Liver retransplantation for primary nonfunction: analysis of a 20-year single-center experience

The postoperative Model for End stage Liver Disease score as a predictor of short-term outcome after transplantation of extended criteria donor livers

BACKGROUND

Recently, the postoperative Model for End stage Liver Disease score (POPMELD) was suggested as a definition of postoperative graft dysfunction and a predictor of outcome after liver transplantation (LT).

AIM

The aim of the present study was to validate this concept in the context of extended criteria donor (ECD) organs.

PATIENTS AND METHODS

Single-center prospectively collected data (OPAL study/01/11-12/13) of 116 ECD LTs were utilized. For each recipient, the Model for End stage Liver Disease (MELD) score was calculated for 7 postoperative days (PODs). The ability of international normalized ratio, bilirubin, aspartate aminotransferase, Donor Risk Index, a recent definition of early allograft dysfunction, and the POPMELD was compared to predict 90-day graft loss. Predictive abilities were compared by receiver operating characteristic curves, sensitivity and specificity, and positive and negative predictive values.

RESULTS

The median Donor Risk Index was 1.8. In all, 60.3% of recipients were men [median age of 54 (23-68) years]. The median POD1-7 peak-aspartate aminotransferase value was 1052 (194-17 577) U/l. The rate of early allograft dysfunction was 22.4%. The 90-day graft survival was 89.7%. Out of possible predictors of the 90-day graft loss MELD on POD5 was the best predictor of outcome (area under the curve=0.84). A MELD score of 16 or more on POD5 predicted the 90-day graft loss with a specificity of 80.8%, a sensitivity of 81.8%, and a positive and negative predictive value of 31 and 97.7%.

CONCLUSION

A MELD score of 16 or more on POD5 is an excellent predictor of outcome in ECD donor LT. Routine evaluation of POPMELD scores might support clinical decision-making and should be reported routinely in clinical trials.

Long-term results after transplantation of pediatric liver grafts from donation after circulatory death donors

Background

Liver grafts from donation after circulatory death (DCD) donors are increasingly accepted as an extension of the organ pool for transplantation. There is little data on the outcome of liver transplantation with DCD grafts from a pediatric donor. The objective of this study was to assess the outcome of liver transplantation with pediatric DCD grafts and to compare this with the outcome after transplantation of livers from pediatric donation after brain death (DBD) donors.

Method

All transplantations performed with a liver from a pediatric donor (≤16 years) in the Netherlands between 2002 and 2015 were included. Patient survival, graft survival, and complication rates were compared between DCD and DBD liver transplantation.

Results

In total, 74 liver transplantations with pediatric grafts were performed; twenty (27%) DCD and 54 (73%) DBD. The median donor warm ischemia time (DWIT) was 24 min (range 15–43 min). Patient survival rate at 10 years was 78% for recipients of DCD grafts and 89% for DBD grafts (p = 0.32). Graft survival rate at 10 years was 65% in recipients of DCD versus 76% in DBD grafts (p = 0.20). If donor livers in this study would have been rejected for transplantation when the DWIT ≥30 min (n = 4), the 10-year graft survival rate would have been 81% after DCD transplantation. The rate of non-anastomotic biliary strictures was 5% in DCD and 4% in DBD grafts (p = 1.00). Other complication rates were also similar between both groups.

Conclusions

Transplantation of livers from pediatric DCD donors results in good long-term outcome especially when the DWIT is kept ≤30 min. Patient and graft survival rates are not significantly different between recipients of a pediatric DCD or DBD liver. Moreover, the incidence of non-anastomotic biliary strictures after transplantation of pediatric DCD livers is remarkably low.

Primary graft dysfunction of the liver: definitions, diagnostic criteria and risk factors

Primary graft dysfunction is a multifactorial syndrome with great impact on liver transplantation outcomes. This review article was based on studies published between January 1980 and June 2015 and retrieved from PubMed database using the following search terms: "primary graft dysfunction", "early allograft dysfunction", "primary non-function" and "liver transplantation". Graft dysfunction describes different grades of graft ischemia-reperfusion injury and can manifest as early allograft dysfunction or primary graft non-function, its most severe form. Donor-, surgery- and recipient-related factors have been associated with this syndrome. Primary graft dysfunction definition, diagnostic criteria and risk factors differ between studies. RESUMO A disfunção primária do enxerto hepático é uma síndrome multifatorial com grande impacto no resultado do transplante de fígado. Foi realizada uma ampla revisão da literatura, consultando a base de dados PubMed, em busca de estudos publicados entre janeiro de 1980 e junho de 2015. Os termos descritivos utilizados foram: "primary graft dysfunction", "early allograft dysfunction", "primary non-function" e "liver transplantation". A disfunção traduz graus diferentes da lesão de isquemia e reperfusão do órgão, e pode se manifestar como disfunção precoce ou, na forma mais grave, pelo não funcionamento primário do enxerto. Fatores relacionados ao doador, ao transplante e ao receptor contribuem para essa síndrome. Existem definições diferentes na literatura quanto ao diagnóstico e aos fatores de risco associados à disfunção primária.

CT Features of Primary Graft Nonfunction after Liver Transplantation

Purpose To determine computed tomographic (CT) features of primary graft nonfunction (PNF) after liver transplantation in comparison with those of early graft failure or death by identifiable causes. Materials and Methods Institutional review board approval was obtained and informed consent was waived. Among 3947 adult liver transplantations performed in one institution between May 2002 and May 2015, 72 patients died or had graft failure within 10 days, and 38 of them were evaluated with CT. PNF was diagnosed in 21 patients. The other 17 patients who died or had early graft failure were considered the non-PNF control group. On unenhanced CT images, graft attenuation was compared qualitatively. Graft attenuation was measured quantitatively and, if available, the difference between preoperative and postoperative CT (interval change) attenuation was evaluated. Unenhanced CT was evaluated for relative parenchymal enhancement. Statistical analyses included the Fisher exact and χ² tests with Yates correction and the Student t test. Results On unenhanced CT images, grafts with PNF more commonly showed low (eight of 26 [31%]) or extremely low (18 of 26 [69%]) qualitative attenuation compared with grafts in the non-PNF group (three of 21 [14%], one of 21 [5%]; P < .001). The mean attenuation value (30.5 HU ± 10.8) was significantly lower and the mean interval change (24.7 HU ± 12.5) was significantly higher in the PNF group than in the non-PNF group (49.7 HU ± 8.0 and 9.7 HU ± 10.1, respectively; P < .001 and P = .001). There was no significant difference in the proportion of grafts that showed poor enhancement on postcontrast CT images between the PNF group and the non-PNF group (nine of 24 [38%] vs two of 20 [10%], respectively; P = .08). Conclusion Recipients with PNF after liver transplantation tended to show low or extremely low attenuation on unenhanced CT images, and this finding was seen more frequently in patients with PNF than in those who died of identifiable causes and in those with early graft failure. ^© RSNA, 2016 Online supplemental material is available for this article.

