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Khot R, Shelman NR, Ludwig DR, Nair RT, Anderson MA, Venkatesh SK, Paspulati RM, Parker RA, Menias CO. Acquired ductopenia: an insight into imaging findings. Abdom Radiol (NY) 2024:10.1007/s00261-024-04462-x. [PMID: 38954003 DOI: 10.1007/s00261-024-04462-x] [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: 04/21/2024] [Accepted: 06/15/2024] [Indexed: 07/04/2024]
Abstract
Hepatic ductopenia is a pathologic diagnosis characterized by a decrease in the number of intrahepatic bile ducts as a consequence of various underlying etiologies. Some etiologies, such as primary sclerosing cholangitis, primary biliary cholangitis, and ischemic cholangitis, often have distinctive imaging findings. In contrast, other causes such as chronic rejection following liver transplantation, drug-induced biliary injury, infection, malignancy such as lymphoma, and graft-versus-host disease may only have ancillary or non-specific imaging findings. Thus, diagnosing ductopenia in conditions with nonspecific imaging findings requires a multidimensional approach, including clinical evaluation, serological testing, imaging, and liver histology to identify the underlying cause. These etiologies lead to impaired bile flow, resulting in cholestasis, liver dysfunction, and, ultimately, cirrhosis and liver failure if the underlying cause remains untreated or undetected. In the majority of instances, individuals diagnosed with ductopenia exhibit a positive response to treatment addressing the root cause or cessation of the causative agent. This article focuses on acquired causes of ductopenia, its clinical manifestation, histopathology, imaging diagnosis, and management.
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Affiliation(s)
- Rachita Khot
- Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.
| | - Nathan R Shelman
- Department of Pathology, University of Kentucky, Lexington, KY, USA
| | - Daniel R Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Rashmi T Nair
- Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Mark A Anderson
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sudhakar K Venkatesh
- Division of Abdominal Imaging, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Raj Mohan Paspulati
- Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Rex A Parker
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Christine O Menias
- Division of Abdominal Imaging, Department of Radiology, Mayo Clinic, Scottsdale, AZ, USA
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Polat KY, Yazar Ş, Kargi A, Aslan S, Demirdağ H, Gürbulak B, Astarcioğlu İ. Comparing the Outcomes of Deceased-Donor and Living-Donor Liver Re-Transplantation In Adult Patients. Transplant Proc 2023:S0041-1345(23)00169-0. [PMID: 37085384 DOI: 10.1016/j.transproceed.2023.01.039] [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: 04/23/2023]
Abstract
BACKGROUND Patients with liver graft failures have an extremely low chance of finding a cadaveric graft in countries with a scarcity of deceased donors. We compared the outcomes of liver re-transplantation with living-donor liver grafts (re-LDLT) and deceased-donor liver grafts (re-DDLT) in adult patients (>18 years). METHODS The medical records of 1513 (1417 [93.6%] LDLT and 96 [6.3%] DDLT) patients who underwent liver transplantation at Memorial Hospital between January 2011 and October 2022 were reviewed. Forty patients (24 adults and 16 pediatric) were re-transplanted (2.84%); 24 adult patients (2.72%: 25 re-LDLT, 1 patient with second re-LDLT) were divided into 2 groups: re-DDLT (n = 6) and re-LDLT (n = 18). The groups were compared in demographics, pre-, peri-, postoperative characteristics, and outcomes. RESULTS The overall survival rates were 91.7%, 79.2%, 75.0%, and 75% for <30 days, 31 to 90 days, 1, and 3 years, respectively. The LDLT group was significantly younger (P = .022), had smaller graft weight (P = .03), shorter mechanical ventilation (P = .036) but longer operation time (P = .019), and hospitalization period (P = .003). The groups were otherwise comparable. There was no statistically significant difference in survival rates between the groups (P = .058), although the re-LDLT group had an evidently higher survival rate (88.9% and 83.3 % vs 50.0%). CONCLUSION Re-LDLT has shown comparable outcomes to re-DDLT, if not better (even not far from significance P = .058). These results may encourage performing re-LDLTs in patients with indications for re-LT without worrying about low chances of survival, especially in countries with limited sources of deceased donors.
