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Özbilgin M, Egeli T, Ağalar C, Özkardeşler S, Oğuz VA, Akarsu M, Sağol Ö, Ünek T, Karademir S, Astarcıoğlu I. Complications and Long-Term Outcomes in Adult Patients Undergoing Living Donor Liver Transplantation Because of Fulminant Hepatitis. Transplant Proc 2023:S0041-1345(23)00168-9. [PMID: 37137763 DOI: 10.1016/j.transproceed.2023.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/05/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND The present study investigates the complications that may occur during long-term follow-up in patients aged 18 years and older undergoing living donor liver transplantation (LDLT) in our clinic because of fulminant hepatitis. METHODS The study included patients aged 18 years and older with a minimum survival of 6 months who underwent an LDLT between June 2000 and June 2017. The demographic data of the patients were evaluated in terms of late-term complications. RESULTS Of the 240 patients who met the study criteria, 8 (3.3%) underwent LDLT for fulminant hepatitis. The indication for transplantation in patients with fulminant hepatitis was cryptogenic liver hepatitis in 4 patients, acute hepatitis B infection in 2 patients, hemochromatosis in 1 patient, and toxic hepatitis in 1 patient. Of the 240 patients, 65 (27%) undergoing LDLT underwent a liver biopsy for suspected rejection because of an elevation in liver function test results during follow-up. Histopathologic scoring was carried out according to the Banff scoring system. A diagnosis of late acute rejection was made in only 1 of the 8 patients (12.5%) who underwent LDLT for fulminant hepatitis. CONCLUSION Patients with fulminant hepatitis must be prepared for an LDLT, if available, while waiting for a cadaveric donor. The results of the present study suggest that LDLTs in patients with fulminant hepatitis are safe, and the outcomes are acceptable in terms of survival and complications.
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Affiliation(s)
- Mücahit Özbilgin
- Department of General Surgery, Dokuz Eylül University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit, Izmir, Turkey.
| | - Tufan Egeli
- Department of General Surgery, Dokuz Eylül University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit, Izmir, Turkey
| | - Cihan Ağalar
- Department of General Surgery, Dokuz Eylül University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit, Izmir, Turkey
| | - Sevda Özkardeşler
- Department of Anesthesiology and Reanimation, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Vildan Avkan Oğuz
- Department of Infectious Diseases, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Mesut Akarsu
- Department of Gastroenterology, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Özgül Sağol
- Department of Pathology, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Tarkan Ünek
- Department of General Surgery, Dokuz Eylül University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit, Izmir, Turkey
| | - Sedat Karademir
- Department of General Surgery, Güven Hospital, Ankara, Turkey
| | - Ibrahim Astarcıoğlu
- Department of General Surgery, Memorial Bahçelievler Hospital, Istanbul, Turkey
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Abstract
Sickle hepatopathy is an umbrella term describing various pattern of liver injury seen in patients with sickle cell disease. The disease is not uncommon in India; in terms of prevalence, India is second only to Sub-Saharan Africa where sickle cell disease is most prevalent. Hepatic involvement in sickle cell disease is not uncommon. Liver disease may result from viral hepatitis and iron overload due to multiple transfusions of blood products or due to disease activity causing varying changes in vasculature. The clinical spectrum of disease ranges from ischemic injury due to sickling of red blood cells in hepatic sinusoids, pigment gall stones, and acute/chronic sequestration syndromes. The sequestration syndromes are usually episodic and self-limiting requiring conservative management such as antibiotics and intravenous fluids or packed red cell transfusions. However, rarely these episodes may present with coagulopathy and encephalopathy like acute liver failure, which are life-threatening, requiring exchange transfusions or even liver transplantation. However, evidence for their benefits, optimal indications, and threshold to start exchange transfusion is limited. Similarly, there is paucity of the literature regarding the end point of exchange transfusion in this scenario. Liver transplantation may also be beneficial in end-stage liver disease. Hydroxyurea, the antitumor agent, which is popularly used to prevent life-threatening complications such as acute chest syndrome or stroke in these patients, has been used only sparingly in hepatic sequestrations. The purpose of this review is to provide insights into epidemiology of sickle cell disease in India and pathogenesis and classification of hepatobiliary involvement in sickle cell disease. Finally, various management options including exchange transfusion, liver transplantation, and hydroxyurea in hepatic sequestration syndromes will be discussed in brief.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ACLF, Acute on chronic liver failure
- ALF, Acute liver failure
- ALT, Alanine transaminase
- AST, Aspartate transaminase
- FFP, Fresh frozen plasma
- GIT, Gastrointestinal tract
- HAV, Hepatitis A virus
- HBV, Hepatitis B virus
- HCV, Hepatitis C virus
- HEV, Hepatitis E virus
- HIC, Hepatic iron content
- HbS, Sickle hemoglobin
- HbSS, Sickle cell disease homozygous
- INR, International normalized ratio
- PT, Prothrombin time
- RUQ, Right upper quadrant
- SC, Scheduled caste
- SCD, Sickle cell disease
- SCIC, Sickle cell intrahepatic cholestasis
- ST, Scheduled tribe
- TJLB, Transjugular liver biopsy
- UDCA, Ursodeoxycholic acid
- cholelithiasis
- intrahepatic cholestasis
- sickle cell hepatopathy
- sickle cholangiopathy
- sickle hepatic crisis
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Affiliation(s)
| | - Anil C. Anand
- Address for correspondence. Anil C Anand, Professor and Head, Department of Gastroenterology & Hepatology, Kalinga Institute of Medical Sciences, Bhubneshwar, India.
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3
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Ballas SK. Comorbidities in aging patients with sickle cell disease. Clin Hemorheol Microcirc 2018; 68:129-145. [DOI: 10.3233/ch-189003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Samir K. Ballas
- Cardeza Foundation for Hematologic Research, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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Szymczak M, Kaliciński P, Kowalewski G, Broniszczak D, Markiewicz-Kijewska M, Ismail H, Stefanowicz M, Kowalski A, Teisseyre J, Jankowska I, Patkowski W. Acute liver failure in children-Is living donor liver transplantation justified? PLoS One 2018; 13:e0193327. [PMID: 29474400 PMCID: PMC5825073 DOI: 10.1371/journal.pone.0193327] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/08/2018] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Living donor liver transplantation (LDLT) in patients with acute liver failure (ALF) has become an acceptable alternative to transplantation from deceased donors (DDLT). The aim of this study was to analyze outcomes of LDLT in pediatric patients with ALF based on our center's experience. MATERIAL AND METHODS We enrolled 63 children (at our institution) with ALF who underwent liver transplantation between 1997 and 2016. Among them 24 (38%) underwent a LDLT and 39 (62%) received a DDLT. Retrospectively analyzed patient clinical data included: time lapse between qualification for transplantation and transplant surgery, graft characteristics, postoperative complications, long-term results post-transplantation, and living donor morbidity. Overall, we have made a comparison of clinical results between LDLT and DDLT groups. RESULTS Follow-up periods ranged from 12 to 182 months (median 109 months) for LDLT patients and 12 to 183 months (median 72 months) for DDLT patients. The median waiting time for a transplant was shorter in LDLT group than in DDLT group. There was not a single case of primary non-function (PNF) in the LDLT group and 20 out of 24 patients (83.3%) had good early graft function; 3 patients (12.5%) in the LDLT group died within 2 months of transplantation but there was no late mortality. In comparison, 4 out of 39 patients (10.2%) had PNF in DDLT group while 20 patients (51.2%) had good early graft function; 8 patients (20.5%) died early within 2 months and 2 patients (5.1%) died late after transplantation. The LDLT group had a shorter cold ischemia time (CIT) of 4 hours in comparison to 9.2 hours in the DDLT group (p<0.0001). CONCLUSIONS LDLT is a lifesaving procedure for pediatric patients with ALF. Our experience showed that it may be performed with very good results, and with very low morbidity and no mortality among living donors when performed by experienced teams following strict procedures.
