Liver transplantation: an overview

Outcomes of 50 Cases of Pediatric Liver Transplantation for Intrapulmonary Shunt While Considering the Deteriorated Prognosis of Severe Intrapulmonary Shunt Patients

BACKGROUND

Intrapulmonary shunt (IPS) is recognized in 10% of chronic liver disease patients. Liver transplantation (LT) is associated with a high risk of morbidity and mortality in patients with IPS.

PATIENTS AND METHODS

Of 519 pediatric LT cases between November 2005 and October 2018, 50 patients with IPS were enrolled in this study. The patients were divided into 3 groups, according to the shunt ratio, calculated by scintigraphy: mild (15%-20%, n = 26), moderate (20%-40%, n = 19), and severe (> 40%, n = 5). We compared the patients' characteristics before LT and the outcomes of LT between these groups.

RESULTS

The major original disease resulting in LT in the mild and moderate groups was biliary atresia (73.1% and 52.6%, respectively), while that in the severe group was congenital portosystemic shunt (60%). The median ages at LT were 7.5, 6.1, and 8.3 years in the mild, moderate, and severe groups, respectively. All of the mild and moderate IPS patients lived; however, 3 patients with severe IPS (60.0%) died within 3 months. The shunt ratios of the mild and moderate IPS patients normalized within 2 years after LT, while the 2 surviving severe IPS patients showed a slight improvement. The autopsy findings of the lung in 1 deceased severe IPS patient showed medial hypertrophy and proliferation of intimal cells of the pulmonary arteries, suggesting a diagnosis of portopulmonary hypertension.

CONCLUSIONS

LT can be safely performed for mild and moderate IPS patients; however, LT for severe IPS patients should be carefully indicated because concomitant portopulmonary hypertension may be masked by IPS.

Extracorporeal Liver Perfusion: Applications of an Improved Model for Experimental Studies of the Liver

Long-term extracorporeal liver perfusion of up to 24 hours was achieved with an improved model of pig liver perfusion. Functional and structural integrity of the extracorporeal liver was maintained during the entire duration of extracorporeal perfusion. After 24 hours SGOT was 33.5 (± 6.5) U/L, bile production was 11.5 ml/h. Survival of hepatectomized pigs could be extended to 18.9 (± 3.8) hours with extracorporeal liver perfusion (p < 0.01). The improvement of liver perfusion in our particular model is primarily based on optimised perfusion of the low pressure system of the portal and hepatic vein by the application of sinusoidal pressure profiles. These pressure profiles imitate intra-abdominal conditions and achieve homogeneous perfusion of the low pressure system of the portal vein and complete drainage of hepatic venous blood.

Cirrhosis and hepatopulmonary syndrome

Hepatopulmonary syndrome (HPS) is characterized as a triad: liver disease, intrapulmonary vascular dilatation and arterial hypoxemia. HPS is reported to be present in 4% to 32% of adult patients with end-stage liver disease and in 9%-20% of children. The pathogenesis of HPS has not been clearly identified. Portal hypertension causes impairment in the perfusion of the bowel and increases the enteral translocation of Gram (-) bacteria and endotoxins. This stimulates the release of vasoactive mediators, such as tumor necrosis factor-alpha, heme oxygenase-derived carbon monoxide and nitric oxide. Genetic alterations have not been associated with this syndrome yet; however, cytokines and chemokines have been suggested to play a role. Recently, it was reported that cumulated monocytes lead to the activation of vascular endothelial growth factor-dependent signaling pathways and pulmonary angiogenesis, which plays an important role in HPS pathogenesis. At present, the most effective and only radical treatment is a liver transplant (LT). Cirrhotic patients who are on the waiting list for an LT have a shorter survival period if they develop HPS. Therefore, it is suggested that all cirrhotic cases should be followed closely for HPS and they should have priority in the waiting list.

Removing financial barriers to organ and bone marrow donation: the effect of leave and tax legislation in the U.S

Many U.S. states have passed legislation providing leave to organ and bone marrow donors and/or tax benefits for live and deceased organ and bone marrow donations and to employers of donors. We exploit cross-state variation in the timing of such legislation to analyze its impact on organ donations by living and deceased persons, on measures of the quality of the transplants, and on the number of bone marrow donations. We find that these provisions do not have a significant impact on the quantity of organs donated. The leave laws, however, do have a positive impact on bone marrow donations, and the effect increases with the size of the population of beneficiaries and with the generosity of the legislative provisions. Our results suggest that this legislation works for moderately invasive procedures such as bone marrow donation, but these incentives may be too low for organ donation, which is riskier and more burdensome.

Role of methotrexate in the treatment of chronic cholestatic disorders

This article examines the therapeutic potential of methotrexate (MTX) in the treatment of cholestatic liver disease, with specific reference to its use in primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC). In PBC patients, evidence suggests that a particular subset of patients may benefit, either biochemically or symptomatically, from the addition of MTX to their therapeutic regimen. How best to define these potential MTX responders remains unclear, but may warrant a "therapeutic trial" in some patients with more aggressive disease or in patients with refractory and disabling PBC-related symptoms. In contrast, PSC continues to be an immensely challenging disease to effectively treat, and the role of MTX for treating PSC patients remains dubious.