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Affiliation(s)
- Kamil Yalçin Polat
- Bahçelievler Memorial Hospital, Organ Transplantation Center, Istanbul, Turkey
| | - Şerafettin Yazar
- Bahçelievler Memorial Hospital, Organ Transplantation Center, Istanbul, Turkey
| | - Ahmet Kargi
- Bahçelievler Memorial Hospital, Organ Transplantation Center, Istanbul, Turkey
| | - Serdar Aslan
- Bahçelievler Memorial Hospital, Organ Transplantation Center, Istanbul, Turkey
| | - Hakan Demirdağ
- Bahçelievler Memorial Hospital, Department of Gastroenterology, Istanbul, Turkey
| | - Bünyamin Gürbulak
- Bahçelievler Memorial Hospital, Organ Transplantation Center, Istanbul, Turkey.
| | - İbrahim Astarcioğlu
- Bahçelievler Memorial Hospital, Organ Transplantation Center, Istanbul, Turkey
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3
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Intraoperative dialysis with the use of a mobile dialysis system during liver transplantation. Adv Med Sci 2022; 67:208-215. [PMID: 35568010 DOI: 10.1016/j.advms.2022.04.004] [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: 10/01/2021] [Revised: 03/22/2022] [Accepted: 04/29/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Over the last few years, transplant centers have started to use various intraoperative renal replacement therapy (ioRRT) modalities during liver transplantation (LT) in patients with pre-existing renal impairment. Here, we present a study on the safety and clinical outcomes of intraoperative hemodialysis (ioHD) performed using a mobile dialysis system during LT. PATIENTS AND METHODS We retrospectively analyzed 102 adult patients undergoing LT with ioHD; pre-existing renal failure and/or intraoperative metabolic derangement were ioHD treatment indications. RESULTS Our study cohort consisted of three groups: LT with preoperative serum creatinine (sCr) < 2 mg/dL (Group 1:n = 22), LT with preoperative sCr ≥2 mg/dL (Group 2:n = 73), and simultaneous liver-kidney transplantation (Group 3:n = 7). Among the procedures, 30% were re-transplantations. The mean calculated Model for End-stage Liver Disease score in Group 2 was 39.2, and 67% of patients were hospitalized in the intensive care unit. Patients in Group 1 were less acutely ill but developed severe intraoperative derangements and, therefore, underwent urgent ioHD intraoperatively. However, it was delayed when compared to Group 2. All groups achieved post-reperfusion potassium levels <4 mmol/L and a decrease in central venous pressure. No serious procedural complications occurred. Post-reperfusion syndrome occurred in 12.7% of patients. Elevated mortality was likely due to the high illness severity in the cohort. CONCLUSIONS Performing ioHD with a mobile dialysis system during LT was safe and effective, while being easier to perform than continuous techniques. Its effect on intra- and postoperative outcomes should be addressed in a study with a control group.
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Angelico R, Sensi B, Manzia TM, Tisone G, Grassi G, Signorello A, Milana M, Lenci I, Baiocchi L. Chronic rejection after liver transplantation: Opening the Pandora’s box. World J Gastroenterol 2021; 27:7771-7783. [PMID: 34963740 PMCID: PMC8661381 DOI: 10.3748/wjg.v27.i45.7771] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/25/2021] [Accepted: 11/21/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic rejection (CR) of liver allografts causes damage to intrahepatic vessels and bile ducts and may lead to graft failure after liver transplantation. Although its prevalence has declined steadily with the introduction of potent immunosuppressive therapy, CR still represents an important cause of graft injury, which might be irreversible, leading to graft loss requiring re-transplantation. To date, we still do not fully appreciate the mechanisms underlying this process. In addition to T cell-mediated CR, which was initially the only recognized type of CR, recently a new form of liver allograft CR, antibody-mediated CR, has been identified. This has indeed opened an era of thriving research and renewed interest in the field. Liver biopsy is needed for a definitive diagnosis of CR, but current research is aiming to identify new non-invasive tools for predicting patients at risk for CR after liver transplantation. Moreover, the minimization or withdrawal of immunosuppressive therapy might influence the establishment of subclinical CR-related injury, which should not be disregarded. Therapies for CR may only be effective in the “early” phases, and a tailored management of the immunosuppression regimen is essential for preventing irreversible liver damage. Herein, we provide an overview of the current knowledge and research on CR, focusing on early detection, identification of non-invasive biomarkers, immunosuppressive management, re-transplantation and future perspectives of CR.