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Affiliation(s)
- Marek Szymczak
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Piotr Kaliciński
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Grzegorz Kowalewski
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Dorota Broniszczak
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | | | - Hor Ismail
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Marek Stefanowicz
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Adam Kowalski
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Joanna Teisseyre
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Irena Jankowska
- Department of Gastroenterology, Hepatology and Immunology, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Waldemar Patkowski
- Department of General, Transplant and Liver Surgery, Warsaw Medical University, Warsaw, Poland
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5
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Uchida H, Sakamoto S, Fukuda A, Sasaki K, Shigeta T, Nosaka S, Kubota M, Nakazawa A, Nakagawa S, Kasahara M. Sequential analysis of variable markers for predicting outcomes in pediatric patients with acute liver failure. Hepatol Res 2017; 47:1241-1251. [PMID: 28032939 DOI: 10.1111/hepr.12859] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 12/01/2016] [Accepted: 12/26/2016] [Indexed: 02/08/2023]
Abstract
AIM Our aim was to analyze serial changes in the predictive variables and a scoring system retrospectively adapted to evaluate outcomes in pediatric patients with acute liver failure (ALF). METHODS We retrospectively collected data on 65 patients with ALF. The 65 patients were divided into two groups according to the need for liver transplantation (LT) as follows: LT group (n = 54) and non-LT group (n = 11). The early determination scoring system of the indications for LT proposed by the Intractable Hepato-Biliary Diseases Study Group of Japan (JIHBDSG) was used in our study. The area under the receiver operating characteristic curve (AUROC) was calculated for the JIHBDSG score between the LT group and non-LT group at the time of diagnosis (day 0) and day 3, and day 5 after the diagnosis. RESULTS A JIHBDSG score of >3 at day 5 was found to identify the patients requiring LT with 83.7% sensitivity, 81.8% specificity, and 83.3% diagnostic accuracy. Based on a comparison of AUROC values, the JIHBDSG score on day 5 (AUROC 0.91) was higher than that on day 0 (AUROC 0.75) and day 3 (AUROC 0.84). CONCLUSION We showed that a serial analysis of the JIHBDSG score might be useful for predicting outcomes of ALF in pediatric patients who fulfilled the criteria of LT indication in our center. However, further studies are needed to validate our results.
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Affiliation(s)
- Hajime Uchida
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kengo Sasaki
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takanobu Shigeta
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Shunsuke Nosaka
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Masaya Kubota
- Division of Neurology, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Nakazawa
- Division of Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Division of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Nutan F, Gollahalli NS. Coexisting Sickle Cell Anemia and Sarcoidosis: A Management Conundrum! Clin Med Insights Blood Disord 2017; 10:1179545X16685314. [PMID: 28579850 PMCID: PMC5428084 DOI: 10.1177/1179545x16685314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 11/17/2016] [Indexed: 12/02/2022]
Abstract
Sickle cell disease and Sarcoidosis are conditions that are more common in the African American population. In this report we share an unfortunate patient who had hepatic sarcoidosis but could not receive steroids since that precipitated acute liver failure. We have discussed potential therapy options but we need more options that improve mortality.
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Affiliation(s)
- Fnu Nutan
- Virginia Commonwealth University (VCU), Richmond, VA, USA
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Malik A, Merchant C, Rao M, Fiore RP. Rare but Lethal Hepatopathy-Sickle Cell Intrahepatic Cholestasis and Management Strategies. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:840-3. [PMID: 26613743 PMCID: PMC4671447 DOI: 10.12659/ajcr.895218] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patient: Male, 31 Final Diagnosis: Sickle cell intrahepatic cholestasis Symptoms: Abdominal pain • fever • jaundice Medication: — Clinical Procedure: Exchange transfusion Specialty: Hematology
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Affiliation(s)
- Aamir Malik
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ, USA
| | - Chandni Merchant
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ, USA
| | - Mana Rao
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ, USA
| | - Rosemary P Fiore
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ, USA
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8
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Weiss A, Tapia V, Parina R, Berumen J, Hemming A, Mekeel K. Living Donor Hepatectomy: Is it Safe? Am Surg 2015. [DOI: 10.1177/000313481508101038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Living donor hepatectomy (LDH) is high risk to a healthy donor and remains controversial. Living donor nephrectomy (LDN), conversely, is a common practice. The objective is to examine the outcomes of LDH and compare this risk profile to LDN. The Nationwide Inpatient Sample was queried for hepatectomies and nephrectomies from 1998 to 2011. LDH or LDN were identified by donor ICD-9 codes. Outcomes included in-hospital mortality and complications. Bivariate analysis compared nondonor hepatectomy or nondonor nephrectomy (NDN). Multivariate analyses adjusted for baseline organ disease, malignancy, or benign lesions. There were 430 LDH and 9211 nondonor hepatectomy. In-hospital mortality was 0 and 6 per cent, respectively ( P < 0.001); complications 4 and 33 per cent ( P < 0.001). LDH had fewer complications [odds ratio (OR) 0.15 (0.08–0.26)]. There were 15,631 LDN and 117,966 NDN. Mortality rates were 0.8 per cent LDN and 1.8 per cent NDN ( P < 0.001). Complications were 1 and 21 per cent ( P < 0.001). LDN had fewer complications [OR 0.06 (0.05–0.08)] and better survival [OR 0.32 (0.18–0.58)]. Complication rates were higher in LDH than LDN (4% vs 1%, P < 0.001), but survival was similar (0% vs 0.8% mortality, P = 0.06). In conclusion, morbidity and mortality rates of LDH are significantly lower than hepatectomy for other disease. This study suggests that the risk profile of LDH is comparable with the widely accepted LDN.
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Affiliation(s)
- Anna Weiss
- From the Transplant Division, Department of Surgery, University of California San Diego, San Diego, California
| | - Viridiana Tapia
- From the Transplant Division, Department of Surgery, University of California San Diego, San Diego, California
| | - Ralitza Parina
- From the Transplant Division, Department of Surgery, University of California San Diego, San Diego, California
| | - Jennifer Berumen
- From the Transplant Division, Department of Surgery, University of California San Diego, San Diego, California
| | - Alan Hemming
- From the Transplant Division, Department of Surgery, University of California San Diego, San Diego, California
| | - Kristin Mekeel
- From the Transplant Division, Department of Surgery, University of California San Diego, San Diego, California
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9
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Shalimar, Acharya SK. Management in acute liver failure. J Clin Exp Hepatol 2015; 5:S104-15. [PMID: 26041950 PMCID: PMC4442864 DOI: 10.1016/j.jceh.2014.11.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 11/26/2014] [Indexed: 12/12/2022] Open
Abstract
Acute liver failure (ALF) is a rare, potentially fatal complication of severe hepatic illness resulting from various causes. In a clinical setting, severe hepatic injury is usually recognised by the appearance of jaundice, encephalopathy and coagulopathy. The central and most important clinical event in ALF is occurrence of hepatic encephalopathy (HE) and cerebral edema which is responsible for most of the fatalities in this serious clinical syndrome. The pathogenesis of encephalopathy and cerebral edema in ALF is unique and multifactorial. Ammonia plays a central role in the pathogenesis. The role of newer ammonia lowering agents is still evolving. Liver transplant is the only effective therapy that has been identified to be of promise in those with poor prognostic factors, whereas in the others, aggressive intensive medical management has been documented to salvage a substantial proportion of patients. A small fraction of patients undergo liver transplant and the remaining are usually treated with medical therapy. Therefore, identification of the complications and causes of death in such patients, and use of appropriate prognostic models to identify those who need liver transplant and those who can be managed with medical treatment is a vital component of therapeutic strategy. In this review, we discuss the various pathogenetic mechanisms and treatment options available.
