Liver transplantation for hepatocellular carcinoma: recent advances in China

Orthotopic liver transplantation is currently the best treatment option for selected patients with hepatocellular carcinoma (HCC). From 1980 to 2011, 8874 patients with HCC in China underwent liver transplantation. The organ donation classification criteria of China (China criteria), which are established by the Government of China, are divided into three parts: China criteria I, donation after brain death; China criteria II, donation after cardiac death and China criteria III, donation after dual brain-cardiac death. Data from the China Liver Transplant Registry(CLTR) System shows that patients within the Milan criteria have higher survival rates than those who are beyond these criteria. Based on CLTR data, altogether 416 patients received living-donor liver transplantation(LDLT) in China. Their 1-year and 3-year survival rates were significantly higher than those of the non-LDLT recipients. The most common early stage(<30 days after liver transplantation) complications include pleural effusion, diabetes, peritoneal effusion or abscess, postoperative infection, hypertension and intraperitoneal hemorrhage; while the most common late stage (≥ 30 days after liver transplantation) complications were diabetes, hypertension, biliary complications,postoperative infection, tacrolimus toxicity and chronic graft rejection. The incidence of vascular complication, which is the main reason for acute graft failure and re-transplantation, was 2.4%. Liver transplantation is an effective treatment for patients with HCC in China.

[Primary sclerosing cholangitis: modern concepts]

This review deals with primary sclerosing cholangitis (PSC) as a challenging problem in gastroenterology. Definition of PSC is presented, its putative pathogenetic and etiological factors, clinical symptoms, complications and concomitant disorders, methods of laboratory and instrumental diagnostics are described. Special attention is given to modern approaches to the treatment of the disease, dietoherapy, pharmacotherapy, auxiliary therapeutic modalities, indications for liver transplantation and its outcomes.

Trends of Immunosuppression and Outcomes Following Liver Transplantation: An Analysis of the United Network for Organ Sharing Registry

Advances in immunosuppression (IS) agents and strategies have resulted in reduced rejection rates and improved survival outcomes after liver transplantation. The use of induction and maintenance IS agents is both associated with reductions in acute rejection (AR) risk within the first 6 to 12 months posttransplant and with superior failure-free survival. With the lowered incidence of allograft losses attributable to rejection, the long-term sequelae of IS have become the major therapeutic challenge. The long-term use of calcineurin inhibitors and corticosteroids in maintenance immunotherapy regimens has been implicated in the development of renal dysfunction, infections, metabolic derangements, de novo and recurrent malignancies, and the propagation of hepatitis C virus reinfection. Our analysis of the United Network for Organ Sharing registry shows the use of induction and maintenance therapy is each associated with reductions in AR risk, thereby improving post-transplant survival. The administration of intensive induction regimens appears to be safe and exhibits an additive beneficial effect. Therefore, the use of intensive induction regimens may be warranted to allow for reductions in long-term maintenance IS to minimize drug toxicities while preserving graft outcomes.

Liver Transplantation at Mayo Clinic Florida

Over the sixteen year history of liver transplantation (LT) at Mayo Clinic in Jacksonville, Florida (MCF), we have maintained a practice devoted to excellence in pre- and post-LT management for patients suffering from end stage liver disease. With an emphasis on quality, MCF has made several adjustments with the goal of better utilizing marginal grafts for both successful post-transplant outcomes and minimizing waitlist mortality. This systematic approach is most exemplified in our experience with donation after cardiac death (DCD) liver allografts. Understanding the events during procurement has been critical to reducing the complications associated with donor warm ischemia time that are unique to DCD allografts. Better matching of donors to recipients has helped identify patients who are safe to receive more marginal grafts with successful patient and graft survival. Recognizing the spectrum of degree of sickness in patients undergoing LT, we implemented a multidisciplinary approach that allows for the avoidance of the intensive care unit after LT. In these ways, MCF continues to distinguish itself as an innovator in the field of transplantation for the benefit of continued better care for our patients suffering from end stage liver disease.