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Affiliation(s)
- Roberta Angelico
- Department of Surgery Sciences, HPB and Transplant Unit, University of Tor Vergata, Rome 00100, Italy
| | - Bruno Sensi
- Department of Surgery Sciences, HPB and Transplant Unit, University of Tor Vergata, Rome 00100, Italy
| | - Tommaso M Manzia
- Department of Surgery Sciences, HPB and Transplant Unit, University of Tor Vergata, Rome 00100, Italy
| | - Giuseppe Tisone
- Department of Surgery Sciences, HPB and Transplant Unit, University of Tor Vergata, Rome 00100, Italy
| | - Giuseppe Grassi
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
| | | | - Martina Milana
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
| | - Ilaria Lenci
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
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5
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Smith NK, Zerillo J, Kim SJ, Efune GE, Wang C, Pai SL, Chadha R, Kor TM, Wetzel DR, Hall MA, Burton KK, Fukazawa K, Hill B, Spad MA, Wax DB, Lin HM, Liu X, Odeh J, Torsher L, Kindscher JD, Mandell MS, Sakai T, DeMaria S. Intraoperative Cardiac Arrest During Adult Liver Transplantation: Incidence and Risk Factor Analysis From 7 Academic Centers in the United States. Anesth Analg 2021; 132:130-139. [PMID: 32167977 DOI: 10.1213/ane.0000000000004734] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intraoperative cardiac arrest (ICA) has a reported frequency of 1 in 10,000 anesthetics but has a much higher estimated incidence in orthotopic liver transplantation (OLT). Single-center studies of ICA in OLT are limited by small sample size that prohibits multivariable regression analysis of risks. METHODS Utilizing data from 7 academic medical centers, we performed a retrospective, observational study of 5296 adult liver transplant recipients (18-80 years old) between 2000 and 2017 to identify the rate of ICA, associated risk factors, and outcomes. RESULTS ICA occurred in 196 cases (3.7% 95% confidence interval [CI], 3.2-4.2) and mortality occurred in 62 patients (1.2%). The intraoperative mortality rate was 31.6% in patients who experienced ICA. In a multivariable generalized linear mixed model, ICA was associated with body mass index (BMI) <20 (odds ratio [OR]: 2.04, 95% CI, 1.05-3.98; P = .0386), BMI ≥40 (2.16 [1.12-4.19]; P = .022), Model for End-Stage Liver Disease (MELD) score: (MELD 30-39: 1.75 [1.09-2.79], P = .02; MELD ≥40: 2.73 [1.53-4.85], P = .001), postreperfusion syndrome (PRS) (3.83 [2.75-5.34], P < .001), living donors (2.13 [1.16-3.89], P = .014), and reoperation (1.87 [1.13-3.11], P = .015). Overall 30-day and 1-year mortality were 4.18% and 11.0%, respectively. After ICA, 30-day and 1-year mortality were 43.9% and 52%, respectively, compared to 2.6% and 9.3% without ICA. CONCLUSIONS We established a 3.7% incidence of ICA and a 1.2% incidence of intraoperative mortality in liver transplantation and confirmed previously identified risk factors for ICA including BMI, MELD score, PRS, and reoperation and identified new risk factors including living donor and length of surgery in this multicenter retrospective cohort. ICA, while rare, is associated with high intraoperative mortality, and future research must focus on therapy to reduce the incidence of ICA.