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Key Words
- AASLD, American Association For the Study of Liver
- ALF, Acute Liver Failure
- ALFED, Acute Liver Failure Early Dynamic Model
- BBB, Blood Brain Barrier
- BCAA, Branched Chain Amino acid
- CBF, Cerebral Blood Flow
- CPP, Cerebral Perfusion Pressure
- CVVHD, Continuous Veno-Venous Hemodialysis
- FFP, Fresh Frozen Plasma
- GM-CSF, Granulocyte Macrophage Colony Stimulating Factor
- HE, Hepatic Encephalopathy
- ICU, Intensive Care Unit
- IEI, Icterus Encephalopathy Interval
- IL-1β, Interleukin-1 beta
- IL6, Interlekin 6
- INR, International Normalized Ratio
- LOLA, l-Ornithine L Aspartate
- LOPA
- LOPA, l-Ornithine Phenyl Acetate
- MAP, Mean Arterial Pressure
- NAC, N-Acetyl Cysteine
- NO, Nitric Oxide
- OLT, Orthotopic Liver Transplantation
- PCWP, Pulmonary Capillary Wedge Pressure
- PEEP, Positive End Expiratory Pressure
- PT, Prothrombin Time
- SIMV, Synchronous Intermittent mandatory Ventilation
- SIRS, Systemic Inflammatory Response Syndrome
- SPEAR, Selective Parenteral and Enteral Antibiotic Regimen
- TNF-α, Tumor Necrosis Factor alfa
- UCD, Urea Cycle Disorder
- USALF, United States Acute liver Failure Study Group
- ammonia
- cerebral edema
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Affiliation(s)
| | - Subrat K. Acharya
- Address for correspondence: Subrat K. Acharya, Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India.
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Ates M, Hatipoglu S, Dirican A, Isik B, Ince V, Yilmaz M, Aydin C, Ara C, Kayaalp C, Yilmaz S. Right-lobe living-donor liver transplantation in adult patients with acute liver failure. Transplant Proc 2014; 45:1948-52. [PMID: 23769080 DOI: 10.1016/j.transproceed.2012.10.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 10/30/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Right-lobe living-donor liver transplantation (RLDLT) is an excellent option to reduce donor shortages for adult patients with acute liver failure (ALF). The aim of this study was to evaluate the etiologies and outcomes of 30 consecutive adult patients who underwent emergency RLDLT for ALF. METHODS Between January 2007 and September 2011, we examined data from medical records of patients with ALF who underwent RLDLT. RESULTS Their mean age was 32.2 ± 13.05 years. The etiologies of ALF were acute hepatitis B (n = 11; 36.6%), hepatitis A (n = 4; 13.3%), drug intoxication (n = 4; 13.3%), pregnancy (n = 2; 6.7%), hepatitis B with pregnancy (n = 1; 3.3%), mushroom intoxication (n = 1; 3.3%), and unknown (n = 7; 23.3%). The mean hepatic coma grade (Model for End-Stage Liver Disease score) was 34.13 ± 8.72. The 43 (48.7%) postoperative complications were minor (grades I-II) and 44 (51.3%) were major (grades III-V). Reoperation was required in 14 of 30 (47%) recipients (grades IIIb-IVa). Deaths occurred owing to pulmonary (n = 2), cardiac (n = 1), septic (n = 2), or encephalopathic (n = 4) complications. The mean durations of intensive care unit stay and postoperative hospitalization were 3.2 ± 2.3 and 29.5 ± 23 days, respectively. The survival rate was 70%. The mean follow-up duration was 305 days (range, 1-1582). CONCLUSION Liver transplantation is potentially the only curative modality, markedly improving the prognosis of patients with ALF. The interval between ALF onset and death is short and crucial because of the rapid, progressive multiorgan failure. Thus, RLDLT should be considered to be a life-saving procedure for adult patients with ALF, requiring quicker access to a deceased-donor liver graft and a short ischemia time.
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Affiliation(s)
- M Ates
- Department of General Surgery, Inonu University, School of Medicine, Malatya, Turkey.
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11
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Ballas SK, Kesen MR, Goldberg MF, Lutty GA, Dampier C, Osunkwo I, Wang WC, Hoppe C, Hagar W, Darbari DS, Malik P. Beyond the definitions of the phenotypic complications of sickle cell disease: an update on management. ScientificWorldJournal 2012; 2012:949535. [PMID: 22924029 PMCID: PMC3415156 DOI: 10.1100/2012/949535] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 04/01/2012] [Indexed: 12/25/2022] Open
Abstract
The sickle hemoglobin is an abnormal hemoglobin due to point mutation (GAG → GTG) in exon 1 of the β globin gene resulting in the substitution of glutamic acid by valine at position 6 of the β globin polypeptide chain. Although the molecular lesion is a single-point mutation, the sickle gene is pleiotropic in nature causing multiple phenotypic expressions that constitute the various complications of sickle cell disease in general and sickle cell anemia in particular. The disease itself is chronic in nature but many of its complications are acute such as the recurrent acute painful crises (its hallmark), acute chest syndrome, and priapism. These complications vary considerably among patients, in the same patient with time, among countries and with age and sex. To date, there is no well-established consensus among providers on the management of the complications of sickle cell disease due in part to lack of evidence and in part to differences in the experience of providers. It is the aim of this paper to review available current approaches to manage the major complications of sickle cell disease. We hope that this will establish another preliminary forum among providers that may eventually lead the way to better outcomes.
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Affiliation(s)
- Samir K Ballas
- Cardeza Foundation and Department of Medicine, Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107, USA.
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12
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Miloh T, Kerkar N, Parkar S, Emre S, Annunziato R, Mendez C, Arnon R, Suchy F, Rodriguez-Laiz G, Del Rio Martin J, Sturdevant M, Iyer K. Improved outcomes in pediatric liver transplantation for acute liver failure. Pediatr Transplant 2010; 14:863-9. [PMID: 20609170 DOI: 10.1111/j.1399-3046.2010.01356.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
UNLABELLED OLT is a life-saving option for ALF. AIM To evaluate our outcomes in pediatric OLT for ALF. METHODS Retrospective review of our data between 1992 and 2007. RESULTS Of 142 children with ALF, 126 were listed, of which 40 spontaneously improved, nine died, and 77 underwent OLT (median waiting time four days). Fifty-three children received deceased donor grafts (34 whole and 19 split grafts), and there were 24 living donor grafts. The one- and five-yr patient survival was 87% and 80%, and graft survival 83% and 79%, respectively. Thirteen patients died after OLT, and there were nine retransplants in seven patients. Patient weight, length of stay, creatinine, and infection were significantly associated with death; increased weight and black ethnicity were associated with graft loss on univariate analysis, but not on multivariate analysis. There were no significant differences in patient survival (one and five yr), graft loss, or other complications between the groups. CONCLUSION We report the largest single-center study of OLT in pediatric ALF, demonstrating no difference in outcomes between different graft types. Our liberal use of segmental grafts may allow earlier OLT in this high-risk cohort and contribute to our excellent outcomes.