Graft Reconditioning before Liver Transplantation

BACKGROUND

The high demand for livers for transplantation has led to organs of limited quality being accepted to expand the donor pool. This is associated with inferior outcomes due to more pronounced preservation injury. Accordingly, recent research has aimed to develop preservation modalities for improved preservation as well as strategies for liver viability assessment and liver reconditioning.

METHODS

The PubMed database was searched using the terms 'perfusion', 'liver', 'preservation', and 'reconditioning' in various combinations, and the according literature was reviewed.

RESULTS

Several perfusion techniques have been developed in recent years with the potential for liver reconditioning. Preclinical and first emerging clinical data suggest feasibility, safety, and superiority over the current gold standard of cold storage.

CONCLUSION

This review outlines current advances in the field of liver preservation with an emphasis on liver reconditioning methods.

Circulating sterols as predictors of early allograft dysfunction and clinical outcome in patients undergoing liver transplantation

INTRODUCTION

Sensitive and specific assessment of the hepatic graft metabolism after liver transplantation (LTX) is essential for early detection of postoperative dysfunction implying the need for consecutive therapeutic interventions.

OBJECTIVES

Here, we assessed circulating liver metabolites of the cholesterol pathway, amino acids and acylcarnitines and evaluated their predictive value on early allograft dysfunction (EAD) and clinical outcome in the context of LTX.

METHODS

The metabolites were quantified in the plasma of 40 liver graft recipients one day pre- and 10 days post-LTX by liquid chromatography/tandem mass spectrometry (LC-MS/MS). Plant sterols as well as cholesterol and its precursors were determined in the free and esterified form; lanosterol in the free form only. Metabolites and esterification ratios were compared to the model for early allograft function scoring (MEAF) which is calculated at day 3 post-LTX from routine parameters defining EAD.

RESULTS

The hepatic esterification ratio of all sterols, but not amino acids and acylcarnitine concentrations, showed substantial metabolic disturbances post-LTX and correlated to the MEAF. In ROC analysis, the low esterification ratio of β-sitosterol and stigmasterol from day 1 and of the other sterols from day 3 were predictive for a high MEAF, i.e. EAD. Additionally, the ratio of esterified β-sitosterol and free lanosterol were predictive for all days and the esterification ratio of the other sterols at day 3 or 4 post-LTX for 3-month mortality.

CONCLUSION

Low ratios of circulating esterified sterols are associated with a high risk of EAD and impaired clinical outcome in the early postoperative phase following LTX.

Interferon-γ, interleukin-10 and interferon-inducible protein 10 (CXCL10) as serum biomarkers for the early allograft dysfunction after liver transplantation

Orthotopic liver transplantation (LTP) is nowadays a standard procedure, and provides the chance of survival of patients with end-stage non-treatable chronic liver disease or acute liver failure. Despite long-term survival with a good quality of life in the majority of patients, about 20% develop early allograft dysfunction (EAD), which leads to death or the need for re-transplantation. Therefore, the early diagnosis of EAD and evaluation of its risk factors are very important. Many primary pathological processes leading to EAD are accompanied by the release of different mediators and by a change of biochemical parameters detectable in the peripheral blood. The aim of this study was to investigate cytokines as well as soluble mediators in the serum of patients with and without EAD from our LTP bank, and to evaluate their predictive and prognostic values for EAD. We demonstrated for the first time that the level of IFNγ during the nearest preoperative period may serve as a predictive parameter for EAD. We additionally found that IL-10 and CXCL10 (IP-10) levels in the early postoperative period can be prognostic for EAD. We believe our data expand the spectrum of predictive and prognostic parameters for EAD in LTP.

Critical Care of the Liver Transplant Recipient

Patient survival following orthotopic liver transplantation has greatly increased following improvements in surgical technique, anesthetic care, and immunosuppression. The critical care of the liver transplant recipient has paralleled these improvements, largely thanks to input from multidisciplinary teams and institution-specific protocols guiding management and care. This article provides an overview of the approach to critical care of the postoperative adult liver transplant recipient outlining common issues faced by the intensivist. Approaches to extubation and hemodynamic assessment are described. The provision of appropriate immunosuppression, infection prophylaxis, and nutrition is addressed. To aid prompt diagnosis and treatment, intensivists must be aware of postoperative complications of bleeding, primary nonfunction, delayed graft function, vascular thromboses, biliary complications, rejection, and organ dysfunction.

Postoperative Insulin-Like Growth Factor 1 Levels Reflect the Graft's Function and Predict Survival after Liver Transplantation

Background

The reduction of insulin-like growth factor 1 (IGF-1) plasma levels is associated with the degree of liver dysfunction and mortality in cirrhotic patients. However, little research is available on the recovery of the IGF-1 level and its prognostic role after liver transplantation (LT).

Methods

From April 2010 to May 2011, 31 patients were prospectively enrolled (25/6 M/F; mean age±SEM: 55.2±1.4 years), and IGF-1 serum levels were assessed preoperatively and at 15, 30, 90, 180 and 365 days after transplantation. The influence of the donor and recipient characteristics (age, use of extended criteria donor grafts, D-MELD and incidence of early allograft dysfunction) on hormonal concentration was analyzed. The prognostic role of IGF-1 level on patient survival and its correlation with routine liver function tests were also investigated.