Non-alcoholic fatty liver disease and liver transplantation: Outcomes and advances

Non-alcoholic fatty liver disease (NAFLD) is one of the most prevalent causes of chronic liver disease worldwide. In the last decade it has become the third most common indication for liver transplantation in the United States. Increasing prevalence of NAFLD in the general population also poses a risk to organ donation, as allograft steatosis can be associated with non-function of the graft. Post-transplant survival is comparable between NAFLD and non-NAFLD causes of liver disease, although long term outcomes beyond 10 year are lacking. NAFLD can recur in the allograft frequently although thus far post transplant survival has not been impacted. De novo NAFLD can also occur in the allograft of patients transplanted for non-NAFLD liver disease. Predictors for NAFLD post-transplant recurrence include obesity, hyperlipidemia and diabetes as well as steroid dose after liver transplantation. A polymorphism in PNPLA3 that mediates triglyceride hydrolysis and is linked to pre-transplant risk of obesity and NAFLD has also been linked to post transplant NAFLD risk. Although immunosuppression side effects potentiate obesity and the metabolic syndrome, studies of immunosuppression modulation and trials of specific immunosuppression regimens post-transplant are lacking in this patient population. Based on pre-transplant data, sustained weight loss through diet and exercise is the most effective therapy for NAFLD. Other agents occasionally utilized in NAFLD prior to transplantation include vitamin E and insulin-sensitizing agents. Studies of these therapies are lacking in the post-transplant population. A multimodality and multidisciplinary approach to treatment should be utilized in management of post-transplant NAFLD.

Bone disease in patients awaiting liver transplantation. Has the situation improved in the last two decades?

In recent years, there has been speculation about the possibility of a reduction in the incidence of fractures after liver transplantation (LT) because of changes in the characteristics of candidates and the use of different immunosuppressive therapies. We analyzed the characteristics of LT candidates (CTC) and compared them with historical data from a group of LT candidate patients (HTC). Data from 60 CTC patients consecutively included in a screening program of metabolic bone disease were compared with data from 60 HTC patients prospectively evaluated between 1992 and 1993. In all patients, we analyzed the clinical and laboratory characteristics, bone mineral density (BMD) dual-energy X-ray absorptiometry, and skeletal fractures. Patients in the CTC group were older than patients in the HTC group. The CTC group had lower femoral neck T scores. No differences were observed between groups in the proportion of patients with osteoporosis (22 vs. 30 %, p = ns) or fractures (36 vs. 33 %, p = ns). The percentage of patients with normal BMD decreased from 38 to 20 %. 25(OH)D values were low in both groups. Only 7.5 % of the CTC patients received calcium and/or vitamin D supplementation. The prevalence of fractures among CTC patients was similar to that seen two decades ago. At present, candidates for LT are older and have lower femoral bone mass. Vitamin D deficiency remains frequent; however, calcium and/or vitamin D supplementation is uncommon.

Liver transplantation in alcoholic patients: impact of an alcohol addiction unit within a liver transplant center

BACKGROUND

Many concerns about liver transplantation in alcoholic patients are related to the risk of alcohol recidivism. Starting from 2002, an Alcohol Addiction Unit (AAU) was formed within the liver transplant center for the management of alcoholic patients affected by end-stage liver disease and included in the waiting list for transplantation. We evaluated retrospectively the impact of the AAU on alcohol recidivism after transplantation. The relationship between alcohol recidivism and the duration of alcohol abstinence before transplant was evaluated as well.

METHODS

Between 1995 and 2010, 92 cirrhotic alcoholic patients underwent liver transplantation. Clinical evaluation and management of alcohol use in these patients was provided by psychiatrists with expertise in addiction medicine not affiliated to the liver transplant center before 2002 (n = 37; group A), or by the clinical staff of the AAU within the liver transplant center starting from 2002 (n = 55; group B).