Liver cirrhosis and hepatic stellate cells

The cirrhosis represents the final stage of several chronic hepatic diseases and it is characterized by the presence of fibrosis and morphologic conversion from the normal hepatic architecture into structurally abnormal nodules. In the evolution of the disease there is loss of the normal vascular relationship and portal hypertension. There are also regenerative hepatocellular alterations that become more prominent with the progression of the disease. The liver transplantation continues to be the only therapeutic option in cases of disease in terminal phase. The hepatic stellate cells (HSC) are perisinusoidal cells that store vitamin A and produce growth factors, citocins, prostaglandins and other bioactive substances. They can suffer an activation process that convert them to cells with a phenotype similar to myofibroblasts. When activated, they present increased capacity of proliferation, mobility, contractility and synthesis of collagen and other components of extracellular matrix. They possess cytoplasmic processes adhered to sinusoids and can affect the sinusoidal blood flow. HSC are important in pathogenesis of fibrosis and portal hypertension.

Characteristics and prevalence of intrapulmonary shunt detected by contrast echocardiography with harmonic imaging in liver transplant candidates

We investigated the prevalence and characteristics of intrapulmonary shunt using contrast echocardiography with harmonic imaging in 130 liver transplant candidates. We found a high prevalence of intrapulmonary shunts and a significant correlation between the degree of intrapulmonary shunt and the Child-Pugh classification score.

Liver disease in the elderly

Despite several morphologic and functional changes that have been described in the aging liver, most relevant studies fail to identify a significant age-related deficit in liver function in humans. One of the important age-related changes is a decrease in regenerative capacity, which may partly explain the impaired recovery after severe viral and toxic injury in the elderly. Nevertheless, livers from older subjects are used successfully for transplantation. Substantial morbidity and mortality in the elderly is attributable to liver diseases, and the number of patients older than 65 years of age with chronic liver disease is increasing rapidly. Although there are no liver diseases specific to advanced age, the presentation, clinical course and management of liver diseases in the elderly may differ in important respects from those of younger individuals.

Life quality of patients undergoing liver transplantation

The aim of this study was to assess the life quality of a group of patients who had undergone liver transplantation using (1) a psychological test to evaluate family relations, work activity, emotional state and social relationships; (2) the quantification of hospital dependence and degree of fitness for work. Included in the study were 32 patients using the following criteria: diagnosis of hepatic cirrhosis and minimum posttransplant follow-up of 6 months. The average age of the study population was 44.8 +/- 10.5 years; there were 23 males and 9 females, with an average follow-up of 15 months. The psychological test used was the Quality of Life Scale (QLS) which consists of 21 items each scoring from 1 to 6 points. The questionnaire was completed before transplantation by all the patients, and after transplantation by 32 patients at 6 months, 20 at 12 months and 12 at 24 months. Hospital dependence was evaluated by the number of admissions and number of days per admission. Lastly, we compared fitness for work before transplantation and at 1 and 2 years after transplantation. The QLS test showed a post-transplant improvement in the four aspects assessed, particularly in the personal aspects (emotions and family) (P < 0.001). Hospital dependence following liver transplantation decreased significantly compared with the pretransplant situation (P < 0.01). Finally, the post-transplant percentage of unfitness for work decreased with time, reaching a significant differences 2 years after transplantation (P < 0.05).

Postoperative tracheal extubation after orthotopic liver transplantation

BACKGROUND

The duration of postoperative mechanical ventilation and its influence on pulmonary function in liver transplant recipients is still debated controversially.

METHODS

We retrospectively analyzed the incidence of immediate tracheal extubation, prolonged mechanical ventilation (>24 h following surgery), and episodes of reintubation in 546 patients who underwent orthotopic liver transplantation (OLT) at our institution.

RESULTS

Immediate tracheal extubation in the operating theater was achieved in 18.7% of patients, and prolonged mechanical ventilation was required by 11.2% of patients. In these, median time of extubation was 49.5 h, whereas the remaining 70.1% of patients required ventilation support for a median 5 h after OLT. As risk factors for prolonged mechanical ventilation we identified the indications of acute liver failure and retransplantation, as well as factors such as mechanical ventilation prior to OLT, massive intraoperative bleeding, and severe reperfusion injury of the liver graft. The incidence of reintubation was 8.8% in patients who were immediately extubated following surgery, and 13.1% in patients who underwent extubation within 24 h. The incidence was significantly increased in patients requiring prolonged mechanical ventilation (36.1%).

CONCLUSIONS

Immediate tracheal extubation was safe and well tolerated. The incidence of reintubation was not increased when compared to patients in whom extubation succeeded later. However, special attention should be given to transplant recipients presenting in reduced clinical condition at the time of OLT, undergoing complicated surgery, or receiving liver allografts with severe reperfusion injury because of an increased risk for prolonged mechanical ventilation.

Reduced transfusion requirements by recombinant factor VIIa in orthotopic liver transplantation: a pilot study

BACKGROUND

Large transfusion requirements, i.e., excessive blood loss, during orthotopic liver transplantation (OLT) are correlated with increased morbidity and mortality. Recombinant factor VIIa (rF-VIIa) has been shown to improve hemostasis in a variety of conditions, but has never been studied in liver transplantation.

