1
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Yi NJ, Kim J, Hong SY, Kang HG. Combined liver-kidney transplantation in pediatric patients. Pediatr Transplant 2024; 28:e14666. [PMID: 38059323 DOI: 10.1111/petr.14666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 09/16/2023] [Accepted: 11/21/2023] [Indexed: 12/08/2023]
Abstract
Combined liver-kidney transplantation (CLKT) is a surgical procedure that involves transplanting both liver and kidney organs. There are two types of CLKT: simultaneous liver-kidney transplantation (smLKT) and sequential LKT (sqLKT). CLKT accounts for a small percentage of liver transplantations (LTs), particularly in pediatric cases. Nevertheless, the procedure has demonstrated excellent outcomes, with high survival rates and lower rejection rates. The main indications for CLKT in pediatric patients differ somewhat from that in adults, in which end-stage kidney disease after LT is the major indication. In children, congenital diseases are common reason for performing CLKT; the examples of such diseases include autosomal recessive polycystic kidney disease with congenital hepatic fibrosis which equally affects both organs, and primary hyperoxaluria type 1, a primary liver disease leading kidney failure. The decision between smLKT or sqLKT depends on the dominant organ failure, the specific pathophysiology, and available organ sources. However, there remain significant surgical and societal challenges surrounding CLKT. Innovations in pharmacology and genetic engineering have decreased the necessity for CLKT in early-diagnosed cases without portal hypertension or kidney replacement therapy. Nonetheless, these advancements are not universally accessible. Therefore, decision-making algorithms should be crafted, considering region-specific organ allocation systems and prevailing medical environments.
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Affiliation(s)
- Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jiyoung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Su Young Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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2
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Wu G, Liu C, Ma N, Zhou X, Zhao L, Zhang Y, Zhang W, Liang T. Successful combined auxiliary partial liver and intestinal transplantation in two highly sensitized, cross-match positive patients. Clin Transplant 2023; 37:e14865. [PMID: 36416299 DOI: 10.1111/ctr.14865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/09/2022] [Accepted: 10/29/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Sensitization to human leukocyte antigen (HLA) creates an immunological barrier to intestinal transplantation (ITx). Current desensitization therapies are limited and ineffective in the most highly sensitized patients. A co-transplanted whole liver transplant can protect a kidney, heart, or intestinal allograft from antibody-mediated injury. Whether an auxiliary partial liver allograft provides effective protection for highly sensitized intestinal transplant recipients is unknown. METHODS Two patients with strong HLA donor-specific antibody at high titer against their deceased donors underwent combined auxiliary partial liver and ITx across a positive cross-match. The left lateral lobes from the combined-graft recipients and the right liver lobes from the deceased donors were transplanted as a domino procedure to other four patients. RESULTS Two combined-graft recipients have had an uneventful postoperative course without major complications at a 12- and 24-month follow-up, respectively. Intestinal graft function has been excellent with no evidence of humoral or cellular rejection. While a positive cross-match turned negative, titers of donor-specific HLA antibodies gradually declined over time after transplant. The left liver lobes procured from the combined-graft recipients were successfully transplanted into two pediatric patients (age 1.9, 2.4 years) and the right lobes from two deceased donors were successfully transplanted into two adult patients. All transplant procedures went well, without post-operative complications related to the splitting technique. CONCLUSION Our results indicate that an auxiliary liver transplant can effectively protect a co-transplanted intestinal allograft against rejection and suggest that this combined procedure may serve as a useful therapeutic adjunct for a highly sensitized intestinal transplant candidate.
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Affiliation(s)
- Guosheng Wu
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chaoxu Liu
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Nan Ma
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xile Zhou
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Long Zhao
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuntao Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wentong Zhang
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang University Cancer Center, Zhejiang University, Hangzhou, China
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3
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Florentino RM, Morita K, Haep N, Motomura T, Diaz-Aragon R, Faccioli LA, Collin de l’Hortet A, Cetin Z, Frau C, Vernetti L, Amler AK, Thomas A, Lam T, Kloke L, Takeishi K, Taylor DL, Fox IJ, Soto-Gutierrez A. Biofabrication of synthetic human liver tissue with advanced programmable functions. iScience 2022; 25:105503. [PMID: 36404924 PMCID: PMC9672940 DOI: 10.1016/j.isci.2022.105503] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/01/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Advances in cellular engineering, as well as gene, and cell therapy, may be used to produce human tissues with programmable genetically enhanced functions designed to model and/or treat specific diseases. Fabrication of synthetic human liver tissue with these programmable functions has not been described. By generating human iPSCs with target gene expression controlled by a guide RNA-directed CRISPR-Cas9 synergistic-activation-mediator, we produced synthetic human liver tissues with programmable functions. Such iPSCs were guide-RNA-treated to enhance expression of the clinically relevant CYP3A4 and UGT1A1 genes, and after hepatocyte-directed differentiation, cells demonstrated enhanced functions compared to those found in primary human hepatocytes. We then generated human liver tissue with these synthetic human iPSC-derived hepatocytes (iHeps) and other non-parenchymal cells demonstrating advanced programmable functions. Fabrication of synthetic human liver tissue with modifiable functional genetic programs may be a useful tool for drug discovery, investigating biology, and potentially creating bioengineered organs with specialized functions.