Results

All patients showed low preoperative IGF-1 levels (mean±SEM: 29.5±2.1), and on postoperative day 15, a significant increase in the IGF-1 plasma level was observed (102.7±11.7 ng/ml; p<0.0001). During the first year after LT, the IGF-1 concentration remained significantly lower in recipients transplanted with older donors (>65 years) or extended criteria donor grafts. An inverse correlation between IGF-1 and bilirubin serum levels at day 15 (r = -0.3924, p = 0.0320) and 30 (r = -0.3894, p = 0.0368) was found. After multivariate analysis, early (within 15 days) IGF-1 normalization [Exp(b) = 3.913; p = 0.0484] was the only prognostic factor associated with an increased 3-year survival rate.

Conclusion

IGF-1 postoperative levels are correlated with the graft’s quality and reflect liver function. Early IGF-1 recovery is associated with a higher 3-year survival rate after LT.

The microRNA Expression Profile in Donation after Cardiac Death (DCD) Livers and Its Ability to Identify Primary Non Function

Donation after cardiac death (DCD) livers are marginal organs for transplant and their use is associated with a higher risk of primary non function (PNF) or early graft dysfunction (EGD). The aim was to determine if microRNA (miRNA) was able to discriminate between DCD livers of varying clinical outcome. DCD groups were categorized as PNF retransplanted within a week (n=7), good functional outcome (n=7) peak aspartate transaminase (AST) ≤ 1000 IU/L and EGD (n=9) peak AST ≥ 2500 IU/L. miRNA was extracted from archival formalin fixed post-perfusion tru-cut liver biopsies. High throughput expression analysis was performed using miRNA arrays. Bioinformatics for expression data analysis was performed and validated with real time quantitative PCR (RT-qPCR). The function of miRNA of interest was investigated using computational biology prediction algorithms. From the array analysis 16 miRNAs were identified as significantly different (p<0.05). On RT-qPCR miR-155 and miR-940 had the highest expression across all three DCD clinical groups. Only one miRNA, miR-22, was validated with marginal significance, to have differential expression between the three groups (p=0.049). From computational biology miR-22 was predicted to affect signalling pathways that impact protein turnover, metabolism and apoptosis/cell cycle. In conclusion, microRNA expression patterns have a low diagnostic potential clinically in discriminating DCD liver quality and outcome.

First experience of liver transplantation with type 2 donation after cardiac death in France

Organ donation after unexpected cardiac death [type 2 donation after cardiac death (DCD)] is currently authorized in France and has been since 2006. Following the Spanish experience, a national protocol was established to perform liver transplantation (LT) with type 2 DCD donors. After the declaration of death, abdominal normothermic oxygenated recirculation was used to perfuse and oxygenate the abdominal organs until harvesting and cold storage. Such grafts were proposed to consenting patients < 65 years old with liver cancer and without any hepatic insufficiency. Between 2010 and 2013, 13 LTs were performed in 3 French centers. Six patients had a rapid and uneventful postoperative recovery. However, primary nonfunction occurred in 3 patients, with each requiring urgent retransplantation, and 4 early allograft dysfunctions were observed. One patient developed a nonanastomotic biliary stricture after 3 months, whereas 8 patients showed no sign of ischemic cholangiopathy at their 1-year follow-up. In comparison with a control group of patients receiving grafts from brain-dead donors (n = 41), donor age and cold ischemia time were significantly lower in the type 2 DCD group. Time spent on the national organ wait list tended to be shorter in the type 2 DCD group: 7.5 months [interquartile range (IQR), 4.0-11.0 months] versus 12.0 months (IQR, 6.8-16.7 months; P = 0.08. The 1-year patient survival rates were similar (85% in the type 2 DCD group versus 93% in the control group), but the 1-year graft survival rate was significantly lower in the type 2 DCD group (69% versus 93%; P = 0.03). In conclusion, to treat borderline hepatocellular carcinoma, LT with type 2 DCD donors is possible as long as strict donor selection is observed.

Liver transplantation for the referring physician

Liver transplantation has become the treatment of choice for nearly all causes of end-stage liver disease, fulminant liver failure, and selected primary hepatic malignancies. The demand for liver transplantation has persistently outmatched the availability of donor organs leading to the development of novel strategies to expand the donor pool. The authors review the process of liver transplant evaluation, methods used to address the donor shortage, and disease-specific outcomes and challenges and discuss posttransplant care.

A score model for the continuous grading of early allograft dysfunction severity

Early allograft dysfunction (EAD) dramatically influences graft and patient outcomes. A lack of consensus on an EAD definition hinders comparisons of liver transplant outcomes and management of recipients among and within centers. We sought to develop a model for the quantitative assessment of early allograft function [Model for Early Allograft Function Scoring (MEAF)] after transplantation. A retrospective study including 1026 consecutive liver transplants was performed for MEAF score development. Multivariate data analysis was used to select a small number of postoperative variables that adequately describe EAD. Then, the distribution of these variables was mathematically modeled to assign a score for each actual variable value. A model, based on easily obtainable clinical parameters (ie, alanine aminotransferase, international normalized ratio, and bilirubin) and scoring liver function from 0 to 10, was built. The MEAF score showed a significant association with patient and graft survival at 3-, 6- and 12-month follow-ups. Hepatic steatosis and age for donors; cold/warm ischemia times and postreperfusion syndrome for surgery; and intensive care unit and hospital stays, Model for End-Stage Liver Disease and Child-Pugh scores, body mass index, and fresh frozen plasma transfusions for recipients were factors associated significantly with EAD. The model was satisfactorily validated by its application to an independent set of 200 patients who underwent liver transplantation at a different center. In conclusion, a model for the quantitative assessment of EAD severity has been developed and validated for the first time. The MEAF provides a more accurate graft function assessment than current categorical classifications and may help clinicians to make early enough decisions on retransplantation benefits. Furthermore, the MEAF score is a predictor of recipient and graft survival. The standardization of the criteria used to define EAD may allow reliable comparisons of recipients' treatments and transplant outcomes among and within centers.