RESULTS

Group B, as compared with group A, showed a significantly lower prevalence of alcohol recidivism (16.4 vs. 35.1%; p = 0.038) and a significantly lower mortality (14.5 vs. 37.8%; p = 0.01). Furthermore, an analysis of group B patients with either ≥6 or <6 months of alcohol abstinence before transplantation showed no difference in the rate of alcohol recidivism (21.1 vs. 15.4%; p = ns).

CONCLUSIONS

The presence of an AAU within a liver transplant center reduces the risk of alcohol recidivism after transplantation. A pretransplant abstinence period <6 months might be considered, at least in selected patients managed by an AAU.

Liver transplantation in 2013: challenges and controversies

Liver transplantation has changed over the past 50 years from an experimental surgery to a life saving intervention that is the treatment of choice for selected patients with end stage liver disease. Since Starzl attempted the first liver transplant in 1963, the procedure has evolved into one that occurs over 12000 times a year worldwide and has one year survival rates approaching 90% and five year survival rates above 70%. With the success of liver transplantation, challenges and controversies have arisen as well. The aim of this review is to discuss the epidemiology of liver transplantation and highlight those challenges and controversies that exist. Current controversies include appropriate selection of recipients and equitable prioritization for allograft distribution. Future challenges include a decrement in donor quality and availability and an ageing medically complex patient and donor population. Addressing these challenges and controversies will dominate transplantation research for the foreseeable future.

Clinical operational tolerance in liver transplantation: state-of-the-art perspective and future prospects

BACKGROUND

Liver transplantation is the definite treatment for end-stage liver diseases with satisfactory results. However, untoward effects of life-long immunosuppression prevent the development of alternative strategies to achieve better long-term outcome. Achieving clinical operational tolerance is the ultimate goal.

DATA SOURCES

A PubMed and Google Scholar search using terms: "immune tolerance", "liver transplantation", "clinical trial", "operational tolerance" and "immunosuppression withdrawal" was performed, and relevant articles published in English in the past decade were reviewed. Full-text publications relevant to the field were selected and relevant articles from reference lists were also included. Priority was given to those articles which are relevant to the review.

RESULTS

Because of the inherent tolerogenic property, around 20%-30% of liver transplantation recipients develop spontaneous operational tolerance after immunosuppression withdrawal, and the percentage may be even higher in pediatric living donor liver transplantation recipients. Several natural killer and gammadeltaT cell related markers have been identified to be associated with the tolerant state in liver transplantation patients. Despite the progress, clinical operational tolerance is still rare in liver transplantation. Reprogramming the recipient immune system by creating chimerism and regulatory cell therapies is among newer promising means to achieve clinical liver transplantation tolerance in the future.

CONCLUSION

Although clinical operational tolerance is still rare in liver transplantation recipients, ongoing basic research and collaborative clinical trials may help to decipher the mystery of transplantation tolerance and extend the potential benefits of drug withdrawal to an increasing number of patients in a more predictable fashion.

Progress and outcomes of the first high-volume pediatric liver transplantation program in Saudi Arabia

In 2010, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, established a dedicated Organ Transplant Center to overcome the inadequacy in transplantation care in the region. Due to the high need for solid organ transplantation in children, this center focused on pediatric transplantation. Between 2011 and 2013, a total of 112 pediatric liver transplantations have been performed in our center, mostly from living donors (n=103, 92%). Eight percent of transplants were performed from deceased donors (n=9). Of the 112 transplants, 38.4% of children were below one year of age. There was a predominance of genetic-metabolic disorders (48.2%) as indications for transplant. Extra-hepatic biliary atresia was the indication in only 29.5% of transplant cases. End-stage liver disease of unknown origin accounted for 7.1% of cases. The actuarial recipient and graft survival are 93% and 89%, respectively. In-hospital morbidities amounted to 17% for surgical complications (n=19) and 18% for medical complications (n=20). Seven percent of recipients developed biopsy proven rejection during hospital stay. Five patients died late after discharge suddenly at home or at peripheral hospitals for unknown reasons. Overall, this newly established pediatric liver transplantation program could develop into a high-volume pediatric liver transplantation center in a short period of time due to the high need for liver transplantation in the country. In contrast to the experience in western or eastern countries, there is a high rate of indications for metabolic/genetic disorders. The early results of patient and graft survival are convincing. The long-term outcomes were compromised by an insufficient general healthcare system and cultural barriers.

