyperperfusion syndrome (n=1), complete graft thrombosis (n=1) with Factor V Leiden on a regimen of therapeutic heparin (n=1), sepsis and concomitant graft dysfunction with venous outflow tract injury (n=1), and venous outflow tract thrombosis and parenchymal thermal injury with sepsis (n=1). Preoperative, intraoperative, or postoperative severe vessel wall injury was evident in 6/8 early failures. Two patients had late graft failure, 1 from recurrent hepatitis C and 1 with sepsis/multisystem organ failure. There were no significant differences in graft size, rejection episodes, or operative or ischemic times between patients with and without graft failure. In conclusion, LDALT failed in 10/49 (20%) of our patients, with 8/10 occurring within 1 month post-LDALT owing to vascular/thrombotic complications experienced during the early phase of our institutional experience. Perioperative vessel wall injury appeared to be a major factor in predicting early graft loss.

New era of liver transplantation for hepatitis B: a 17-year single-center experience.

To evaluate the variables affecting orthotopic liver transplantation (OLT) outcome for hepatitis B virus (HBV) in a large patient cohort over a 17-year period. Historically, OLT for chronic HBV infection has been associated with aggressive reinfection and poor survival results. More recently, OLT outcome has been improved with the routine use of antiviral therapy with either hepatitis B immune globulin (HBIg) or lamivudine; however, HBV recurrence remains common. The authors studied the factors affecting HBV recurrence and outcome of transplantation, including the effects of combination viral prophylaxis with HBIg and lamivudine. A retrospective review of 166 OLT recipients for chronic HBV over a 17-year period at a single center was performed. Median follow-up was 29 months. HBV recurrence was defined by HBsAg seropositivity after OLT. HBIg monotherapy was used in 28 (17%) patients, lamivudine monotherapy in 20 (12%), and HBIg and lamivudine combination in 89 (54%); 29 (17%) did not receive any HBV prophylaxis. Hepatocellular carcinoma (HCC) was present in 43 patients (26%) and urgent United Network for Organ Sharing (UNOS) status was assigned to 27 patients (16%). Univariate and multivariate analyses were performed to identify factors that affected OLT outcome. Overall 1-, 3-, and 5-year patient survival rates were 85.8%, 73.6%, and 71.8%, respectively. As expected, HBV recurrence-free survival rates were significantly lower than overall survival rates (76.4%, 58.7%, and 48.3%). When compared with a nontreated cohort, OLT recipients receiving combination viral prophylaxis with HBIg and lamivudine showed markedly reduced HBV recurrence rates and significantly improved 1- and 3-year recurrence-free survival rates. By univariate estimates, patient survival was reduced in the presence of HCC, in the Asian population, and urgent candidates by UNOS classification. Graft loss rates were significantly increased in urgent OLT candidates, Asians, patients with pretransplant positive DNA, and in the presence of HCC. Factors that were significant by univariate analysis or thought to be clinically relevant were subjected to multivariate analysis. By multivariate estimates, urgent UNOS or presence of HCC adversely affected patient and graft survival rates, whereas combination prophylactic therapy strongly predicted improved patient and graft survival rates as well as recurrence-free survival rates. Orthotopic liver transplantation for HBV under combination viral prophylaxis results in survival rates equivalent to other indications. Pretransplant viral replication, UNOS status, and the presence of HCC are all sensitive markers for posttransplantation outcome. Viral prophylactic therapy has effectively reduced HBV recurrence and prolonged survival outcomes. The combination of HBIg and lamivudine is the prophylactic regimen of choice.

Transmission of hepatitis B infection from hepatitis B core antibody--positive liver allografts is prevented by lamivudine therapy.

Donor shortage has led to the use of hepatitis B core antibody (anti-HBc)--positive (anti-HBc(+)) liver allografts for patients in need of relatively urgent orthotopic liver transplantation (OLT). Because anti-HBc(+) allografts transmit hepatitis B virus (HBV) infection at a high rate, effective prophylaxis is required. We assessed the effectiveness of lamivudine in preventing HBV transmission by anti-HBc(+) allografts. Between March 1996 and March 2000 at Cedars-Sinai Medical Center (Los Angeles, CA), 15 of 169 patients (8.9%) received liver allografts from anti-HBc(+) donors. Six patients were hepatitis B surface antigen (HBsAg)(+) (group 1), and 9 patients were HBsAg negative (HBsAg(-); group 2) before OLT. All patients were administered lamivudine, 100 or 150 mg/d, orally after OLT. Patients who were HBsAg(+) before OLT also were administered hepatitis B immunoglobulin (HBIG) prophylaxis. Hepatitis B serological tests were performed on all patients, and HBV DNA was determined in liver tissues in 10 patients. All 15 patients remained HBsAg(-) at their last follow-up 2 to 40 months (mean, 17 months) post-OLT. All patients in group 1 had antibody to HBsAg (anti-HBs) titers greater than 250 mIU/mL post-OLT (mean follow-up, 20 months; range, 7 to 40 months). Of the 2 patients in group 1 who underwent liver biopsy after OLT, 1 patient had detectable hepatic HBV DNA despite being anti-HBs(+) and HBsAg(-). Among the patients in group 2, none acquired anti-HBc or HBsAg. Hepatic HBV DNA was undetectable in the 7 patients in group 2 who underwent liver biopsy after OLT. Anti-HBc(+) allografts can be safely used in patients who undergo OLT for chronic hepatitis B and susceptible transplant recipients if prophylaxis with combination HBIG and lamivudine or lamividine alone is administered after OLT, respectively. However, more data are needed to determine the efficacy of lamivudine monotherapy in preventing transmission of HBV infection from anti-HBc(+) liver allografts to susceptible recipients.

Upper Extremity Veno-arterial Shunting during Pediatric Orthotopic Liver Transplantation

Upper Extremity Veno-arterial Shunting during Pediatric Orthotopic Liver Transplantation

Predictable and unpredictable hazards of erythropoietic protoporphyria

A female patient with a long history of erythropoietic protoporphyria developed progressive rapid derangement of hepatic function requiring urgent orthotopic liver transplantation. In the immediate post-operative period the patient developed unusual and serious complications, including a generalized axonal neuropathy, intestinal ulceration and a large second-degree phototoxic burn of the abdominal wall. Recovery was achieved only after prolonged intensive hospital care and rehabilitation. Attention is drawn to the need for protecting such patients from phototoxic injury during prolonged surgery and the importance of rapid transfer to a specialized unit at the earliest sign of hepatic failure.