Effect of remote ischemic postconditioning on patients undergoing living donor liver transplantation

The aim of this study was to evaluate the protective effect of remote ischemic postconditioning (RIPostC) on graft function and acute kidney injury (AKI) after living donor liver transplantation (LT). Recipients undergoing elective living donor LT were randomly assigned to either the RIPostC group or the control group. Immediately after reperfusion, 4 cycles of ischemia and reperfusion lasting for 5 minutes each were performed on 1 upper limb in the RIPostC group. Graft function was assessed through evaluations of the serum levels of total bilirubin and liver enzymes and the prothrombin time for 28 days after surgery. The incidence of AKI, as defined by the Risk, Injury, Failure, Loss, and End-Stage Kidney Disease classification, was evaluated within 28 days of the operation. In addition, the incidences of graft dysfunction, acute cellular rejection, and major complications; the 1-, 3-, and 6-month mortality rates; the length of stay in the intensive care unit; and the length of hospital stay were also investigated. In all, 78 patients were enrolled in the analysis (n = 39 in each group). No differences in graft function or clinical outcomes were observed between the groups. The incidences of postoperative AKI were 38% (n = 15) in the RIPostC group and 72% (n = 28) in the control group (P = 0.006). Despite no improvements in postoperative graft function, RIPostC decreased the incidence of postoperative AKI after living donor LT in this study. However, no other clinical benefits with respect to the complication rate, length of hospital stay, or short-term mortality rate were observed. Thus, further studies will be needed to evaluate the clinical efficacy of RIPostC in LT fully.

Primary graft dysfunction after liver transplantation

BACKGROUND

Primary graft dysfunction (PGD) causes complications in liver transplantation, which result in poor prognosis. Recipients who develop PGD usually experience a longer intensive care unit and hospital stay and have higher mortality and graft loss rates compared with those without graft dysfunction. However, because of the lack of universally accepted definition, early diagnosis of graft dysfunction is difficult. Additionally, numerous factors affect the allograft function after transplantation, making the prediction of PGD more difficult. The present review was to analyze the literature available on PGD and to propose a definition.

DATA SOURCE

A search of PubMed (up to the end of 2012) for English-language articles relevant to PGD was performed to clarify the characteristics, risk factors, and possible treatments or interventions for PGD.

RESULTS

There is no pathological diagnostic standard; many documented definitions of PGD are different. Many factors, such as donor status, procurement and transplant process and recipient illness may affect the function of graft, and ischemia-reperfusion injury is considered the direct cause. Potential managements which are helpful to improve graft function were investigated. Some of them are promising.

CONCLUSIONS

Our analyses suggested that the definition of PGD should include one or more of the following variables: (1) bilirubin ≥ 10 mg/dL on postoperative day 7; (2) international normalized ratio ≥ 1.6 on postoperative day 7; and (3) alanine aminotransferase or aspartate aminotransferase >2000 IU/L within 7 postoperative days. Reducing risk factors may decrease the incidence of PGD. A majority of the recipients could recover from PGD; however, when the graft progresses into primary non-function, the patients need to be treated with re-transplantation.

Postoperative care in pediatric liver transplantation

In the last 25 years, liver transplantation in children has become an effective, definitive, and universally accepted treatment for terminal liver diseases. Long-term survival exceeds 80% and improves each year as the result of constant technical advancements and improvements in immediate postoperative intensive care and clinical control.

A proposal to grade the severity of early allograft dysfunction after liver transplantation

Objective:

To propose a grading system for early hepatic graft dysfunction.

Methods:

A retrospective study from a single transplant center. Recipients of liver transplants from deceased donors, transplanted under the MELD system were included. Early graft dysfunction was defined by Olthoff criteria. Multiple cut-off points of post-transplant laboratory tests were used to create a grading system for early graft dysfunction. The primary outcome was 6-months grafts survival.

Results:

The peak of aminotransferases during the first postoperative week correlated with graft loss. The recipients were divided into mild (aminotransferase peak >2,000IU/mL, but <3,000IU/mL); moderate (aminotransferase peak >3,000IU/mL); and severe (aminotransferase peak >3,000IU/mL + International Normalized Ratio ≥1.6 and/or bilirubin ≥ 10mg/dL in the 7^th postoperative day) early allograft dysfunction. Moderate and severe early dysfunctions were independent risk factors for graft loss. Patients with mild early dysfunction presented with graft and patient survival comparable to those without graft dysfunction. However, those with moderate early graft dysfunction showed worse graft survival than those who had no graft dysfunction. Patients with severe early dysfunction had graft and patient survival rates worse than those of any other groups.

Conclusion:

Early graft dysfunction can be graded by a simple and reliable criteria based on the peak of aminotransferases during the first postoperative week. The severity of the early graft dysfunction is an independent risk factor for allograft loss. Patients with moderate early dysfunction showed worsening of graft survival. Recipients with severe dysfunction had a significantly worse prognosis for graft and patient survival.

Endogenous signal transducer and activator of transcription 3 is required for the protection of hepatocytes against warm ischemia/reperfusion injury

Warm ischemia/reperfusion (I/R) is a common clinical problem during liver transplantation and liver resection. Warm ischemia also occurs during trauma and shock. However, there is still no safe and promising strategy for protecting the liver from I/R injury. Signal transducer and activator of transcription 3 (STAT3) is a major immediate response molecule for protecting cell survival. In this study, we first confirmed that a pharmacological STAT3 inhibitor, (E)-2-cyano-3-(3,4-dihydrophenyl)-N-(phenylmethyl)-2-propenamide (AG490), significantly reduced the survival of HepG2 cells, regardless of the serum condition. Furthermore, we created hepatocyte-specific STAT3-deficient mice with the cyclization recombination-locus of X-over P1 (Cre-LoxP) system to study the mechanisms of STAT3 in liver I/R injury. We found that the alanine aminotransferase level was significantly higher in hepatocyte-specific STAT3-deficient mice versus wild-type (WT) mice in a 70% liver I/R injury model. A histopathological examination showed that hepatocyte-specific STAT3-deficient mice suffered more severe damage than WT mice despite similar numbers of polymorphonuclear neutrophils in the 2 groups. These results indicate that endogenous STAT3 signaling in hepatocytes is required for protection of the liver in vitro and in vivo against warm I/R injury. In conclusion, endogenous STAT3 plays an important role in protecting the liver against I/R injury, and STAT3-targeting therapy could be a therapeutic approach to combating liver I/R injury.