METHODS

We performed a single-center, open-label, pilot study in adult patients undergoing OLT for cirrhosis Child-Pugh B or C, to assess efficacy and safety of rFVIIa. rFVIIa (80 microg/kg) was administered at the start of the operation, to be repeated according to predefined criteria. Packed red blood cells (RBC), fresh-frozen plasma, and platelet concentrates were administered according to predefined criteria. Perioperative transfusion requirements in study patients were compared with matched controls.

RESULTS

Six patients were enrolled in the study. All received a single dose of rFVIIa. Transfusion requirements (given as median, with range in parentheses) were lower in the study group than in matched controls: 1.5 (0-5) vs. 7 (2-18) units of allogeneic RBC (P=0.006), 0 (0-2) vs. 3.5 (0-23) units of autologous RBC (P=0.043), total amount of RBC 3 (0-5) vs. 9 (4-40) units (P=0.002). Transfused fresh-frozen plasma was 1 (0-7) vs. 8 (2-35) units (P=0.011). Blood loss was 3.5 L (1.4-5.3) vs. 9.8 L (3.7-35.0) (P=0.004). One study patient developed a hepatic artery thrombosis at day 1 postoperatively.

CONCLUSIONS

A single dose of 80 microg/kg rFVIIa significantly reduced transfusion requirements during OLT. Further study is needed to establish the optimally effective and safe dose of rFVIIa in orthotopic liver transplantation.

High prevalence of pulmonary diffusion abnormalities without interstitial changes in long-term survivors of liver transplantation

Abnormalities in lung function are frequent findings in patients with terminal stage chronic liver disease. While spirometric parameters improve early after liver transplantation, a reduction in diffusion capacity has been reported up to 15 months after transplantation. It is unknown to what extent this disturbance in gas exchange occurs among long term survivors after liver transplantation. We assessed lung function in terms of spirometry, and gas exchange as well as pulmonary morphology by high resolution computed tomography (HRCT) in 40 patients 38 months (median, range 20-147 months) after liver transplantation. The prevalence of restrictive or obstructive changes was not different from predicted values. For the whole group of long-term survivors the carbon monoxide transfer coefficient (KCO) was reduced to 71.3 + 12.0% predicted (P < 0.05). HRCT revealed interstitial changes in only 2/40 (5.0%), emphysematous bullae in 2/40 (5.0%) and pleural thickening in 9/40 (22.5%). Diffusion abnormalities are prevalent in the majority of patients after liver transplantation, whereas spirometric abnormalities are absent also in the long term. The high prevalence of impaired gas exchange and the absence of interstitial lesions imply that changes in pulmonary blood vessels are the most likely cause.

Long-term outcome of living related liver transplantation for patients with intrapulmonary shunting and strategy for complications

BACKGROUND

In 320 living related liver transplantation performed between June 1990 and September 1997, there were 21 living related liver transplantation for patients with intrapulmonary shunting, manifested by digital clubbing, cyanosis, and dyspnea. We report the long-term outcome for more 6 months and our strategy to overcome complications in these recipients.

PATIENTS

A total of 21 patients (age range 2-33 years, 19 children and 2 adults, 6 males and 15 females) were classified into three grades according to shunt ratio calculated by TcMAA pulmonary scintigraphy; 5 in mild group (shunt ratio: less than 20%), 6 in moderated group (20%-40%), and 10 in severe group (more than 40%). The original underlying liver disease was biliary atresia in all patients.

RESULTS

Spearmen's correlation coefficient rank test revealed that shunt ratio correlated significantly with PaO2 in room air (P=0.0001), PaO2 in 100% oxygen (P=0.0004), hematocrit (P=0.0276), and period of dyspnea before transplantation (P=0.023).

COMPLICATIONS

Wound infection occurred in 80, 66, and 80%, and bile leakage in 20, 0, 40% in mild, moderate, and severe group, respectively. Patients who had portal vein thrombosis, and intracranial complication were classified as severe group and the incidence was 20 and 20%, respectively. The patient actuarial one year survival was 80, 66.7, and 48%, in mild, moderate, and severe group, respectively, although there was no significant difference. All patients who survived improved hepatopulmonary syndrome and the length of period required for the resolution was significantly correlated to the preoperative shunt ratio (P=0.023).

COMMENTS

Patients with severe shunting are susceptible to wound infection and bile leak. The trend of higher incidence of portal thrombosis and intracranial complications in the severe group was closely related high hematocrit. Secure surgical technique to reduce bile leak and delayed primary wound closure to reduce wound infection were found to be effective. Anticoagulant therapy by infusing heparin through the portal vein followed by coumadin could prevent fatal portal vein thrombosis without counter risk of fatal cerebral hemorrhage.