Update in liver transplantation

Successful transplant outcomes require optimal patient selection and timing. Currently the major limitation facing liver transplant centers is the shortage of organs. The limited availability of organs has led to long waiting periods for liver transplantation and consequently many patients become seriously ill or die while on the waiting list. This has major implications in the selection of patients, as well as the timing of transplant, for optimal use of these scarce organs. Indications and contraindications have changed slightly over the years and will be reviewed in this article. Timing for transplantation has changed more dramatically in recent years since major changes to organ allocation systems have been undertaken to provide clinicians with a better way to prioritize patients for liver transplant.

Trends in liver transplantation 2011

This review will highlight some of the important recent trends in liver transplantation. When possible, we will compare and contrast these trends across various regions of the world, in an effort to improve global consensus and better recognition of emerging data.

Liver transplantation at the Ochsner Clinic: programmatic expansion and outcomes improvement

Liver transplantation has become the best and most durable treatment for both acute and chronic liver disease. Over 1400 liver transplants have been performed at the Ochsner Clinic since the first successful transplant in 1987. Since its inception, the program has gone through several changes and advancements and has become one of the largest liver transplant programs in the United States. We have helped evolve steroid sparing immunosuppression and the use of extended criteria, donor organs. Establishment of criteria for the selection of recipients for re-transplantation has resulted in better than expected short and long-term results. Our center has faced the challenge of Hurricane Katrina and overcome it. We have improved steadily in both outcomes and transplants performed. The Ochnser Clinic Liver Transplant program will continue to improve access and outcomes for all patients with liver disease.

Liver transplantation for hepatocellular carcinoma: past, present, and future

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death globally. HCC is an aggressive disease with high fatality as reflected by the close numbers of annual deaths per year from HCC and annual incidence worldwide. In the United States, HCC incidence has increased substantially during the past two decades and is projected to continue to rise. Surgical resection remains the best treatment option for anatomically resectable tumors in patients with well-preserved liver function. For patients who are not resection candidates, liver transplantation offers treatment not only for HCC, but also for the cirrhotic liver. Liver transplantation for HCC is a rapidly evolving field. The results have dramatically improved with implementation of surveillance, careful selection of patients for transplantation, and pre-transplant tumor ablation. New promising tumor biomarkers, therapies for hepatitis C virus, molecular targeted therapies for HCC, and immunosuppression will ensure even better outcomes moving forward. This review discusses how liver transplant for HCC has changed over the many years, is currently improving, and how future research will shape better results.

Liver transplantation at the University of Tennessee Health Science Center in Memphis, Tennessee: the current era 2006-2012

Transplantation at the University of Tennessee Health Science Center in Memphis, which began at the William F. Bowld Hospital and transferred to Methodist University Hospital in 2004, includes pediatric transplantation at LeBonheur Children's Medical Center. The multidisciplinary institute is dedicated to the treatment of patients with end-stage liver and kidney disease and allows those patients access to the integrated expertise of transplant surgeons, hepatologists, and nephrologists. The current, and most successful, era for the program began in 2006, when a change in leadership and clinical vision led to a dramatic increase in clinical activity. These changes have included wider acceptance of potential recipients for liver transplantation and broader use of marginal donor allografts. Streamlined surgical techniques have decreased operative times and have limited blood product usage. Additionally, the program uses an innovative immunosuppression protocol with the world's largest reported series of steroid-free, rabbit anti-thymocyte globulin induction and delayed introduction of tacrolimus in an effort to limit adverse effects of immunosuppression. Such adverse effects may include: infections, post-transplant diabetes mellitus, bone disease, and accelerated fibrosis from recurrent HCV related to steroids and impaired renal function from tacrolimus. These changes have resulted in aggressive donor usage with low complication rates and excellent outcomes.