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Affiliation(s)
- Rodrigo M. Florentino
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kazutoyo Morita
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nils Haep
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Takashi Motomura
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | | | - Zeliha Cetin
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carla Frau
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lawrence Vernetti
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Drug Discovery Institute, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Tobias Lam
- Cellbricks GmbH, Gustav-Meyer-Allee 25, 13355 Berlin, Germany
| | - Lutz Kloke
- Cellbricks GmbH, Gustav-Meyer-Allee 25, 13355 Berlin, Germany
| | - Kazuki Takeishi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - D. Lansing Taylor
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Drug Discovery Institute, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ira J. Fox
- Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Surgery, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, PA, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alejandro Soto-Gutierrez
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Drug Discovery Institute, University of Pittsburgh, Pittsburgh, PA, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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4
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Vasudevan AK, Shanmugam NP, Rammohan A, Rela M. Managing recurrent portal steal in auxiliary liver transplantation for non-cirrhotic metabolic liver disease. Pediatr Transplant 2022; 26:e14389. [PMID: 36100998 DOI: 10.1111/petr.14389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/01/2022] [Accepted: 08/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND APOLT has been proposed as a treatment modality for certain types of NCMLD. While the short-term outcomes of this operation have been comparable with orthotopic LT, its long-term outcomes have sparsely been reported. We present one such case of Citrullinemia type I who underwent APOLT and developed recurrent PS. CASE REPORT A 2-year-old male child with a diagnosis of Citrullinemia type I underwent APOLT with a left lateral segment from a split deceased donor liver, and his postoperative period was unremarkable. Ammonia-lowering agents were stopped 1 week following the operation and the child was discharged home on a normal diet. Four years following APOLT, the child presented with altered sensorium and seizures. A diagnosis of PS was made. Subsequent to an embolization of the native liver's right anterior portal vein his sensorium improved and he remained clinically stable on a normal diet. Six years following the APOLT, the child again presented with features of acute encephalopathy. Imaging was suggestive of PS. A portal vein embolization of the native portal vein was performed and the child's clinical condition improved. At 6 months' follow-up, the child remains well on a normal diet. CONCLUSIONS While the early impediments in this technique may have been overcome, in the absence of any realistic clinical application gene therapy, the debate of long-term phenotypic metabolic correction for NCMLD by APOLT needs to be revisited.
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Affiliation(s)
| | | | | | - Mohamed Rela
- Dr. Rela Institute & Medical Centre, Chennai, India
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5
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Auxiliary Partial Orthotopic Liver Transplantation for Acute Liver Failure: Not Supportive Enough? Indian J Surg 2022. [DOI: 10.1007/s12262-021-02925-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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6
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Vimalesvaran S, Dhawan A. Liver transplantation for pediatric inherited metabolic liver diseases. World J Hepatol 2021; 13:1351-1366. [PMID: 34786171 PMCID: PMC8568579 DOI: 10.4254/wjh.v13.i10.1351] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/23/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) remains the gold standard treatment for end stage liver disease in the pediatric population. For liver based metabolic disorders (LBMDs), the decision for LT is predicated on a different set of paradigms. With improved outcomes post-transplantation, LT is no longer merely life saving, but has the potential to also significantly improve quality of life. This review summarizes the clinical presentation, medical treatment and indications for LT for some of the common LBMDs. We also provide a practical update on the dilemmas and controversies surrounding the indications for transplantation, surgical considerations and prognosis and long terms outcomes for pediatric LT in LBMDs. Important progress has been made in understanding these diseases in recent years and with that we outline some of the new therapies that have emerged.
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Affiliation(s)
- Sunitha Vimalesvaran
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London SE5 9RS, United Kingdom
| | - Anil Dhawan
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London SE5 9RS, United Kingdom
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7
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Menon J, Vij M, Sachan D, Rammohan A, Shanmugam N, Kaliamoorthy I, Rela M. Pediatric metabolic liver diseases: Evolving role of liver transplantation. World J Transplant 2021; 11:161-179. [PMID: 34164292 PMCID: PMC8218348 DOI: 10.5500/wjt.v11.i6.161] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/13/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023] Open
Abstract
Metabolic liver diseases (MLD) are the second most common indication for liver transplantation (LT) in children. This is based on the fact that the majority of enzymes involved in various metabolic pathways are present within the liver and LT can cure or at least control the disease manifestation. LT is also performed in metabolic disorders for end-stage liver disease, its sequelae including hepatocellular cancer. It is also performed for preventing metabolic crisis’, arresting progression of neurological dysfunction with a potential to reverse symptoms in some cases and for preventing damage to end organs like kidneys as in the case of primary hyperoxalosis and methyl malonic acidemia. Pathological findings in explant liver with patients with metabolic disease include unremarkable liver to steatosis, cholestasis, inflammation, variable amount of fibrosis, and cirrhosis. The outcome of LT in metabolic disorders is excellent except for patients with mitochondrial disorders where significant extrahepatic involvement leads to poor outcomes and hence considered a contraindication for LT. A major advantage of LT is that in the post-operative period most patients can discontinue the special formula which they were having prior to the transplant and this increases their well-being and improves growth parameters. Auxiliary partial orthotopic LT has been described for patients with noncirrhotic MLD where a segmental graft is implanted in an orthotopic position after partial resection of the native liver. The retained native liver can be the potential target for future gene therapy when it becomes a clinical reality.