Selective bowel decontamination of recipients for prevention against liver injury following orthotopic liver transplantation: evaluation with rat models

Gut-derived substances can activate Kupffer cells to provoke hepatic necrosis after partial hepatectomy in rats. A similar situation may occur during orthotopic liver transplantation (OLT), as congestion in the intestinal wall, caused by portal vein occlusion, is inevitable during the operation. The contribution of such substances to liver injury following OLT was investigated in rats. Oral administration of polymyxin B sulfate for 7 days significantly altered intestinal bacterial flora in rats; Enterobacteriaceae diminished and anaerobes such as Bifidobacterium , Lactobacillus, Bacteroides, and Eubacterium increased in number, compared with the control rats. Also, this treatment significantly reduced endotoxin concentration in the portal blood 30 minutes after blood reflow following portal vein occlusion. When OLT was performed in rats using the liver preserved in cold University of Wisconsin solution for 18 hours, tissue factor activity in Kupffer cells (KC) isolated from the transplanted liver 1 hour after the operation was significantly higher than in that of normal rats. This increase was significantly reduced by pretreatment of the recipients with polymyxin B sulfate. In these recipients, serum alanine aminotransferase activity, tumor necrosis factor alpha (TNF alpha) concentration, and histological extent of liver necrosis were significantly attenuated at 24 hours after the operation compared with those of control rats. We conclude that the substances derived from bacilli sensitive to polymyxin B sulfate in the gut may be a contributing factor to liver injury following OLT in rats; we feel that this probably occurs by entering of the substances into the portal blood during the ahepatic phase of the operation to activate KC. Selective bowel decontamination of recipients with polymyxin B sulfate would be a candidate for protection against early graft failure following OLT.

Pruritus in chronic hepatitis C: association with high serum bile acids, advanced pathology, and bile duct abnormalities

Pruritus is a common symptom of chronic cholestatic liver diseases but is considered rare in chronic hepatitis. We observed pruritus to be an unusually common complaint in patients with advanced chronic hepatitis C. We reviewed the records of 175 chronic hepatitis C patients to identify patients with severe, diffuse, unexplained pruritus; 12 consecutive prospective patients undergoing liver biopsy for chronic hepatitis C served as controls. Assessment included laboratory biochemical tests and assessment of liver pathology by stage, grade, hepatic activity index, and a bile duct score. Pruritus was present in nine (5.1%) patients. Serum AST, ALT, alkaline phosphatase, GGTP, total bilirubin, and ferritin were similar in pruritics and controls. Pruritics had higher serum bile acids (2028.4 +/- 223.1 mmol/liter vs 423.1 +/- 194.3, P < 0.001), higher transferrin saturation (57.5 +/- 6.8% vs 33.2 +/- 3.3, P < 0.01), and lower HCV RNA by bDNA (24.5 +/- 12.7 x 10(5) vs 172.7 +/- 54.1 x 10(5), P < 0.05). Pathology revealed cirrhosis in 6/9 (66.6%) pruritics vs 1/12 (8.3%) controls (P < 0.01). Pruritics had higher pathologic stage (3.7 +/- 0.2 vs 2.2 +/- 0.4, P < 0.01), grade (4.4 +/- 0.2 vs 2.1 +/- 0.2, P < 0.001), activity index (14.3 +/- 1.9 vs 8.6 +/- 1.9, P < 0.025), and bile duct score (7.6 +/- 0.6 vs 4.7 +/- 0.4, P < 0.01). Of eight pruritics treated with IFN-alpha2b, two had complete ALT response and one relapsed. Pruritus followed a relapsing course and only three patients partially responded despite a variety of interventions. In conclusion, pruritus is a common complication of advanced CHC. Its presence is associated with high serum bile acids, advanced pathology and bile duct abnormalities. The clinical course of pruritus is relapsing and response to therapy is inconsistent. These features suggest that pruritus in CHC has a pathogenesis that may vary from that of chronic cholestatic diseases.

Hepatopulmonary syndrome with progressive hypoxemia as an indication for liver transplantation: case reports and literature review

In the hepatopulmonary syndrome (HPS), a pulmonary vascular complication of liver disease, severe hypoxemia due to pulmonary vascular dilatation can be extremely debilitating. Determining whether patients with advanced liver disease and HPS should be considered for liver transplantation is difficult. We describe three patients with progressive and severe hypoxemia who underwent successful liver transplantation and had resolution of their arterial hypoxemia. In these patients, the progressive pulmonary deterioration accelerated the need and was considered an indication for liver transplantation rather than being considered an absolute or relative contraindication. In addition, we review the literature on 81 pediatric and adult patients with HPS who underwent liver transplantation and specifically highlight mortality, morbidity, syndrome resolution, and prognostic factors. Posttransplantation mortality (16%) was associated with the severity of hypoxemia (mean arterial oxygen tension [PaO2] in 68 survivors was 54.2 +/- 13.2 mm Hg and in 13 nonsurvivors was 44.7 +/- 7.7 mm Hg; P<0.03). Patients with a pretransplantation PaO2 of 50 mm Hg or lower had significantly more frequent mortality (30%) in comparison with those with a PaO2 greater than 50 mm Hg (4%; P<0.02). Pulmonary recommendations that address the severity of hypoxemia and candidacy for liver transplantation are discussed.

Resolution of cirrhosis-related pulmonary shunting in two children with a transplanted liver

We treated two children with hypoxemia caused by intrapulmonary shunting associated with cirrhosis secondary to extrahepatic biliary atresia. Following orthotopic liver transplantation, digital clubbing and intrapulmonary shunting were resolved, as demonstrated by normalization of room air arterial blood gases, reduction in shunt fraction, and perfusion lung scanning with 99mTc-labeled macroaggregates of albumin. We recommend that early liver transplantation be considered for young subjects with a severe hepatopulmonary syndrome.