Comparison of short- and long-term outcomes after early versus late liver retransplantation: a single-center experience

BACKGROUND

As the survival of patients after liver transplantation (LT) improves, the requirement of liver retransplantation (reLT) for late graft failure has grown. Although some have reported that the short-term outcome of late reLT was comparable with that of early reLT, it remains unknown whether long-term survival of late reLT is inferior to that of early reLT patients.

MATERIALS AND METHODS

We reviewed early (<6 mo after primary LT) and late (≥6 mo after primary LT) reLT cases performed between January 2000 and December 2010.

RESULTS

Sixteen early and 32 late reLT cases were analyzed. There was no significant difference regarding the number of units of red blood cells transfused during the transplantation between the groups, whereas operative time was significantly longer in the late reLT cases. Graft loss within 3 mo after early and late reLT was 18.6% and 15.6%, respectively. Patient and graft survival rates after 1, 3, 5, and 10 y in the late reLT group were 80.6%, 73.3%, 73.3%, and 67.7% and 80.7%, 69.1%, 63.3%, and 54.3%, respectively, whereas those in the early reLT group were 75.0%, 75.0%, 64.3%, and 64.3% and 81.3%, 75.0%, 64.3%, and 32.1%, respectively. There was no significant difference in patient or graft survival rates between the groups (P = 0.91 and 0.91, respectively).

CONCLUSIONS

Acceptable short- and long-term survival were provided in early and late reLT. The time between the primary LT and reLT does not seem to play significant role in the prognosis of reLT in the long term.

Avaliação da proteína acídica fibrilar glial como marcador da injúria por isquemia-reperfusão hepática

OBJETIVO: Avaliar a expressão da Proteína Acídica Fibrilar Glial após a injúria por isquemia-reperfusão. MÉTODOS: vinte e quatro ratos foram distribuídos em quatro grupos: Controle, submetidos à anestesia e biópsia hepática; Simulação, injeção de heparina através da veia cava e dissecção do pedículo hepático superior, biópsia após 24 horas; Isquemia 30 minutos, mesmo procedimento do grupo Simulação, acrescido de clampeamento do pedículo hepático superior por 30 minutos; Isquemia 90 minutos, mesmo procedimento do grupo Isquemia 30 minutos, porém com período de clampeamento de 90 minutos. Após 24 horas de observação, os animais foram submetidos à laparotomia e seus fígados avaliados macroscopicamente, microscopicamente, por coloração de Hematoxilina-Eosina (HE) e submetidos à análise da expressão da GFAP por Western Blotting. RESULTADOS: Não se observou diferença no aspecto macroscópico dos fígados entre os diferentes grupos experimentais, tendo todos evidenciado morfologia normal. A análise por HE não evidenciou diferenças significativas, no que diz respeito à morfologia lobular. Por outro lado, nos grupos isquemia, foram encontrados infiltrados neutrofílicos e pequenas áreas de necrose. A expressão de GFAP foi semelhante em todos os grupos, seja qualitativamente quanto quantitativamente. CONCLUSÃO: A expressão da Proteína Acídica Fibrilar Glial não se alterou em nosso modelo de isquemia-reperfusão.

Preservation solutions for liver transplantation in adults: celsior versus custodiol: a systematic review and meta-analysis with an indirect comparison of randomized trials

BACKGROUND

The University of Wisconsin (UW) solution has been recognized as the gold standard for liver preservation; however, it possesses some limitations, and other solutions exist for organ preservation. The aim of this study was to compare the liver functions of transplanted grafts that had been stored in Celsior and Custodiol solutions.

METHODS

We searched the MEDLINE, EMBASE, LILACS, Cochrane Central Register of Controlled Trials, and SCIELO databases. We included randomized and quasi-randomized, controlled trials that compared the efficacy and safety of Celsior and Custodiol with UW solution for liver preservation in adults. The factors that were considered for analysis were their impacts on primary dysfunction (primary nonfunction and initial poor function), ischemic-type biliary lesions, and patient and graft survival rates. Because of the lack of direct evidence, an indirect comparison of Celsior and Custodiol was calculated.

RESULTS

We identified 3 randomized controlled trials and 1 quasi-randomized, controlled trial to pool in a meta-analysis of Celsior versus UW solutions. The number of episodes of primary dysfunction was lower in the Celsior group (7.4%) than in the UW group (9.8%), but the difference was not significant (relative risk [RR], 0.68; 95% confidence interval [CI], 0.22-1.97). Two randomized controlled trials compared Custodiol and Wisconsin solutions were identified. The number of episodes of primary dysfunction was also lower in the Custodiol group (3.0%) compared with the Wisconsin group (8.4%), but the difference was not significant (RR, 0.36; 95% CI, 0.08-1.70). An indirect comparison using data from the main analysis revealed no difference between the Celsior and Custodiol solutions (RR, 1.88; 95% CI, 0.57-6.16).

CONCLUSION

The Celsior and Custodiol solutions performed similarly to UW solution as preservation solutions in liver transplantation clinical settings.

What is the prognosis after retransplantation of the liver?

In patients with failing liver grafts, hepatic retransplantation cannot be abandoned for the ethical and practical reasons that have been detailed previously. The current recommendations involve a strategy for risk stratification of retransplant candidates. The long-term patient and graft survival outcomes after ReLT are excellent and acceptable for the low and intermediate groups, respectively. However, pursuing ReLT in transplant candidates in the high-risk category cannot be recommended. Furthermore, ReLT should be reserved for centers equipped to manage the difficulties of the endeavor because it is a technically demanding operation that requires surgical expertise and excellent anesthesiology and critical care support both before and after transplantation.