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Affiliation(s)
- Tamir Miloh
- Department of Pediatrics and Recanati Miller Transplant Institute, Department of Surgery, Mount Sinai Hospital, New York, NY, USA.
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13
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Gastrointestinal and hepatic complications of sickle cell disease. Clin Gastroenterol Hepatol 2010; 8:483-9; quiz e70. [PMID: 20215064 DOI: 10.1016/j.cgh.2010.02.016] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 02/12/2010] [Accepted: 02/21/2010] [Indexed: 02/07/2023]
Abstract
Sickle cell disease (SCD) is an autosomal recessive abnormality of the beta-globin chain of hemoglobin (Hb), resulting in poorly deformable sickled cells that cause microvascular occlusion and hemolytic anemia. The spleen is almost always affected by SCD, with microinfarcts within the first 36 months of life resulting in splenic atrophy. Acute liver disorders causing right-sided abdominal pain include acute vaso-occlusive crisis, liver infarction, and acute hepatic crisis. Chronic liver disease might be due to hemosiderosis and hepatitis and possibly to SCD itself if small, clinically silent microvascular occlusions occur chronically. Black pigment gallstones caused by elevated bilirubin excretion are common. Their small size permits them to travel into the common bile duct but cause only low-grade obstruction, so hyperbilirubinemia rather than bile duct dilatation is typical. Whether cholecystectomy should be done in asymptomatic individuals is controversial. The most common laboratory abnormality is an elevation of unconjugated bilirubin level. Bilirubin and lactate dehydrogenase levels correlate with one another, suggesting that chronic hemolysis and ineffective erythropoiesis, rather than liver disease, are the sources of hyperbilirubinemia. Abdominal pain is very common in SCD and is usually due to sickling, which resolves with supportive care. Computed tomography scans might be ordered for severe or unremitting pain. The liver typically shows sickled erythrocytes and Kupffer cell enlargement acutely and hemosiderosis chronically. The safety of liver biopsies has been questioned, particularly during acute sickling crisis. Treatments include blood transfusions, exchange transfusions, iron-chelating agents, hydroxyurea, and allogeneic stem-cell transplantation.
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14
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Narayan S, Saha A, Naidu CS, Ramesh G, Chatterjee J, Nambiar P, Puri P, Sharma AK. The First Successful Pediatric Liver Transplant in the Armed Forces. Med J Armed Forces India 2009; 65:365-7. [PMID: 27408293 DOI: 10.1016/s0377-1237(09)80101-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 08/12/2009] [Indexed: 11/18/2022] Open
Affiliation(s)
- S Narayan
- Senior Advisor (Pediatrics & Neonatology), Army Hospital (Research & Referral), Delhi Cantt
| | - A Saha
- Consultant, Army Hospital (Research & Referral), Delhi Cantt
| | - C S Naidu
- Senior Advisor (Surgery & GI Surgery), Army Hospital (Research & Referral), Delhi Cantt
| | - G Ramesh
- Senior Advisor (Anaesthesia & CT Anaesthesia), Army Hospital (Research & Referral), Delhi Cantt
| | - J Chatterjee
- Senior Advisor (Anaesthesia & Pediatric Anaesthesia), Army Hospital (Research & Referral), Delhi Cantt
| | - P Nambiar
- MO & Transplant Coordinator, Army Hospital (Research & Referral), Delhi Cantt
| | - P Puri
- Senior Advisor (Medicine & Gastroenterology), Army Hospital (Research & Referral), Delhi Cantt
| | - A K Sharma
- Brig i/c Adm & Cdr Tips, Army Hospital (Research & Referral), Delhi Cantt
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15
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Cariús L, Pacheco-Moreira L, Balbi E, Leal C, Gonzalez A, Agoglia L, Araújo C, Enne M, Martinho J. Living Donor Liver Transplantation for Acute Liver Failure: A Single Center Experience. Transplant Proc 2009; 41:895-7. [DOI: 10.1016/j.transproceed.2009.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Living-related donor liver transplantation for children with fulminant hepatic failure in Israel. J Pediatr Gastroenterol Nutr 2009; 48:451-5. [PMID: 19322055 DOI: 10.1097/mpg.0b013e318196c379] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Liver transplantation is considered the treatment of choice for most children with deteriorating fulminant hepatic failure (FHF). Living-related donor liver transplantation (LDLT) has been suggested as an alternative to cadaveric liver transplantation to overcome the shortage of organ donors. However, experience with LDLT for children with FHF is limited in the Western world. OBJECTIVE To present the experience with LDLT for children with FHF in a major referral center in Israel. METHODS The files of all children who underwent primary LDLT for FHF were reviewed for demographic, clinical, and laboratory parameters before and after transplantation. RESULTS : During 1996 to 2007, 13 children diagnosed with FHF underwent primary LDLT. Median age was 4 years (range 0.75-14 years); the causes of FHF were acute hepatitis A in 4 patients and were unknown in 9 patients. Short-term complications, documented in 12 children, included mainly hepatic artery thrombosis (n = 5), which warranted retransplantation in 3 cases, and biliary leaks (n = 3). Three patients died within the first month after LDLT of severe intraoperative bleeding (n = 1), severe brain edema (n = 1), and multiorgan failure (n = 1). Long-term complications were less common and included mainly ascending cholangitis (n = 3). Patient survival rate was 68% at 1 year and 57% at 5 years. None of the donors had long-term complications. CONCLUSIONS Among children with FHF, LDLT can serve as a timely and lifesaving alternative to cadaveric donation, and could reduce the dependence on cadaveric livers in this setting.
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17
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Uribe M, González G, Alba A, Godoy J, Ferrario M, Hunter B, Iñiguez R, Cavallieri S, Díaz V, Macho L, Ferrón S, Buckel E. Living Donor Liver Transplantation in Pediatric Patients With Acute Liver Failure: Safe and Effective Alternative. Transplant Proc 2008; 40:3253-5. [DOI: 10.1016/j.transproceed.2008.03.128] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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18
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Sakamoto S, Haga H, Egawa H, Kasahara M, Ogawa K, Takada Y, Uemoto S. Living donor liver transplantation for acute liver failure in infants: the impact of unknown etiology. Pediatr Transplant 2008; 12:167-73. [PMID: 18307664 DOI: 10.1111/j.1399-3046.2007.00718.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Infants with ALF occasionally have the most urgent need for a liver transplant. In urgent situations for liver transplantation, LDLT has been advocated. Between July 1995 and April 2004, medical records of 15 infants undergoing LDLT for ALF of unknown etiology were reviewed and their outcomes were compared with infants undergoing LDLT for other liver diseases. They received LLS (n = 9), MS (n = 3), and RMS (n = 3) grafts. Eight technical complications occurred, with a similar incidence for LDLT and the other liver diseases. On the other hand, the liver biopsies after LDLT showed a significantly higher incidence of ACR with centrilobular injuries. Ten patients died after primary LDLT because of refractory rejection (n = 6), rotavirus infection (n = 2), chronic rejection (n = 1), and surgical complications (n = 1). With a median follow-up of 7.0 months, five-yr graft and patient survival rates were 17.8% and 26.7%, respectively. In conclusion, the outcome of LDLT for ALF in infants, especially cases with unknown etiology, was unsatisfactory and refractory rejection often led to liver failure. From our observation the centrilobular changes were characteristics of ACR in infantile LDLT for cryptogenic ALF.