Quantitative evaluation of histological features in "time-zero" liver allograft biopsies as predictors of rejection or graft failure: receiver-operating characteristic analysis application

Harvest injury in liver transplantation adversely affects both allograft function and subsequent acute rejection. The aim of this study was to use receiver-operating characteristic (ROC) analysis to determine the strength of histological features in time-zero liver allograft biopsies as predictors of subsequent acute rejection episodes or primary allograft failure. The study population consisted of 38 patients who underwent orthotopic liver transplantation between 1989 and 1992. Time-zero biopsies and all subsequent biopsies were retrospectively reviewed. The following time-zero histological features were graded: hepatocyte swelling, centrilobular necrosis, centrilobular hemorrhage, neutrophilic infiltrate, cholestasis, and number of apoptotic cells. Eleven transplants showed primary graft nonfunction; 15 experienced one or more episodes of moderate to severe acute rejection; 4 experienced only mild rejection episodes; and 8 showed no rejection over long follow-up periods. ROC analysis showed that the presence of hepatocyte swelling in the time-zero biopsy is a significant predictor of subsequent moderate to severe rejection. Apoptotic cells, centrilobular hemorrhage, hepatocyte swelling, and centrilobular necrosis were all significant predictors of primary graft failure. No histological feature was predictive of subsequent mild rejection. In conclusion, certain histological features serve as markers for adverse outcomes in the liver transplant population. Patients who show apoptotic cells, centrilobular hemorrhage and necrosis, or hepatocyte swelling in their time-zero biopsy should be monitored carefully for signs of graft failure and rejection.

Artificial liver support: the pipe dream of today should be the reality of the near future

The title of this article is taken from an interesting Letter to the Editor entitled 'Artificial liver support-Pipe dream or reality' by Cattral and Levy of the Toronto Hospital, Canada, published in the New England Journal of Medicine 1994, in which the authors persuasively propose possibilities of artificial liver support and suggest its advantages. We find that their suggestions agree with the core of our thoughts on this subject. The present article deals with the concept of implanting livers taken from humans, primates or non-primates (e.g. hog) into patients in parallel with their own metabolically fatigued or cirrhotic livers, with minimal surgical manipulation, as a prelude to total artificial liver support via a liver dialysis device. While the possibility exists that the host liver may recover function, a donor liver, whether implanted into the patient's abdomen or connected in vitro to the patient's circulatory system extracorporeally, may provide the host liver respite and a period for recovery and proliferation, if possible. Once recovery is under way, the donor liver may be removed and the patient will not experience the usual risks of rejection and the necessary side-effects of immunosuppression associated with conventional full hepatectomy and donor transplantation. The viability of a liver implantation model in rats is correlated in this article with hepatic acute phase response.

Pulmonary complications of liver transplantation

The preoperative pulmonary evaluation of organ transplant candidates involves the diagnosis of unexplained pulmonary infiltrates or symptoms, interpretation of pulmonary function abnormalities, and an assessment of surgical risk. Pretransplant pulmonary considerations in patients with end-stage hepatic diseases relate primarily to hypoxemia from poorly understood intrapulmonary vascular dilatations, mechanical dysfunction, and states of increased extravascular lung water. Except in severe cases, however, these generally do not prohibit liver transplantation, and even are likely to improve after transplant surgery. Early postoperative complications may be categorized as those expected from extensive intra-abdominal surgery that requires significant volume resuscitation, which typically are managed in the usual manner for those clinical situations. As immunosuppression begins to have an effect, the LTx recipient becomes susceptible to the same opportunistic infectious organisms (with their frequent pulmonary involvement) that cause significant morbidity and mortality in recipients of other solid organ transplants. Because many of the immunosuppressive agents also are the same, noninfectious side effects such as pulmonary edema and malignancy also are similar. As with all immunocompromised patients, prophylaxis, when possible, persistent infection surveillance, and an aggressive diagnostic and therapeutic approach help decrease the impact of pulmonary dysfunction in LTx recipients.

The hepatopulmonary syndrome. Effect of liver transplantation

The role of liver transplantation as a treatment for the hepatopulmonary syndrome (HPS) has had an evolving and controversial history. Although early experience was disappointing, more recent experience has documented resolution of HPS-associated hypoxemia after liver transplantation. This article reviews the history of liver transplantation for patients with the hepatopulmonary syndrome. In addition, we discuss the clinical features that have been considered to predict successful reversibility and the time frame over which reversal occurs. Despite this evolution of thought, many basic questions still remain.

The importance of late infections for the long-term outcome after liver transplantation

We investigated the late infections of 400 consecutive liver transplantations performed in 368 patients. After a mean follow-up of 45 months, a total of 180 late infections occurred in 110 liver recipients. Frequent agents were CMV, enterococcus, candida and staphylococcus. Pneumonia was the most dangerous late infection with a high mortality rate. Late infections were responsible for ten deaths that were all caused by atypical pneumonia. The majority of late infections appeared during the first year after liver transplantation. Thereafter, the risk of infection declined significantly.