Primary graft dysfunction after living donor liver transplantation is characterized by delayed functional hyperbilirubinemia

The purpose of this study is to propose a new concept of primary graft dysfunction (PGD) after living donor liver transplantation (LDLT), characterized by delayed functional hyperbilirubinemia (DFH) and a high early graft mortality rate. A total of 210 adult-to-adult LDLT grafts without anatomical, immunological or hepatitis-related issues were included. All of the grafts with early mortality (n = 13) caused by PGD in LDLT had maximum total bilirubin levels >20 mg/dL after postoperative day 7 (p < 0.001). No other factors, including prothrombin time, ammonia level or ascites output after surgery were associated with early mortality. Thus, DFH of >20 mg/dL for >seven consecutive days occurring after postoperative day 7 (DFH-20) was used to characterize PGD. DFH-20 showed high sensitivity (100%) and specificity (95.4%) for PGD with early mortality. Among the grafts with DFH-20 (n = 22), those with early mortality (n = 13) showed coagulopathy (PT-INR > 2), compared with those without mortality (p = 0.002). Pathological findings in the grafts with DFH-20 included hepatocyte ballooning and cholestasis, which were particularly prominent in the centrilobular zone. PGD after LDLT is associated with DFH-20 caused by graft, recipient and surgical factors, and increases the risk of early graft mortality.

Predictive index for long-term survival after retransplantation of the liver in adult recipients: analysis of a 26-year experience in a single center

OBJECTIVE

To develop a prognostic scoring system for risk stratification of patients with hepatic graft failure (GF) undergoing retransplants of the liver (ReLT) and improve patient selection.

SUMMARY OF BACKGROUND DATA

Retransplantation of the liver remains controversial because of inferior outcomes compared with the primary orthotopic liver transplantation (OLT) and raises concerns of inappropriate utilization of a scarce donor organ resource. Data on risk stratification of ReLT patients for long-term survival outcomes are limited.

METHODS

We conducted an analysis from our prospective database of 466 adults' ReLT between February 1984 and September 2010. Mean follow-up was 3 years. Each independent predictor for allograft failure was assigned risk score (RS) points of 1 or 2, proportional to the corresponding parameter estimate under the Cox model: Predictive index category (PIC) 1, RS = 0; PIC II, RS = 1 to 2; PIC III, RS = 3 to 4; and PIC IV, RS = 5 to 12.

RESULTS

Eight risk factors predictive for GF after ReLT included recipient age greater than 55 years, Model for End-Stage Liver Disease score greater than 27, history of prior OLT greater than 1, pre-ReLT requirement for mechanical ventilation, serum albumin less than 2.5 g/dL, donor age greater than 45 years, intraoperative requirement of packed red blood cell transfusion greater than 30 units, and performance of ReLT between 15 and 180 days from the prior OLT. Five-year GF-free survival was significantly higher in PIC I (65%) than in PIC II (53%), PIC III (43%), and PIC IV (20%) groups (P < 0.001).

CONCLUSIONS

This risk-stratification model was highly predictive of long-term outcome after liver retransplantation in adult recipients. This formula provides a practical guide for selection of candidates for retransplantation of the liver that can lead to improved patient outcomes and optimal utilization of a scarce resource.

Preoperative fasting protects mice against hepatic ischemia/reperfusion injury: mechanisms and effects on liver regeneration

We show that brief periods of fasting induce functional changes similar to those induced by long-term dietary restriction in mice, and these changes include protection from ischemia/reperfusion (I/R) injury. In this study, we investigated the mechanisms of protection induced by fasting, and we determined the effect on liver regeneration after partial hepatectomy. Partial hepatic ischemia (75 minutes) was induced in ad libitum fed mice and in 1- to 3-day-fasted mice, and one-third or two-thirds hepatectomy was performed in ad libitum fed mice and 3-day-fasted mice. Preoperative fasting for 2 or 3 days significantly decreased hepatocellular I/R injury. Hepatic gene expression of heme oxygenase 1 (HO-1), superoxide dismutase 2 (SOD2), glutathione peroxidase 1 (Gpx1), and glutathione reductase (GSR) was significantly up-regulated in 3-day-fasted mice at the baseline and 6 hours after reperfusion. After reperfusion, p-selectin and interleukin-6 (IL-6) levels were significantly lower, and superoxide radical generation, lipid peroxidation, and neutrophil influx were significantly attenuated in 3-day-fasted mice. Preoperative fasting did not affect liver regeneration after one-third hepatectomy. Hepatic gene expression of IL-6 and transforming growth factor β1 was significantly higher in 3-day-fasted mice before and after one-third hepatectomy. Tumor necrosis factor α expression significantly increased after one-third hepatectomy in 3-day-fasted mice. After a 3-day fast and two-thirds hepatectomy, liver regeneration and subsequent postoperative recovery were compromised. In conclusion, up-regulation of the stress response gene HO-1 and the antioxidant enzymes SOD2, Gpx1, and GSR at the baseline and a better response after reperfusion likely underlie the protection induced by fasting against hepatic I/R injury. Preoperative fasting may be a promising new strategy for protecting the liver against I/R injury during liver transplantation and minor liver resections, although its effect on extended hepatectomy warrants further exploration.

Critical care issues in patients after liver transplantation

The majority of patients who undergo liver transplantation (LT) spend some time in the intensive care unit during the postoperative period. For some, this is an expected part of the immediate posttransplant recovery period, whereas for others, the stay is more prolonged because of preexisting conditions, intraoperative events, or postoperative complications. In this review, 4 topics that are particularly relevant to the postoperative intensive care of LT recipients are discussed, with an emphasis on current knowledge specific to this patient group. Infectious complications are the most common causes of early posttransplant morbidity and mortality. The common patterns of infection seen in patients after LT and their management are discussed. Acute kidney injury and renal failure are common in post-LT patients. Kidney injury identification, etiologies, and risk factors and approaches to management are reviewed. The majority of patients will require weaning from mechanical ventilation in the immediate postoperative period; the approach to this is discussed along with the approach for those patients who require a prolonged period of mechanical ventilation. A poorly functioning graft requires prompt identification and appropriate management if the outcomes are to be optimized. The causes of poor graft function are systematically reviewed, and the management of these grafts is discussed.