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19
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Acharya SK, Bhatia V. Acute Liver Failure. APOLLO MEDICINE 2007. [DOI: 10.1016/s0976-0016(11)60465-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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20
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Kilic M, Aydin U, Noyan A, Arikan C, Aydogdu S, Akyildiz M, Karasu Z, Zeytunlu M, Alper M, Batur Y. Live donor liver transplantation for acute liver failure. Transplantation 2007; 84:475-9. [PMID: 17713430 DOI: 10.1097/01.tp.0000276987.55382.e2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute liver failure (ALF) carries a high mortality unless urgent orthotopic liver transplantation (OLT) is performed on time. Live donors are utilized to treat this irreversible condition first in pediatric cases and then in adults. Herein, we aimed to report our experience with live donors for ALF in a country of a deceased donor organ donation rate is only 1.5 per million people. METHODS Among the 245 live donor liver transplantations (LDLT) performed from June 1999 to December 2005, 14 of them (6%) were performed for ALF in 8 pediatric and 6 adult cases. Right lobes were harvested for the adult cases whereas left lateral segments were harvested for pediatric cases, except one child transplanted with a right lobe graft. The etiology of the disease was; acute hepatitis B in four cases, hepatitis A in three cases, Wilson disease two cases, autoimmune hepatitis in two cases, and was unknown in three cases. RESULTS Three-year graft and patient survival is 79% for these series. Five of the six adult patients and six of the eight pediatric cases survived after transplantation. There was not any donor mortality or major morbidity. CONCLUSIONS LDLT offers a safe and effective modality of treatment for ALF for both pediatric and adult patients to overcome the problem of organ shortage especially in countries where the chance of receiving an organ from a deceased donor is low.
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Affiliation(s)
- Murat Kilic
- Department of Surgery, Ege University Hospital, Izmir, Turkey.
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21
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Zhang F, Wang X, Li X, Kong L, Sun B, Li G, Qian X, Chen F, Wang K, Lu S, Pu L, Lu L. Emergency adult living donor right lobe liver transplantation for fulminant hepatic failure. ACTA ACUST UNITED AC 2007; 1:282-6. [DOI: 10.1007/s11684-007-0054-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Accepted: 03/06/2007] [Indexed: 12/29/2022]
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22
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Nadalin S, Heuer M, Wallot M, Auth M, Schaffer R, Sotiropoulos GC, Ballauf A, van der Broek MAJ, Olde-Damink S, Hoyer PF, Broelsch CE, Malagò M. Paediatric acute liver failure and transplantation: The University of Essen experience. Transpl Int 2007; 20:519-27. [PMID: 17355244 DOI: 10.1111/j.1432-2277.2007.00474.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
To report our experience with 17 children who underwent a liver transplantation (LT) for acute liver failure (ALF). All LT procedures (deceased and living donor) were offered. Since 2003 Molecular Adsorbents Recycling System (MARS) was proposed as bridging procedure. We monitored the perioperative course and the short- and long-term outcomes. All children developed pretransplant hepatic encephalopathy (mostly grades II and III); six needed ventilator support and three haemodialysis. Median PELD/MELD score was 30. MARS was used in five children with poor pretransplant prognostic factors: all five survived the LT without sequelae. We performed 13 deceased donor LT (seven whole, five split and onr reduced) and four left lateral LDLT. Postoperative complications were observed in 10 children, requiring re-operation in seven. Two children developed irreversible neurological disorders. After a median follow up of 45 months, 16 children are still alive. About 1- and 5-year cumulative patient survival rates are 94% with a corresponding graft survival of 88% and 81%, respectively. The combination of experienced paediatric ICU management, the application of new liver support devices, and the capacity to offer both living and deceased donor transplant alternatives in a timely fashion represent the best formula to achieve optimal results in children with ALF.
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Affiliation(s)
- Silvio Nadalin
- Department of General-, Visceral- and Transplantation Surgery, University Hospital Essen, Essen, Germany.
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23
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Abstract
Liver transplantation in pediatrics has become an accepted modality of treatment in end-stage liver disease and irreversible acute liver failure. Biliary atresia is the most common indication requiring liver transplantation in children. The diagnosis and causes of acute liver failure in children differ from those in adults. Growth and development require special consideration in children. Regular surveillance of Epstein-Barr virus by polymerase chain reaction and appropriate therapy may reduce the incidence of post-transplant lymphoproliferative disease after transplantation. Adherence to the prescribed medical regimen is essential for good graft function. A multidisciplinary approach is the key to success in liver transplantation in children.
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Affiliation(s)
- Nanda Kerkar
- Division of Pediatric Hepatology, Department of Pediatrics, Mount Sinai School of Medicine, Box 1104, New York, NY 10029, USA
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24
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Nadalin S, Malagò M, Radtke A, Erim Y, Saner F, Valentin-Gamazo C, Schröder T, Schaffer R, Sotiropoulos GC, Li J, Frilling A, Broelsch CE. Current trends in live liver donation. Transpl Int 2007; 20:312-30. [PMID: 17326772 DOI: 10.1111/j.1432-2277.2006.00424.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The introduction of living donor liver transplantation (LDLT) has been one of the most remarkable steps in the field of liver transplantation (LT), able to significantly expand the scarce donor pool in countries in which the growing demands of organs are not met by the shortage of available cadaveric grafts. Although the benefits of this procedure are enormous, the physical and psychological sacrifice of the donors is immense, and the expectations for a good outcome for themselves, as well as for the recipients, are high. We report a current overview of the latest trends in live liver donation in its different aspects (i.e. donor's selection, evaluation, operation, morbidity, mortality, ethics and psychology). This review is based on our center's personal experience with almost 200 LDLTs and a detailed analysis of the international literature of the last 7 years about this topic. Knowing in detail how to approach to the different aspects of living liver donation may be helpful in further improve donor's safety and even recipient's outcome.
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Affiliation(s)
- Silvio Nadalin
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany.
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25
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Abstract
The increasing awareness of liver diseases and their early detection have led to an increase in the number of transplant waiting list candidates over the past decade. This need has not been matched by the actual number of orthotopic liver transplantations performed. Live donor liver transplantation (LDLT) is an innovative surgical technique intended to expand the available organ donor pool. Although LDLT offers definite advantages to the recipient, it offers none to the donor except for the possibility of psychological well-being. Clinical research studies aimed at the prospective collection of data for donors and recipients need to be conducted.
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Affiliation(s)
- Lawrence U Liu
- Division of Liver Diseases, The Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1104, New York, NY 10039, USA
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26
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Barshes NR, Gay AN, Williams B, Patel AJ, Awad SS. Support for the Acutely Failing Liver: A Comprehensive Review of Historic and Contemporary Strategies. J Am Coll Surg 2005; 201:458-76. [PMID: 16125082 DOI: 10.1016/j.jamcollsurg.2005.04.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2005] [Revised: 03/23/2005] [Accepted: 04/11/2005] [Indexed: 12/16/2022]
Affiliation(s)
- Neal R Barshes
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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27
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Reding R. Is it right to promote living donor liver transplantation for fulminant hepatic failure in pediatric recipients? Am J Transplant 2005; 5:1587-91. [PMID: 15943615 DOI: 10.1111/j.1600-6143.2005.00915.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Good clinical results are currently achieved in elective pediatric liver transplantation (LT) with living-related donors. However, the question whether such therapeutic approach may also be promoted in case of fulminant hepatic failure (FHF) remains a matter of debate. This work briefly reviews the ethical background and overall medical results of living-related donation in pediatric LT. When considering FHF, success is essentially conditioned by the availability of a suitable organ donor before the onset of irreversible brain damage and death of the transplant candidate on the waiting list. Accordingly, living donor LT provides several advantages for patients with FHF, including the short waiting time and the access to a transplant with reduced ischemic injury and optimal graft quality; however, living donation is also characterized by several drawbacks to be carefully considered, particularly the possibility of coercion to the recipient's family as well as the operative risks of the emergency donor hepatectomy. The ethical soundness of living parental donor LT for FHF is discussed, with emphasis to the type of medical context, with or without access to an efficient emergency postmortem organ sharing system.