The pruritus of cholestasis

The pruritus of cholestasis is a difficult clinical problem to manage. The pathogenesis of this symptom is unknown. All conventional therapies have been unsuccessful in isolating a particular group of substances that could be implicated as direct or indirect causative agents. It should be emphasized that nonspecific treatment modalities that lower the plasma concentrations of a variety of substances (such as cholestyramine, colestipol, charcoal hemoperfusion, plasmapheresis, partial external diversion of bile, and drugs that induce hepatic enzymes), can potentially ameliorate the pruritus of cholestasis by lowering the circulating levels of an undefined pruritogen or a factor responsible for inducing the primary mechanism of the pruritus. The encouraging results reported by the use of antibiotic therapy for this condition merits investigation. Increased opioidergic neurotransmission is part of the syndrome of cholestasis and it contributes, at least in part, to the pruritus associated with it. Opiate antagonists seem to be an effective alternative therapy for some patients. Recent preliminary reports suggest that other neurotransmitter systems, eg, serotoninergic, may be involved in the pruritus of cholestasis. The need for quantitation of scratching activity cannot be over emphasized. The use of quantitative methodology offers the opportunity to facilitate the study of scratching behavior that is a biological phenomenon secondary to liver disease.

Diagnostic utility of contrast echocardiography and lung perfusion scan in patients with hepatopulmonary syndrome

BACKGROUND & AIMS

Two modalities, contrast echocardiography and lung perfusion scan, are used to identify intrapulmonary vascular dilatation and diagnose hepatopulmonary syndrome (HPS), but a comparison of these two procedures has not been performed. The aim of this study was to compare the use of these diagnostic modalities in detecting intrapulmonary vascular dilatation and diagnosing HPS.

METHODS

Forty consecutive outpatients with biopsy-proven cirrhosis had contrast echocardiography, a lung perfusion scan, and arterial blood gases analyzed.

RESULTS

Fifteen of 40 cirrhotics (38%) had positive contrast echocardiogram results. Seven patients with positive echocardiogram results had gas exchange abnormalities and could be considered to have HPS (7 of 40 [17.5%]). Three of these patients were hypoxemic and had no concurrent cardiopulmonary disease, and each had positive contrast echocardiogram and lung perfusion scan results and were readily diagnosed as having HPS. The other 4 patients (3 hypoxemic and 1 normoxemic with an elevated alveolar-arterial gradient) had coexisting intrinsic lung disease and/or chest radiograph abnormalities complicating the diagnosis of HPS, and each had positive echocardiogram and negative lung scan results. The remaining 8 patients with positive echocardiogram results had normal lung scan and normal gas exchange results. No patient had positive lung scan and negative contrast echocardiogram results.

CONCLUSIONS

Contrast echocardiography is the most useful screening test for intrapulmonary vasodilatation and may be positive more frequently than lung perfusion scans in patients with HPS.

Possible cause of primary graft non-function after orthotopic liver transplantation: a hypothesis with rat models

The cause of primary graft non-function after orthotopic liver transplantation (OLTX) is uncertain, but its clinical features are similar to fulminant hepatic failure with coagulopathy. In preserved livers, endothelial cell damage in the hepatic sinusoids is characteristic, indicating that fibrin deposition in the hepatic sinusoids, which can cause massive hepatic necrosis, might occur in the liver after OLTX. When rat liver was preserved in University of Wisconsin solution at 1 degree C, detachment of endothelial linings into sinusoidal lumens developed with fat-storing cell damage after 18 h. In this liver, hepatic macrophages were activated after reperfusion. Tissue factor activity in hepatic macrophages isolated from livers after OLTX was significantly increased compared to the control liver and this increase was enhanced by addition of endotoxin. In the preserved and transplanted livers, thrombomodulin expression in endothelial cells disappeared and fibrin deposition was seen in the hepatic sinusoids. Intravenous infusion therapy with antithrombin III attenuated liver injury 24 h after OLTX following preservation for 18 h. These results suggest that intravascular coagulation in the hepatic sinusoids associated with liver injury occurs in the liver after OLTX following cold preservation. This coagulopathy may be caused by sinusoidal endothelial cell damage due to regulatory imbalance in coagulation as a result of increased tissue factor activity in hepatic macrophages and decreased thrombomodulin activity in sinusoidal endothelial cells. Fat-storing cell damage may also contribute to the endothelial cell damage. A hypothesis regarding the cause of primary graft non-function after OLTX is proposed.

Aprotinin reduces the need for blood products during liver transplantation

BACKGROUND

Bleeding complications and blood product consumption have been a major concern during liver transplantation. Prevention of plasminogen activation and fibrinolysis by aprotinin administration has been shown to reduce perioperative bleeding during operations associated with high blood-product consumption.

PATIENTS AND METHODS

Use of blood-products (packed red cells, frozen plasma, platelets, and cryoprecipitate) was analyzed both during the three stages of orthotopic liver transplantation and during total hospitalization of the 26 patients transplanted without aprotinin and the subsequent 40 patients with aprotinin. A similar analysis was performed for 15 patients immediately before and after the introduction of aprotinin to eliminate the "learning curve" effect for liver transplantation. The effect of epsilon-amino-caproic acid was analyzed as 13 patients received neither epsilon-aminocaproic acid nor aprotinin and 13 patients received epsilon-aminocaproic acid but not aprotinin.