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Affiliation(s)
- Jagadeesh Menon
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Mukul Vij
- Department of Pathology, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Deepti Sachan
- Department of Transfusion Medicine, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Naresh Shanmugam
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Ilankumaran Kaliamoorthy
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
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8
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Curnock R, Heaton ND, Vilca-Melendez H, Dhawan A, Hadzic N, Vara R. Liver Transplantation in Children With Propionic Acidemia: Medium-Term Outcomes. Liver Transpl 2020; 26:419-430. [PMID: 31715057 DOI: 10.1002/lt.25679] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 10/09/2019] [Indexed: 12/16/2022]
Abstract
Liver transplantation (LT) for patients with propionic acidemia (PA) is an emerging therapeutic option. We present a retrospective review of patients with PA who underwent LT at a tertiary liver center between 1995 and 2015. A total of 14 children were identified (8 males) with median age at initial presentation of 3 days (range, 0-77 days). Pretransplant median protein restriction was 1 g/kg/day (range, 0.63-1.75 g/kg/day), 71% required supportive feeding, and 86% had developmental delay. Frequent metabolic decompensations (MDs) were the main indication for LT with a median age at transplantation of 2.4 years (range, 0.8-7.1 years). Only 1 graft was from a living donor, and 13 were from deceased donors (4 auxiliary). The 2-year patient survival was 86%, and overall study and graft survival was 79% and 69%, respectively. Three patients died after LT: at 43 days (biliary peritonitis), 225 days (acute-on-chronic rejection with multiorgan failure), and 13.5 years (posttransplant lymphoproliferative disease). Plasma glycine and propionylcarnitine remained elevated but reduced after transplant. Of 11 survivors, 5 had at least 1 episode of acute cellular rejection, 2 sustained a metabolic stroke (with full recovery), and 3 developed mild cardiomyopathy after LT. All have liberalized protein intake, and 9 had no further MDs: median episodes before transplant, 4 (range, 1-30); and median episodes after transplant, 0 (range, 0-5). All survivors made some developmental progress after LT, and none worsened at a median follow-up of 5.8 years (range, 2-23 years). LT in PA significantly reduces the frequency of MDs, can liberalize protein intake and improve quality of life, and should continue to be considered in selected cases.
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Affiliation(s)
- Richard Curnock
- Paediatric Inherited Metabolic Diseases, Evelina Children's Hospital, London, United Kingdom
| | - Nigel D Heaton
- Liver Transplantation Surgery, Institute for Liver Studies, King's College Hospital, London, United Kingdom
| | - Hector Vilca-Melendez
- Liver Transplantation Surgery, Institute for Liver Studies, King's College Hospital, London, United Kingdom
| | - Anil Dhawan
- Paediatric Liver, Gastroenterology and Nutrition Centre, King's College Hospital, London, United Kingdom
| | - Nedim Hadzic
- Paediatric Liver, Gastroenterology and Nutrition Centre, King's College Hospital, London, United Kingdom
| | - Roshni Vara
- Paediatric Inherited Metabolic Diseases, Evelina Children's Hospital, London, United Kingdom
- Paediatric Liver, Gastroenterology and Nutrition Centre, King's College Hospital, London, United Kingdom
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9
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Shankar S, Valamparampil J, Rammohan A, Thiruchunapalli D, Reddy MS, Shanmugam N, Rela M. Minimally Invasive Treatment of Metabolic Decompensation Due to Portal Steal in Auxiliary Liver Transplantation. Liver Transpl 2019; 25:960-963. [PMID: 30938922 DOI: 10.1002/lt.25463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 03/18/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Sadhana Shankar
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Bharat Institute of Higher Education and Research, Chennai, India.,The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Joseph Valamparampil
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Bharat Institute of Higher Education and Research, Chennai, India.,The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Bharat Institute of Higher Education and Research, Chennai, India.,The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Deepashree Thiruchunapalli
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Bharat Institute of Higher Education and Research, Chennai, India.,The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Mettu S Reddy
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Bharat Institute of Higher Education and Research, Chennai, India.,The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Naresh Shanmugam
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Bharat Institute of Higher Education and Research, Chennai, India
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Bharat Institute of Higher Education and Research, Chennai, India.,The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India.,Institute of Liver Studies, King's College Hospital, London, United Kingdom
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10
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Kasahara M, Sakamoto S, Horikawa R, Fukuda A. Auxiliary Partial Orthotopic Liver Transplantation for Noncirrhotic Metabolic Liver Disease: Reigniting Interest in an Old but New Technique. Liver Transpl 2019; 25:12-13. [PMID: 30472792 DOI: 10.1002/lt.25388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 01/13/2023]
Affiliation(s)
- Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Reiko Horikawa
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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