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Affiliation(s)
- Raymond Reding
- Pediatric Liver Transplant Program, Department of Surgery, Université catholique de Louvain Brussels, Brussels, Belgium.
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28
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Liu CL, Fan ST, Lo CM, Tam PKH, Saing H, Wei WI, Yong BH, Tsoi NS, Wong J. Live donor liver transplantation for fulminant hepatic failure in children. Liver Transpl 2003; 9:1185-90. [PMID: 14586880 DOI: 10.1053/jlts.2003.50235] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The mortality rate among children with fulminant hepatic failure (FHF) on the waiting list for cadaveric donor liver transplantation (CDLT) is high. Results of emergency CDLT in this situation often are unsatisfactory, and a long-term survival rate less than 30% has been reported. Live donor liver transplantation (LDLT) for FHF in children has been advocated, but is reported rarely. We present our experience with LDLT in children with FHF. Between September 1993 and December 2002, primary LDLT was performed for 26 children; 8 of these children had FHF. Patient demographics, clinical and laboratory data, surgical details, complications, and graft and patient survival are reviewed. Four boys and four girls received left-lateral segment (n = 7) and full left-lobe (n = 1) grafts. Mean age was 2.9 +/- 1.2 years (range, 3 months to 11 years). Causes of FHF were drug induced in 2 patients and idiopathic in 6 patients. One child received a blood group-incompatible graft. Two patients died; 1 patient of cytomegalovirus infection at 8.6 months and 1 patient of recurrent hepatitis of unknown cause at 2.8 months after LDLT. The child who received a mismatched graft had refractory rejection and underwent a second LDLT with a blood group-compatible graft 19 days afterward. He eventually died of lymphoproliferative disease. Another patient developed graft failure related to venous outflow obstruction and survived after retransplantation with a cadaveric graft. With a median follow-up of 13.2 months (range, 2.8 to 60.3 months), actuarial graft and patient survival rates were 50% and 62.5%, respectively. Survival results appear inferior compared with those of 18 children who underwent LDLT for elective conditions during the same study period (graft survival, 89%; P =.051; patient survival, 89%; P =.281). Although survival outcomes are inferior to those in elective situations, LDLT is a timely and lifesaving procedure for children with FHF.
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Affiliation(s)
- Chi-Leung Liu
- Centre for the Study of Liver Disease, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.
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29
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Liu CL, Fan ST. Extending the graft size limits of live-donor liver transplantation. Transplantation 2003; 76:641-2. [PMID: 13677341 DOI: 10.1097/01.tp.0000079306.91147.dc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Chi-Leung Liu
- Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China
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30
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Abstract
Acute liver failure is characterized by a dynamic clinical course associated with high mortality. The main prognostic determinant is the development of extrahepatic complications. Close monitoring is mandatory, and prophylactic measures to avoid complications should be initiated. In case of complications, early and aggressive treatment is indicated. To date, artificial liver support devices are still in the experimental phase. Liver transplantation should be considered in patients with predictors of a poor spontaneous prognosis. Therefore, a transplant center should be contacted in every case of acute liver failure.
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Affiliation(s)
- K Rifai
- Abteilung Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover
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31
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Abstract
Patients in high-urgency situations for liver transplantation have a high mortality rate while on the waiting list for cadaveric grafts. In countries where cadaveric organ donation is scarce, the use of living-donor liver transplantation (LDLT) provides the only chance of survival for both pediatric and adult patients. It results in a satisfactory overall survival, from approximately 60% to 75% in pediatric patients and from 70% to 90% in adult patients. Patients who had early LDLT were shown to have a better survival outcome than those who waited for cadaveric organ donation, because a timely graft was available to them before they deteriorated further to multiple organ failure. Patients who were in high-urgency situations for liver transplantation and opted for LDLT were also shown to have significantly better survival outcomes than those who did not opt for this procedure. Although left lobe liver graft can be used successfully in adult-to-adult LDLT in high-urgency situations, there is a trend toward a more frequent use of the larger mass provided by the right lobe of the liver. Adequate venous drainage of the anterior segment of the right lobe liver graft is also considered essential for the favorable outcome of the recipients. Although donor morbidity has been reported to be low in LDLT and no donor death has been reported from Asian transplant centers, standardized definitions of morbidity and better methods for observing and measuring outcomes are necessary to understand and to potentially reduce morbidity.
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Affiliation(s)
- Chi-Leung Liu
- Centre for the Study of Liver Disease and the Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.
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32
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Van Thiel DH, Brems J, Nadir A, Idilman R, Colantoni A, Holt D, Edelstein S. Liver transplantation for fulminant hepatic failure. J Gastroenterol 2003; 37 Suppl 13:78-81. [PMID: 12109672 DOI: 10.1007/bf02990105] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The etiology and prognosis of individuals with various forms of fulminant hepatic failure are reviewed. Special techniques of clinical management and decision making as to when and to whom to transplant in cases of fulminant hepatic failure are reviewed.
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Affiliation(s)
- David H Van Thiel
- Department of Medicine, Loyola University of Chicago, Stritch School of Medicine, Maywood, IL 60153, USA
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33
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Kogan-Liberman D, Emre S, Shneider BL. Recent advances in pediatric liver transplantation. Curr Gastroenterol Rep 2002; 4:84-97. [PMID: 11825546 DOI: 10.1007/s11894-002-0042-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pediatric liver transplantation has matured into a well-established, highly successful treatment for advanced pediatric liver disease. Recent 1-year success rates range from 85% to 95%. This unprecedented achievement is the result of careful selection criteria and optimal timing of transplantation, technical advances in surgical technique, and improved treatment following transplant. This report highlights many recent published findings representing advances that have led to current successful approaches.
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Affiliation(s)
- Debora Kogan-Liberman
- Department of Pediatrics, Recanati/Miller Transplantation Institute, Mount Sinai School of Medicine, Box 1656, One Gustave L. Levy Place, New York, NY 10029, USA
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34
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Abstract
With evolution of surgical technique, advances in immunosuppression, and better understanding of pre- and post-operative care, the 1-yr survival rate after liver transplantation in children has reached 85-90%. As a result, a greater number of patients have been listed for transplantation and waiting times have lengthened. Innovative techniques such as reduced-size, split, and living-donor liver transplantation are being applied more often to decrease long waiting times and reduce associated morbidity and mortality. In this review, living donor liver transplantation in pediatrics is described. Special issues, such as donor and recipient selection, surgical procedures in donors and recipients, and ethical issues, are discussed.
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Affiliation(s)
- Sukru Emre
- The Recanati/Miller Transplantation Institute,The Mount Sinai School of Medicine, New York, New York 10029, USA.