RESULTS

There was a significant reduction in total hospital use of cryoprecipitate, frozen plasma, platelets, and red cells in the aprotinin-treated patients. This reduction was seen during the anhepatic and reperfusion stages of liver transplantation. There was no difference in blood product consumption between the groups who were or were not treated with epsilon-aminocaproic acid.

CONCLUSION

Aprotinin significantly reduces the need for red cell, frozen plasma, platelet, and cryoprecipitate transfusion use during orthotopic liver transplantation, and appears to be more efficacious than epsilon-aminocaproic acid.

Failure of hepatopulmonary syndrome to resolve after liver transplantation and successful treatment with embolotherapy

The hepatopulmonary syndrome is an uncommon accompaniment of chronic liver disease. The outcome of this disorder after orthotopic liver transplantation is variable. We describe a patient with the hepatopulmonary syndrome who underwent orthotopic liver transplantation for autoimmune hepatitis. Her platypnea and orthodeoxia failed to improve postoperatively. Pulmonary angiography showed large pulmonary arteriovenous shunts that were successfully treated with coil embolotherapy.

Survival after a first episode of spontaneous bacterial peritonitis. Prognosis of potential candidates for orthotopic liver transplantation

To determine the potential role of orthotopic liver transplantation (OLT) in cirrhotic patients surviving a first episode of spontaneous bacterial peritonitis (SBP), medical records of 79 patients presenting with a first episode of SBP were reviewed. Of these patients, 37 were selected as potential candidates for OLT using the following criteria: absence of hepatocellular carcinoma; no severe organ failure other than the liver; age < or = 66 years; and survival after SBP > 60 days. Survival time was calculated from the day of SBP diagnosis. Prognostic value of clinical, biological and bacteriological data recorded at the time of SBP was determined using univariate and multivariate analysis (Cox's regression model). Survival rate of the potential candidates for OLT at 3 months, 1 year and 2 years was 94, 46 and 30% respectively. Serum creatinine value (P = 0.001) and Pugh score (P = 0.005) were independently correlated with death. The 1 year survival rate was 80% for the 11 patients with a Pugh score < 10, and 26% for the 26 patients with a Pugh score > or = 10. Our results suggest that after SBP, OLT should be considered in patients with severe liver disease. Survival of patients with a moderate liver disease (i.e. Pugh score < 10) might be relatively high.

Daily determination of individual serum bile acids allows early detection of hepatic allograft dysfunction

Acute graft rejection is still a major cause of morbidity after orthotopic liver transplantation, and its diagnosis necessitates an invasive liver biopsy. Our aim has been to determine whether changes in individual serum bile acid levels after engraftment are sensitive, specific and reliable indicators of graft function and whether these changes can antedate other biochemical indicators of hepatic allograft rejection. Individual bile acids in 200 serum samples taken serially from eight adult liver transplant patients were measured. Patients with biopsy-confirmed graft dysfunction due to rejection or nonrejection causes (n = 6 episodes) had significantly higher serum concentrations of glycocholate plus glycochenodeoxycholate and taurocholate/taurochenodeoxycholate ratios than did noncomplicated grafts (n = 3). These changes antedated any other conventional biochemical parameters by at least 48 hr and were 100% sensitive and specific. None of the conventional liver function tests could match this. Acute rejection episodes (n = 3) were then compared with nonrejection causes of graft dysfunction (n = 3). In acute rejection we noted a significant increase in the concentration of glycodeoxycholate plus deoxycholate and a significant decrease in the cholate/chenodeoxycholate ratio compared with that in nonrejection graft malfunction. Both of these changes antedated any other biochemical parameters by 24 hr. In conclusion, individual serum bile acid assays, after orthotopic liver transplantation, can detect graft dysfunction resulting from any cause at an earlier time than routine biochemical tests, and they are sensitive, specific and reliable for early detection of graft dysfunction. In addition, acute rejection can be distinguished from other causes of graft dysfunction.

Liver transplantation for alcoholic liver disease: survival of patients transplanted with alcoholic hepatitis plus cirrhosis as compared with those with cirrhosis alone

From January 1986 through December 1991, a total of 221 patients with alcoholic liver disease received liver transplantation. In 147 of these cases, complete pretransplant histopathologic, demographic, and laboratory data (minimum of CBC, AST, ALT, total bilirubin, albumin, and prothrombin time) were available for review. Forty-five (30%) of the 147 recipients had alcoholic hepatitis plus cirrhosis (AH), whereas 70% had cirrhosis (CIRR) alone. Age and sex were similar in the subgroups, but the patients with CIRR had a greater AST/ALT ratio, longer protime, and lower platelet count (all p < 0.01). Coexistent hepatitis B (4.7%) or hepatitis C (4.1%) was similar in both groups. Current survival is 80% for patients with AH and 84% for those with CIRR (NS). Overall, survivors were younger (43.4 +/- 1.7 years) than nonsurvivors (53.6 +/- 3.2) (p < 0.01), an age influence that was significant in the CIRR group (p < 0.01) but not in the AH group. Inexplicably, the AST/ALT ratio was greater in AH survivors (1.5 +/- 0.2) than it was in nonsurvivors (0.4 +/- 0.1) (p < 0.01). In patients with CIRR, the platelet count was greater in survivors (252 +/- 29 vs. 86 +/- 11 x 10(9) cells/liter). The data support the clinical impression that patients with chronic decompensated cirrhosis referred for liver transplantation had more severe complications of their liver disease than did those with AH. Survival in both subgroups was similar, but overall the survivors are nearly a decade younger than the nonsurvivors.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of hypothermic storage in liver allograft preservation solutions on vasoactivity and prostacyclin synthesis by the rabbit aorta, in vitro