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Affiliation(s)
- Natalie K Smith
- From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Jeron Zerillo
- From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Sang Jo Kim
- Department of Anesthesiology, Hospital for Special Surgery, New York City, New York
| | - Guy E Efune
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Cynthia Wang
- Department of Anesthesiology, Greater Los Angeles VA Healthcare System, Los Angeles, California
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Todd M Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - David R Wetzel
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael A Hall
- Department of Anesthesiology, Christiana Care Health System, Newark, Delaware
| | - Kristen K Burton
- Department of Anesthesiology and Critical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kyota Fukazawa
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Bryan Hill
- Department of Anesthesiology, The Ohio State University, Columbus, Ohio
| | | | - David B Wax
- From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, The Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Xiaoyu Liu
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Jaffer Odeh
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Laurence Torsher
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - James D Kindscher
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - M Susan Mandell
- Department of Anesthesiology, University of Colorado Hospital, Aurora, Colorado.,The Center for Perioperative & Pain Quality, Safety and Outcomes-PPQiSO, University of Washington Medical Center, Seattle, Washington
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samuel DeMaria
- From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York City, New York
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Al Bahili H, Al Garni A, Al Hasan I, Alsebayel YM, Al Eid M, Al Zaharani A, Qahtani AS, Negmi HH, Al Masri N. Adult Living Donor Liver Re-Transplant Following Late Pediatric Liver Transplant Failure: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:908-913. [PMID: 31239432 PMCID: PMC6610494 DOI: 10.12659/ajcr.914456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patient: Male, 14 Final Diagnosis: Primary sclerosing cholangitis Symptoms: Abdominal and/or epigastric pain • jaundice Medication: — Clinical Procedure: Liver transplantation twice • splenic artery embolization Specialty: Transplantology
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Affiliation(s)
- Hamad Al Bahili
- Multi-Organ Transplant Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah Al Garni
- Multi-Organ Transplant Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ibrahim Al Hasan
- Multi-Organ Transplant Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Yazeed M Alsebayel
- College of Medicine, Imam Mohammed Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Maha Al Eid
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ahmed Al Zaharani
- College of Medicine, Imam Mohammed Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Awad Salem Qahtani
- Multi-Organ Transplant Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Hisham H Negmi
- Multi-Organ Transplant Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Nasser Al Masri
- Multi-Organ Transplant Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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7
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Chen X, Wei L, Zhu Z, Sun L, Qu W, Zeng Z. Hepatic artery reconstruction with interposition of donor's right gastroepiploic artery graft in pediatric living donor liver transplantation for metabolic disease. Pediatr Transplant 2019; 23:e13418. [PMID: 31012241 DOI: 10.1111/petr.13418] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/10/2019] [Accepted: 03/21/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVE We introduce the indications, technique, results of our experience using donor's RGEA as interposition vessel to solve hepatic artery reconstruction problems in P-LDLT. METHODS A retrospective analysis of P-LDLT for children with metabolic diseases from June 2013 to November 2018 in our center was carried out. The arterial conditions, reconstruction methods, and prognosis were analyzed. RESULTS A total of 73 children with metabolic diseases underwent P-LDLT during the period. The LLF was the main graft, accounting for 71.2%. The donor's RGEA was utilized in five cases. There were three children with OTCD and two children with deficiency of CPS1 and MSUD, respectively. In three cases, the grafts' left hepatic arteries were anastomosed with the recipients' PHA using donors' RGEA as interposition vessel. In other two cases, the donors' RGEA was interposed between graft's MHA and the recipient's bifurcation of PHA and GDA. The average follow-up time was 19.7 ± 15.9 month. There were two cases of artery thrombosis or occlusion, and the incidence was 2.7%. No arterial complications occurred in children using RGEA (follow-up time 5.0 ± 3.4 months). CONCLUSION In P-LDLT for patients with metabolic diseases, the application of RGEA as an interposition vessel can solve caliber mismatch and short arteries problem and achieve good results. Compared with traditional arterial anastomosis, it may reduce the incidence of arterial complications.
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Affiliation(s)
- Xiaojie Chen
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lin Wei
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhijun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Tolerance Induction and Organ Protection in Transplantation, Beijing, China
| | - Liying Sun
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Wei Qu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhigui Zeng
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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8
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Ischemic-type biliary lesions: A leading indication of liver retransplantation with excellent results. Clin Res Hepatol Gastroenterol 2019; 43:131-139. [PMID: 30472180 DOI: 10.1016/j.clinre.2017.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 11/01/2017] [Accepted: 11/10/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Liver retransplantation (RLT) is the only life-saving treatment option for patients with a failing graft, but it remains a major challenge because of inferior outcomes and technical difficulties. METHODS This study aimed to evaluate the outcomes of and risk factors for adult RLT in a single center, focusing on the etiology of graft failure. Between 1987 and 2011, 1592 liver transplants (LTs) and 143 RLTs (9%) were performed at our institution. RESULTS The 1-, 5- and 10-year patient survival rates after RLT were 60%, 52% and 39%, and the graft survival rates were 55%, 46% and 32%. The 90-day mortality rate was 32%, mainly due to septic complications (45% of deaths). Ischemic-type biliary lesions (ITBL) were the leading indication for RLT (23%), and patient survival was significantly better in patients retransplanted for ITBL than for any other indication (P<0.02). Indications other than ITBL (P=0.015), the transfusion of more than 7 units (P=0.006) and preoperative dialysis (P=0.005) were the three parameters associated with poor survival after RLT. CONCLUSION Patients with ITBL benefit the most from elective RLT.