Intensive care management of liver transplanted patients

Advances in pre-transplant treatment of cirrhosis-related organ dysfunction, intraoperative patient management, and improvements in the treatment of rejection and infections have made human liver transplantation an effective and valuable option for patients with end stage liver disease. However, many important factors, related both to an increasing "marginality" of the implanted graft and unexpected perioperative complications still make immediate post-operative care challenging and the early outcome unpredictable. In recent years sicker patients with multiple comorbidities and organ dysfunction have been undergoing Liver transplantation; appropriate critical care management is required to support prompt graft recovery and prevent systemic complications. Early post-operative management is highly demanding as significant changes may occur in both the allograft and the "distant" organs. A functioning transplanted liver is almost always associated with organ system recovery, resulting in a new life for the patient. However, in the unfortunate event of graft dysfunction, the unavoidable development of multi-organ failure will require an enhanced level of critical care support and a prolonged ICU stay. Strict monitoring and sustainment of cardiorespiratory function, frequent assessment of graft performance, timely recognition of unexpected complications and the institution of prophylactic measures to prevent extrahepatic organ system dysfunction are mandatory in the immediate post-operative period. A reduced rate of complications and satisfactory outcomes have been obtained from multidisciplinary, collaborative efforts, skillful vigilance, and a thorough knowledge of pathophysiologic characteristics of the transplanted liver.

Liver grafts from selected older donors do not have significantly more ischaemia reperfusion injury

BACKGROUND

There is a general concern that aged organs are more susceptible to ischaemia. In the light of recent proposals to change the liver allocation system by expanding regional sharing, it is feared that increased cold ischaemia time of grafts from older donors may reduce graft survival. The aim of this study was to correlate donor age and the patterns of ischaemia reperfusion injury and synthetic function early after liver transplantation.

METHODS

We performed a retrospective study of first transplants using a single-centre electronic database. Patterns of liver injury (based on transaminases and post-reperfusion biopsy), synthetic function (international normalized ratio [INR]), and graft and patient survival in recipients receiving liver grafts from donors aged ≥ 65 years (group 1, n= 50) were compared with equivalent patterns in a matched cohort of recipients transplanted with grafts from donors aged <65 years (group 2, n= 50).

RESULTS

There was no significant difference in transaminase levels from day 0 to day 6 after transplantation. When groups 1 and 2 were subdivided into two subgroups based on the duration of graft cold ischaemia time (<8 h and ≥ 8 h), there was no statistical difference in transaminase levels during the first 7 days. There were two cases (4%) of primary non-function in group 1 and one (2%) in group 2. Initial poor function did not differ significantly between the groups (26% vs. 24%; P= 0.81). In addition, there was no difference in histological changes in post-reperfusion biopsies (21% vs. 34%; P= 0.078) and rate of acute rejection episodes in the first year (30% vs. 32%; P= 0.99). There was no significant difference between groups 1 and 2 in 1-year patient and graft survivals (78% vs. 90% [P= 0.17]; 88% vs. 94% [P= 0.48], respectively).

CONCLUSIONS

Judiciously selected livers from aged donors are not associated with major increased susceptibility to ischaemia reperfusion injury.

Glucose balance of porcine liver allograft is an important predictor of outcome

BACKGROUND

The role of glucose metabolism in predicting postoperative liver graft function after transplantation is unclear. We investigated the relation between intraoperative glucose balance of the liver allograft and the postoperative graft function and survival in a porcine partial liver transplant model.

MATERIALS AND METHODS

Experiments follow Guiding Principles in the Care and Use of Animals. Fourteen female pigs received liver allografts of 17%-39% recipient liver volume. Recipients were classified into two groups based on positive glucose balance: the mean intraoperative blood glucose of the graft outflow was greater than the blood glucose of inflow, negative glucose balance: the mean blood glucose of graft outflow was less than blood glucose of inflow. Perioperative data and survival were studied.

RESULTS

In the positive group (n=9) intraoperative hepatic artery flow was significantly higher (P=0.028), and oxygen consumption was lower (P=0.018) than the negative group (n=5). Postoperatively, maximal serum aspartate aminotransferase (AST) (P=0.028), alanine aminotransferase (ALT) (P=0.028), and total bilirubin (P=0.027) of the positive group were significantly lower than the negative group. In survival analysis, the positive group had significantly better survival rate than the negative group (P=0.034). Using Periodic acid-Schiff staining, glycogen content of the allograft in the positive group at 10 min post-reperfusion was significantly decreased in comparison with the baseline value in the normal liver (P=0.005), however not statistically different in the negative group (P=0.175).

CONCLUSION

Intraoperative glucose balance can be used as an early predictor of the graft function following transplantation of partial liver allografts.

The role of marginal donors in liver transplantation. The Hungarian experience

A májátültetések számát korlátozza a beültetésre alkalmas donorszervek mennyisége. A szervhiány megoldására az egyik lehetőség az úgynevezett marginális donorok (extended donor criteria) elfogadása a májátültetési programban. Célkitűzés: A magyar májátültetési program szervdonációs jellemzőinek vizsgálata, különös tekintettel a marginális donorokra. Módszer: Donor- és recipiensadatok retrospektív feldolgozása 2003. január és 2008. december között. A marginálisdonor-kritériumrendszert nemzetközi ajánlások alapján állítottuk fel. Eredmények: A vizsgált periódus alatt összesen 1078 donort jelentettek a klinikán. Nyolcszázharmincöt esetben (77,4%) alkalmatlannak ítélték a donormájat a transzplantációra, 243 esetben (22,6%) volt beültetésre alkalmas a donormáj. A beültetett májgraftok közül 40 (16%) származott marginális, 203 (84%) nem marginális donorból. Marginális májgraftok beültetése esetén nem volt különbség a beteg- és grafttúlélésben, a posztoperatív graftfunkciót jelző paraméterekben és az általános szövődmények gyakoriságában. A korai hepatitis C-rekurrencia gyakoribb volt marginális graft beültetése esetén. Következtetések: A májátültetésre váró betegek száma hazánkban is folyamatosan növekszik. Marginális májgraftok alkalmazása esetén a betegek morbiditása és mortalitása nem különbözik számottevően a standard donorokból származó májgraftok beültetése után tapasztalt eredményektől. Hepatitis C-vírus esetén nem javasolt marginális májgraft beültetése. A donorok felső életkori határának kiterjesztése megfontolandó.