Primary graft dysfunction following orthoptic liver transplantation has been ascribed to thrombotic and ischemic complications in a high proportion of cases. It has been suggested that hypothermic storage of livers in preservation solutions elicits damage to the vascular endothelium. Since the endothelium controls vasoactivity and hemostasis via release of endothelium derived relaxing factor (EDRF) and prostacyclin (PGI2), storage injury to the endothelium may predispose the allograft to thrombosis, ischemia and impaired perfusion. In order to test this, the effect of long-term hypothermic storage in modified University of Wisconsin solution (UW), kidney perfusion solution (KPS) and minimum essential medium (MEM) on phenylephrine (PE)-stimulated contraction and acetylcholine (ACh)-stimulated relaxation, as well as PGI2 release by rabbit aortic rings was investigated. Following cold storage for 24, 48 and 72 h, PE and ACh dose response curves were unaffected by storage in MEM, UW or KPS. Following hypothermic storage for 24 h and 48 h, PGI2 release (stimulated with PE, ACh, arachidonate, fluoride, calcium ionophore and phorbol ester) was not significantly altered from zero time responses. These results demonstrate that hypothermic storage of rabbit aortic rings in both UW and KPS do not influence two key endothelial functions (the release of EDRF or PGI2) which in turn indicates that endothelial damage associated with reperfusion following hypothermic storage is not causally related to alterations in EDRF and PGI2 release.

Prophylactic versus emergency sclerotherapy of large esophageal varices prior to liver transplantation

From January 1985 through July 1987, adult patients accepted for liver transplantation with large esophageal varices were enrolled in a study evaluating the use of prophylactic vs emergency sclerotherapy. Six hundred forty-eight subjects received prophylactic sclerotherapy, and 172 received emergent sclerotherapy. Esophageal stricture formation was increased 12.9-fold (P < 0.001), esophageal perforation 6.4-fold (P < 0.005), and postsclerotherapy bleeding esophageal ulcers 3.7-fold (P < 0.001) in those receiving emergency sclerotherapy as opposed to prophylactic sclerotherapy. These differences were even greater if the number of sclerotherapy sessions rather than the number of patients was used as the denominator for the comparisons. In total, 19.6% of emergency sclerotherapy cases were associated with an untoward outcome of sclerotherapy; only 1.9% of cases receiving prophylactic sclerotherapy experienced an untoward outcome (P < 0.001). These data demonstrate that emergency sclerotherapy is associated with a greater prevalence of complications and support earlier studies that show that sclerotherapy prevents variceal bleeding over the short term. The data also suggest that when applied to patients with large varices awaiting orthotopic liver transplantation, it enhances the chance of a patient surviving to be transplanted by preventing a variceal bleed and the spiral of liver failure and death that frequently follows an episode of acute variceal bleeding.

Risk factors for cytomegalovirus and severe bacterial infections following liver transplantation: a prospective multivariate time-dependent analysis

Risk factors for cytomegalovirus and severe bacterial infections were studied prospectively by univariate, multivariate and time-dependent Cox model analysis in 79 consecutive liver transplant patients treated with selective bowel decontamination. Cytomegalovirus infection occurred in 39 patients (49%) and was symptomatic in 22 patients. Twenty-six patients (33%) developed at least one of 43 documented severe bacterial infections. In a multivariate analysis of risk factors for all cytomegalovirus infections, the cytomegalovirus seronegative recipient-cytomegalovirus seropositive donor group was the highest risk group (P < 0.001). Using the same analysis for risk factors for symptomatic cytomegalovirus infections, a prolonged prothrombin time (P < 0.005), a diagnosis of acute fulminant hepatitis as the underlying liver disease (P < 0.01) and a cytomegalovirus seronegative patient receiving a liver from a seropositive donor (P < 0.001) were significant. The treatment with OKT3 therapy (P < 0.008) and hepatic artery thrombosis (P < 0.02) were found to be significant risk factors in a time-dependent univariate analysis but were not independent risk factors when multivariate analysis was utilized. Significant risk factors for major bacterial infections (P < 0.03) using univariate analysis included a prolonged anesthesia, anhepatic and surgical times, as well as the transfusion of large amounts of fresh frozen plasma or autologous blood. In a multivariate analysis, only the transfusion of large amounts of fresh frozen plasma (P < 0.04) was a significant independent risk factor. Cytomegalovirus infection was a risk factor for the development of severe bacterial infections (P < 0.03) in a multivariate time-dependent analysis.