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[Frontiers in liver transplantation in indication and techniques]. Chirurg 2018; 90:102-109. [PMID: 30413847 DOI: 10.1007/s00104-018-0761-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The frontiers in liver transplantation are intrinsically expansions of indications, e.g. hepatocellular carcinoma and (perihilar) cholangiocarcinoma, recipients with more severe concomitant diagnoses or "soft" contraindications and technically demanding reconstruction procedures of vascular structures (for portal vein thrombosis or aorto-hepatic conduits). In addition, an extension of the donor pool with suboptimal donor organs (old donors and steatotic livers) is of interest. METHODS This article presents the current situation based on personal experiences in daily practice and an appropriate literature review. RESULTS A significant reduction of 1‑year patient survival has been reported in Germany. The percentage of so-called marginal donor organs is inversely proportional to the very low donation rate and parallel to the waiting list mortality. Simultaneously, the proportion of inpatients with multiple organ failure is rising. CONCLUSION Results-oriented and controlled liver transplantation currently prohibits making inroads into the previously intrinsic frontiers. As long as the current circumstances do not change, a shift in the intrinsic frontiers of that which is surgically feasible will not be possible. The current situation forces the transplant surgeon to apply a more restrictive indications and organ acceptance policy. With this approach we can try to regain the previously excellent short- and long-term results of a 1‑year survival of 90% and a 20-year survival of 50%.
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10
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Chul Yoon K, Song S, Jwa EK, Lee S, Man Kim J, Kim OK, Kyun Hong S, Yi NJ, Lee KW, Soo Kim M, Hwang S, Suh KS, Lee SK. Survival Outcomes in Split Compared With Whole Liver Transplantation. Liver Transpl 2018; 24:1411-1424. [PMID: 29747216 DOI: 10.1002/lt.25196] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/20/2018] [Accepted: 05/03/2018] [Indexed: 12/11/2022]
Abstract
Split-liver transplantation (SLT) should be cautiously considered because the right trisection (RTS) graft can be a marginal graft in adult recipients. Herein, we analyzed the outcomes of RTS-SLT in Korea, where >75% of adult liver transplantations are performed with living donor liver transplantation. Among 2462 patients who underwent deceased donor liver transplantations (DDLTs) from 2005 to 2014, we retrospectively reviewed 86 (3.5%) adult patients who received a RTS graft (RTS-SLT group). The outcomes of the RTS-SLT group were compared with those of 303 recipients of whole liver (WL; WL-DDLT group). Recipient age, laboratory Model for End-Stage-Liver Disease (L-MELD) score, ischemia time, and donor-to-recipient weight ratio (DRWR) were not different between the 2 groups (P > 0.05). However, malignancy was uncommon (4.7% versus 36.3%), and the donor was younger (25.2 versus 42.7 years) in the RST-SLT group than in the WL-DDLT group (P < 0.05). The technical complication rates and the 5-year graft survival rates (89.0% versus 92.8%) were not different between the 2 groups (P > 0.05). The 5-year overall survival (OS) rate (63.1%) and graft-failure-free survival rate (63.1%) of the RTS-SLT group were worse than that of the WL-DDLT group (79.3% and 79.3%; P < 0.05). The factors affecting graft survival rates were not definite. However, the factors affecting OS in the RTS-SLT group were L-MELD score >30 and DRWR ≤1.0. In the subgroup analysis, OS was not different between the 2 groups if the DRWR was >1.0, regardless of the L-MELD score (P > 0.05). In conclusion, a sufficient volume of the graft estimated from DRWR-matching could lead to better outcomes of adult SLTs with a RTS graft, even in patients with high L-MELD scores.