The future of liver transplantation

Improvements in surgical techniques, postoperative care, and donor and recipient selection have all contributed to the increased success of OLT and to higher survival rates in patients with advanced liver disease. This progress in liver transplantation has occurred in only 45 years, since the preliminary work of Dr. Starzl, and provides a basis for future advances.

Factors affecting graft survival within 1-year post-transplantation in heart and lung transplant: an analysis of the OPTN/UNOS registry

Today, a main focus of the transplant community is the long-term outcomes of lung and heart allograft recipients. However, even early post-transplant survival (within the first post-transplant year) needs improvement, as early graft failure still accounts for many allograft losses. In this chapter, we review the experience of heart and lung transplantation as reported to the Organ Procurement Transplant Network/United Network of Organ Sharing registry and investigate the factors responsible for causing failure in the first post-transplant year. Trends indicate that sicker patients are increasingly being transplanted, thereby limiting improvements in early post-transplant survival. More lung and heart transplant patients are coming to transplant on dialysis. In heart transplant, there is an increase in the number of heart retransplant patients and an increase in patients on extracorporeal membrane oxygenation. For lung transplant, more patients are on a ventilator prior to transplant than in the past 25 years. Given that sicker/riskier patients are now receiving more heart and lung transplants, future studies need to take place to better understand these patients so that they can have the same survival as patients entering transplant with less severe illnesses.

Liver transplantation in the MELD era--analysis of the OPTN/UNOS registry

OVERVIEW OF THE MODEL FOR END-STAGE LIVER DISEASE (MELD): MELD has been successful in its initial aim of reducing pre-transplant mortality by better organ allocation; at the same time, it generated a new challenge of achieving better posttransplant outcomes by adjusting the hierarchy of allocation to sicker patients. Our analysis of 49,867 adult patients in the MELD era (2002 through 2011) showed a change in the dynamics of the transplant population: the number of patients with higher priority (MELD-exception patients and high-MELD patients) has been progressively increasing while the number of those without priority has remained constant or has been decreasing depending on their disease. The re-transplantation rate has been increasing for high-MELD patients. An increase in number has also observed of major racial groups other than Whites. Overall graft survival-including that for re-transplant-has improved, regardless of MELD levels, during the decade since MELD implementation in 2002. 2. MELD WITH PRIMARY DISEASES: Over the past two decades, the incidence of hepatitis C virus (HCV) has been increasing, and after the inception of MELD, hepatocellular carcinoma (HCC) and non-alcoholic liver disease (NASH) have been progressively increasing. There appears to be a general tendency toward lower graft survival in high-MELD patients in both deceased- and living-donor transplantation. However, this trend differed among the 12 primary diseases, in which significantly lower graft survival was observed in high-MELD patients with alcoholic liver disease (ALD), NASH, autoimmune disorders (AI), HCV, hepatitis B virus (HBV) or non-HCC cancers. Overall, HCV seropositive patients had lower graft survival than HCV seronegative patients. This was also true in each high- and low-MELD group. However, analysis of the primary diseases showed four patterns for the impact of HCV seropositivity related to MELD levels: lower graft survival with anti-HCV regardless of MELD level (with acute hepatic failure, metabolic disorders and HBV); no correlation between the impact of HCV antibodies and MELD levels (with primary biliary cirrhosis [PBC], primary sclerosing cholangitis [PSC] and HCC); lowest graft survival with high MELD scores in the presence of HCV antibodies (with AI, ALD and NASH); and worse survival without HCV (non-HCC cancers). 3. MELD EXCEPTION: Among the primary diseases, the five with a high rate of HCC exception (> 70%) were HCC, HCV, HBV, ALD and AI; the four with a high rate of non-HCC exception (> 60%) were non-HCC cancers, PSC, PBC, and "Others." HCC patients with HCC-exception appear to have derived a greater benefit from transplantation, with better graft survival, than HCC patients without exception. The same beneficial effect of non-HCC exception has been observed with non-HCC cancers, the majority of them cholangiocarcinoma.