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35
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Affiliation(s)
- S Emre
- Recanati/Miller Transplantation Institute, The Mount Sinai School of Medicine, New York, New York, USA
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36
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Mack CL, Ferrario M, Abecassis M, Whitington PF, Superina RA, Alonso EM. Living donor liver transplantation for children with liver failure and concurrent multiple organ system failure. Liver Transpl 2001; 7:890-5. [PMID: 11679988 DOI: 10.1053/jlts.2001.27963] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Liver transplantation for pediatric patients in liver failure and multiple organ system failure (MOSF) often results in poor patient survival. Progression of organ failure occurs while awaiting a cadaveric allograft. Therefore, we considered living donor liver transplantation (LDLT) in this critically ill group of children and report our initial results with comparison to a similar group who received cadaveric donation (CAD). A retrospective chart review was performed on all pediatric liver transplant recipients who met criteria for MOSF at the time of transplantation. Data collection involved pretransplantation patient profiles, as well as postoperative complications and patient survival. Eight patients in MOSF received living donor transplants and 11 patients received a cadaveric allograft. Mean wait time was 3.5 days in the LDLT group and 6.5 days in the CAD group. Pretransplantation patient profiles and postoperative complications were similar between groups. Mean cold ischemia times were 3.8 hours in the LDLT group and 7.9 hours in the CAD group (P = .0002). Thirty-day and 6-month survival rates of the LDLT group were 88% and 63% compared with 45% and 27% in the CAD group, respectively. Living donor transplant recipients in MOSF had decreased wait times to transplantation, as well as decreased cold ischemia times, compared with cadaveric transplant recipients. Patients in the LDLT group had markedly improved survival compared with the CAD group. Timely transplantation before worsening organ failure may account for these findings.
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Affiliation(s)
- C L Mack
- Department of Pediatrics, The Siragusa Transplantation Center, Children's Memorial Hospital, Chicago, IL 60614, USA
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37
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Affiliation(s)
- F Lacaille
- Department of Pediatrics, Necker-Enfants Malades Hospital, Paris, France.
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38
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Abstract
Acute liver failure (ALF) is defined as hepatic encephalopathy complicating acute liver injury. The most common etiologies are acute viral hepatitis A and B, medication overdose (e.g., acetaminophen), idiosyncratic drug reactions, ingestion of other toxins (e.g., amanita mushroom poisoning), and metabolic disorders (e.g., Reye's syndrome). Despite advances in intensive care management, mortality continues to be high (40-80%) and is partly related to ALF's complications, such as cerebral edema, sepsis, hypoglycemia, gastrointestinal bleeding, and acute renal failure. Several prognostic models have been developed to determine which patients will spontaneously recover. Treatment is directed at early recognition of the complications and general supportive measures. The only proven therapy for those who are unlikely to recover is liver transplantation. Therefore, recognition of ALF is paramount, and urgent referral to a transplant center is critical to assess transplantation status.
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Affiliation(s)
- R Q Gill
- Division of Gastroenterology, Section of Hepatology and Liver Transplantation, Medical College of Virginia, Commonwealth University, Richmond, Virginia 23298-0341, USA
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39
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Zhu XF, Chen GH, He XS, Lu MQ, Wang GD, Cai CJ, Yang Y, Huang JF. Liver transplantation and artificial liver support in fulminant hepatic failure. World J Gastroenterol 2001; 7:566-8. [PMID: 11819831 PMCID: PMC4688675 DOI: 10.3748/wjg.v7.i4.566] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- X F Zhu
- Transplantation Center, Affiliated First Hospital, Sun Yat-Sen University of Medical Sciences, 510080 Guangzhou, Guangdong Province, China.
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40
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Cui D, Kiuchi T, Egawa H, Hayashi M, Sakamoto S, Ueda M, Kaihara S, Uemoto S, Inomata Y, Tanaka K. Microcirculatory changes in right lobe grafts in living-donor liver transplantation: a near-infrared spectrometry study. Transplantation 2001; 72:291-5. [PMID: 11477355 DOI: 10.1097/00007890-200107270-00022] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND A continuing shortage of cadaveric liver even for adult patients has motivated not a few centers to proceed to living-donor liver transplantation using right lobe grafts. One of controversies is potential congestion in the graft anterior segment by the deprivation of the middle hepatic vein. METHODS Hepatic tissue oxygenation and hemoglobin concentration were investigated with a near-infrared spectroscopy in the course of harvesting and implantation in living-donor liver transplantation. Twenty adult recipients of right lobe graft were involved in the study. The aim of the analysis was to detect tissue congestion or ischemia. RESULTS No significant change in mean hepatic tissue oxygenation and hemoglobin was noted in the right lobe during donor operation even after hepatic parenchymal transection, although some trend for relative congestion, i.e., increased tissue hemoglobin, compared with the left lobe was observed. After graft reperfusion in the recipient, both mean hepatic tissue oxygen saturation and hemoglobin decreased significantly in the anterior segment, which was accompanied by increased heterogeneity of tissue hemoglobin and oxygenation. Increased heterogeneity of oxygenation and decreased tissue hemoglobin were observed also in the posterior segment. CONCLUSIONS The anterior segment in right lobe living-donor liver transplantation is sensitive to ischemia, rather than congestion, at least in the immediate phase after graft reperfusion. The anterior segment seems to be also more prone to circulatory disturbance than the other part of the graft.
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Affiliation(s)
- D Cui
- Department of Transplantation and Immunology, Kyoto University Faculty of Medicine, 54 Kawara-cho, Shogoin, Sakyo-ku Kyoto 606-8507, Japan
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41
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Bentdal O, Brekke IB, Olausson M, Foss A, Husberg B, Ostensen A, Bergan A. Living related liver retransplantation in a 6-month-old child after 60 hours of anhepatic phase following hepatectomy of thrombosed primary liver graft. Transplant Proc 2001; 33:2497-8. [PMID: 11406226 DOI: 10.1016/s0041-1345(01)02076-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- O Bentdal
- Surgical Department, Rikshospitalet, Oslo, Norway
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42
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43
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Sterling RK, Fisher RA. Liver transplantation. Living donor, hepatocyte, and xenotransplantation. Clin Liver Dis 2001; 5:431-60, vii. [PMID: 11385971 DOI: 10.1016/s1089-3261(05)70173-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Liver transplantation is now accepted as effective therapy in the treatment of acute and chronic hepatic failure. Improvements in surgical techniques and immune suppression have led to 5-year survival rates that exceed 70% in most centers. The success of transplantation has led to a dramatic increase in the number of candidates to over 14,000 places on the national waiting list. While the number of patients in need of transplantation increases, there has been little growth in the supply of available cadaveric organs, resulting in an organ shortage crisis. With waiting times often exceeding 1 to 2 years, the waiting list mortality now exceeds 10% in most regions. Several novel approaches have been developed to address the growing disparity between the limited supply and excessive demand for suitable organs.
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Affiliation(s)
- R K Sterling
- Section of Hepatology, Division of Transplantation, Medical College of Virginia at Virginia Commonwealth University, Richmond, Virginia, USA.
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44
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Abstract
Worldwide, viral hepatitis is the leading cause of acute liver failure, whereas acetaminophen hepatotoxicity is the most commonly identified cause in Western countries. Restricting the quantity of acetaminophen tablets dispensed has been shown to reduce morbidity and mortality in countries with a high incidence of acetaminophen overdose. Troglitazone and bromfenac are two recently approved medications that were withdrawn from the market due to an unacceptably high incidence of severe hepatotoxicity. In addition, trovafloxacin, nefazodone, and ritonavir were reported to be associated with severe hepatitis and acute liver failure. Moderate hypothermia is a simple and potentially effective means of reducing intracranial pressure in patients with acute liver failure and cerebral edema. However, controlled clinical trials are needed to determine proper patient selection and optimize treatment. Extracorporeal bioartificial liver support devices remain an exciting but as yet unproven means of supporting acute liver failure patients with advanced encephalopathy. Living donor liver transplantation has recently been reported for adults and children with acute liver failure. However, ethical concerns regarding donor safety and the ability to obtain informed consent without coercion have been raised. Lastly, advances in the identification and isolation of pluripotent liver stem cells in human bone marrow provides hope for a simple and effective means of enhancing native liver regeneration.