The high-risk recipient: the Eighth Annual American Society of Transplant Surgeons' State-of-the-Art Winter Symposium

The evolution of organ transplantation has produced results so successful that many transplant programs commonly see recipients with medical risks, which in the past, would have prohibited transplantation. The Eighth Annual American Society of Transplant Surgeons State-of-the-Art Winter Symposium focused on the high-risk recipient. The assessment of risk has evolved over time, as transplantation has matured. The acceptance of risk associated with a given candidate today is often made in consideration of the relative value of the organ to other candidates, the regulatory environment, and philosophical notions of utility, equity, and fairness. In addition, transplant programs must balance outcomes, transplant volume, and the costs of organ transplantation, which are impacted by high-risk recipients. Discussion focused on various types of high-risk recipients, such as those with coronary artery disease, morbid obesity, and hepatitis C; strategies to reduce risk, such as down-staging of hepatocellular carcinoma and treatment of pulmonary hypertension; the development of alternatives to transplantation; and the degree to which risk can or should be used to define candidate selection. These approaches can modify the impact of recipient risk on transplant outcomes and permit transplantation to be applied successfully to a greater variety of patients.

Pig liver xenotransplantation as a bridge to allotransplantation: which patients might benefit?

Acute liver failure is a potentially devastating clinical syndrome that, without liver transplantation (Tx), is associated with high mortality. Rapid deterioration in clinical status and a shortage of deceased human organs prohibits liver Tx in many patients. Bridging to liver Tx has been attempted by various approaches, for example, bioartificial liver support, extracorporeal pig liver perfusion, and hepatocyte Tx, but none of these approaches has convincingly improved patient survival. The orthotopic Tx of a genetically engineered pig liver could theoretically provide successful bridging. Immediate availability, perfect metabolic condition, adequate size-match and hepatocyte mass, and freedom from potentially pathogenic microorganisms could be assured. The advantages and disadvantages of bridging by pig liver Tx compared with other approaches are discussed. The selection of patients for an initial clinical trial of pig liver Tx would be similar to that of various prior trials in patients experiencing rapid and severe deterioration in liver function. The ability to give truly informed consent for a pig bridging procedure at the time of listing for liver Tx renders the patient with acute-on-chronic liver failure or primary allograft failure is a preferable candidate for this procedure than a patient who is admitted urgently with acute (fulminant) liver failure in whom consent may not be possible. Although several barriers to successful pig organ xenoTx remain, for example, coagulation dysfunction between pig and primate, if these can be resolved by further genetic engineering of the organ-source pigs, a pig liver may prove life saving to patients dying rapidly of liver failure.

Liver retransplantation: a single-centre experience

BACKGROUND

The curative effect of liver transplantation for patients with end-stage liver disease was encouraging in recent years and the 5-year patient survival rate can reach up to 70%. However, some patients might lose grafts due to a variety of reasons, including bile duct complications, vascular complications, primary non-function, graft rejection and disease recurrence etc. Liver retransplantation (re-LT) was the only available means for those patients whose initial grafts had failed, but the inferior outcomes of re-LT compared to primary liver transplantation (PLT) continue to be a major concern. This study aimed to analyze the indications for re-LT, optimal timing of re-LT, and strategies to improve the survival rate after re-LT.

METHODS

From January 2001 to December 2006, we performed 738 liver transplants and 39 re-LT (5.3%) at our center. A retrospective analysis was performed to identify factors (indication for re-LT, preoperative score of model for end-stage liver disease (MELD), interval to re-LT from primary liver transplantation, methods of vascular and biliary reconstruction and common causes of death) associated with survival.

RESULTS

Mean follow-up period was 1.8 years (1 to 5 years). Patients with MELD score less than 20 were better than those whose MELD score was > 20 and MELD score > 30 (1-year survival, 80.0% versus 50.0% and 3/5). The perioperative survival rate of patients who received re-LT at an interval of more than 30 days and less than 8 days after the initial transplantation was higher than those who received retransplantation between 8 to 30 days following the first operation (88.5% and 74.3% versus 50.0%). The main causes of death were infection (60.0%), multiple organ failure (20.0%), vascular complications (10.0%) and biliary fistula (10.0%) in perioperative period. The overall patient survival rate of 1-month, 6-month and 1-year was 80.0%, 76.7% and 66.7%, respectively.

CONCLUSIONS

Our study suggested the favorable results after re-LT. The analysis also showed optimal timing of operation, refined surgical techniques, individualized immunosuppressive regimen and effective prophylaxis and treatment of perioperative infection play an important role in achieving a higher survival after re-LT.

The cumulative effects of cold ischemic time and older donor age on liver graft survival

INTRODUCTION

To provide greater equity among those awaiting a liver transplant, expanded geographic sharing of cadaveric organs has been proposed. A potential unintended consequence could be an increase in cold ischemia time (CIT), which may be deleterious to organs from older donors. This study sought to quantify the relative risk (RR) associated with increased CIT among older donors.

METHODS

A retrospective study examining 18,787 liver transplants within the United Network for Organ Sharing database from 2002 to 2006 was performed. Cox Regression analysis was used to model the RR of graft loss with respect to increased CIT among older donors (>60 years) relative to younger donors (<60 years), while controlling for multiple donor and recipient characteristics.

RESULTS

Relative to younger donors with minimal CIT (<6 h), a 73.0% increase in the risk of graft loss was observed for older donors with a CIT between 8 and 10 h, a 56.9% increase for CIT between 10 and 12 h, and a 92.7% increase for a CIT of 12 or more hours. Additionally, the RR of graft loss for older donors with minimal CIT (<6 h) was greater than the RR for younger donors with a CIT between 0 and 12 h.

CONCLUSION

The additive effects of increased donor age and cold ischemic time greatly impair graft survival. Quantification of the adverse nature of increasing CIT as a potential consequence of wider geographic organ sharing should be considered as allocation policies are modified to improve recipient equity in the face of an aging donor pool.