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Affiliation(s)
- R J Fontana
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan 48109, USA.
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45
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Emergency Adult to Adult Living Donor Liver Transplantation For Fulminant Hepatic Failure ??? Is It Justifiable? Transplantation 2001. [DOI: 10.1097/00007890-200105270-00028] [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]
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Testa G, Malagó M, Broelsch CE. From living related to in-situ split liver transplantation: how to reduce waiting-list mortality. Pediatr Transplant 2001; 5:16-20. [PMID: 11260483 DOI: 10.1034/j.1399-3046.2001.t01-1-00028.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The insufficient number of suitable cadaveric organs for pediatric recipients is the cause of high pretransplant mortality rates and long waiting times. With the introduction of split and living related liver transplantation, the waiting list mortality rate has dropped from greater than 15% to less than 5% and children are transplanted more rapidly. A 5-year patient and graft survival rate of greater than 80% has been obtained in those centers where split and living related liver transplantations are routinely performed. The data analyzed in this paper show that the only current solution to cadaveric organ shortage is a 'multimodal' approach, where whole liver cadaveric transplantation is associated with split and living related liver transplantation.
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Affiliation(s)
- G Testa
- Universitätsklinikum Essen, Germany
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47
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Successful stem cell transplantation following orthotopic liver transplantation from the same haploidentical family donor in a girl with hemophagocytic lymphohistiocytosis. Blood 2000. [DOI: 10.1182/blood.v96.12.3997.h8003997_3997_3999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The case of a 4-month-old girl with familial hemophagocytic lymphohistiocytosis is described. The patient underwent stem cell transplantation from her haploidentical mother 2 months after receiving a living-related liver transplant from the same donor for acute hepatic failure. Conditioning regimen consisted of 16 mg/kg busulfan, 200 mg/kg cyclophosphamide, 10 mg/kg thiothepa, and antithymocyte globulin. Myeloid engraftment occurred on day +10, but CD3+ cells of recipient origin remained. To convert the T-cell chimerism, the patient received donor lymphocyte infusion on day +43, and subsequently the allelic pattern changed to complete donor genotype on day +57. Four months after stem cell transplantation the patient is disease free, with complete donor chimerism in bone marrow and stable hepatic graft function without any immunosuppressive therapy.
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48
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Successful stem cell transplantation following orthotopic liver transplantation from the same haploidentical family donor in a girl with hemophagocytic lymphohistiocytosis. Blood 2000. [DOI: 10.1182/blood.v96.12.3997] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The case of a 4-month-old girl with familial hemophagocytic lymphohistiocytosis is described. The patient underwent stem cell transplantation from her haploidentical mother 2 months after receiving a living-related liver transplant from the same donor for acute hepatic failure. Conditioning regimen consisted of 16 mg/kg busulfan, 200 mg/kg cyclophosphamide, 10 mg/kg thiothepa, and antithymocyte globulin. Myeloid engraftment occurred on day +10, but CD3+ cells of recipient origin remained. To convert the T-cell chimerism, the patient received donor lymphocyte infusion on day +43, and subsequently the allelic pattern changed to complete donor genotype on day +57. Four months after stem cell transplantation the patient is disease free, with complete donor chimerism in bone marrow and stable hepatic graft function without any immunosuppressive therapy.
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49
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Abstract
Successful liver transplantation in a child is often a hard-won victory, requiring all the combined expertise of a dedicated pediatric transplant team. This article outlines the considerable challenges still facing pediatric liver transplant physicians and surgeons. In looking to the future, where should priorities lie to enhance the success already achieved? First, solutions to the donor shortage must be sought aggressively by increasing the use of from split-liver transplants, judicious application of living-donor programs, and increasing the donation rate, perhaps by innovative means. The major immunologic barriers, to successful xenotransplantation make it unlikely that this option will be tenable in the near future. Second, current immunosuppression is nonspecific, toxic, and unable to be individually adjusted to the patient's immune response. The goal of achieving donor-specific tolerance will require new consideration of induction protocols. Developing a clinically applicable method to measure the recipient's immunoreactivity is of paramount importance, for future studies of new immunosuppressive strategies and to address the immediate concern of long-term over-immunosuppression. The inclusion of pediatric patients in new protocols will require the ongoing insistence of pediatric transplant investigators. Third, the current immunosuppressive drugs have a long-term morbidity and mortality of their own. These long-term effects are particularly important in children who may well have decades of exposure to these therapies. There is now some understanding of their long-term renal toxicity and the risk of malignancy. New drugs may obviate renal toxicity, whereas the risk of malignancy is inherent in any nonspecific immunosuppressive regimen. Although progress is being made in preventing and recognizing PTLD, this entity remains an important ongoing concern. The global effect of long-term immunosuppression on the child's growth, development, and intellectual potential is unknown. Of particular concern is the potential for neurotoxicity from the calcineurin inhibitors. Fourth, recurrent disease and new diseases, perhaps potentiated by immunosuppressive drugs, must be considered. Already the recurrence of autoimmune disease and cryptogenic cirrhosis have been documented in pediatric patients. Now, a new lesion, a nonspecific hepatitis, sometimes with positive autoimmune markers, that may progress to cirrhosis has been recognized. It is not known whether this entity is an unusual form of rejection, an unrecognized viral infection, or a response to immunosuppressive drugs themselves. Finally, pediatric transplant recipients, like any other children, must be protected and nourished physically and mentally if they are to fulfill their potential. After liver transplantation the child's growth, intellectual functioning, and psychologic adaptation may all require special attention from parents, teachers, and physicians alike. There is limited understanding of how the enormous physical intervention of a liver transplantation affects a child's cognitive and psychologic function as the child progresses through life. The persons caring for these children have the difficult responsibility of providing services to evaluate these essential measures of children's health over the long term and to intervene if necessary. Part of the transplant physician's our duty to protect and advocate for children is to fight for equal access to health care. In most of the developing world, economic pressures make it impossible to consider liver transplantation a health care priority. In the United States and in other countries with the medical infrastructure to support liver transplantation, however, health care professionals must strive to be sure that the policies governing candidacy for transplantation and allocation of organs are applied justly and uniformly to all children whose lives are threatened by liver disease. In the current regulatory climate that increasingly takes medical decisions out of the hands of physicians, pediatricians must be even more prepared to protect the unique and often complicated needs of children both before and after transplantation. Only in this way can the challenges of the present and the future be met.
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Affiliation(s)
- S V McDiarmid
- Pediatric Liver Transplant Program, University of California Los Angeles Medical Center, Los Angeles, California, USA
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50
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Abstract
Worldwide, viral infection is responsible for the majority of cases of acute liver failure, and the presence of co-existing chronic viral hepatitis may increase its severity. The newly described hepatotrophic viruses, hepatitis G virus and transfusion-transmitted virus, are unlikely to be major aetiological agents. In the USA and western Europe drug-induced hepatotoxicity is the most common cause, and most frequently results from acetaminophen. Hepatotoxicity caused by Ecstasy is increasingly important, particularly in young adults. Hepatic encephalopathy and cerebral oedema remain important and life-threatening complications, and their pathogenesis is not completely understood. The effects of the cerebral metabolism of the high levels of ammonia that circulate in hepatic failure appear to be important. Induced hypothermia is a promising modality of treatment for refractory cerebral oedema, but the only form of treatment known to improve survival is emergency liver transplantation. Living donor and auxiliary liver transplantation are likely to improve survival rates further and reduce the number of patients requiring long-term post-transplant immunosuppression.
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Affiliation(s)
- W Bernal
- Institute of Liver Studies, Kings College Hospital, London, UK
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