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Affiliation(s)
- Kyung Chul Yoon
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Sanghee Song
- Transplantation Center, Seoul National University Hospital, Seoul, South Korea
| | - Eun-Kyoung Jwa
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ok-Kyoung Kim
- Transplantation Center, Seoul National University Hospital, Seoul, South Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Myoung Soo Kim
- Department of Surgery and The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Suk-Koo Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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11
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Abstract
PURPOSE OF REVIEW Review the current knowledge about recurrent primary sclerosing cholangitis (rPSC) after transplant in children. RECENT FINDINGS Recurrent PSC is a significant complication that afflicts 16% of children after liver transplantation for primary sclerosing cholangitis (PSC) at a median onset of 38 months post-transplant. Possible risk factors include younger age at PSC diagnosis or transplant, the presence of overlap syndrome or IBD, and post-transplant induction with thymoglobulin. rPSC impairs the patient's quality of life and can be detrimental to the graft. Preventive options and therapeutic measures are limited. Ursodeoxycholic acid is widely used, but its effect on long-term outcome is unknown. Vancomycin can improve the biochemical profile of rPSC, but it remains unknown whether it halts the disease progression. Pediatric liver transplant for primary sclerosis cholangitis can be complicated by recurrence of the disease, which portends poor outcomes. Although few risk factors have been implicated, larger studies with longer follow-ups are needed to characterize cardinal risk factors for rPSC, as well as evaluate possible preventative and therapeutic options.
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Affiliation(s)
- Nisreen Soufi
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Southern California, Los Angeles, CA, USA
| | - Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Mark Deneau
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, UT, 84113, USA.
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Triguero Cabrera J, Zambudio Carroll N, González Martínez S, Villar Quintana R, Muffak Granero K, Becerra Massare A, Villegas Herrera T, Villar Del Moral JM. Analysis of Indications and Results in Liver Retransplantation: Is Late Retransplantation Worthwhile? Transplant Proc 2018; 50:598-600. [PMID: 29579863 DOI: 10.1016/j.transproceed.2017.12.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 12/19/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Liver retransplantation (LrT) is the only therapeutic option for irreversible hepatic graft failure. Despite various improvements, its technical complexity entails a greater morbidity in the short and long term. The main goal of the study was to analyze the activity of LrT at our center, as well as its indications, timing, postoperative evolution, and the long-term survival of patients. METHODS We designed a descriptive study of a cohort of patients who underwent LrT in a Spanish Hepatic Transplant Unit, between April 1, 2002 and December 31, 2015. RESULTS A total of 366 primary orthotopic liver transplantations were performed, 20 of which were LrTs, resulting in a 5.5% retransplantation rate. The most frequent indication for LrT was hepatic artery thrombosis (HAT) (35%). Twenty-five percent of the LrTs were early retransplantations and 75% were late retransplantations. After LrT, 35% of the grafts showed liver dysfunction. The overall mortality rate was 45%: in early LrT this was 25% and in late LrT it was 46.7%. Graft actuarial survival at 1 month post-LrT was 75% and at 5 years it was 63.6%. The overall actuarial survival after LrT at month 1, year 1, year 3, and year 5 was 80%, 69.6%, 58.9%, and 50.5%, respectively. In the late LrT group, the results proved less favorable, so it is necessary to define the minimum acceptable result before proceeding to a second graft. CONCLUSION Our LrT rate was lower than that reported by other groups in our country. The actuarial survival rates for graft and patient are comparable to those obtained by other groups.
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Affiliation(s)
- J Triguero Cabrera
- Unit of Liver Transplantation, Department of Surgery, Virgen de las Nieves University Hospital, Granada, Spain.
| | - N Zambudio Carroll
- Unit of Liver Transplantation, Department of Surgery, Virgen de las Nieves University Hospital, Granada, Spain
| | - S González Martínez
- Unit of Liver Transplantation, Department of Surgery, Virgen de las Nieves University Hospital, Granada, Spain
| | - R Villar Quintana
- Unit of Liver Transplantation, Department of Surgery, Virgen de las Nieves University Hospital, Granada, Spain
| | - K Muffak Granero
- Unit of Liver Transplantation, Department of Surgery, Virgen de las Nieves University Hospital, Granada, Spain
| | - A Becerra Massare
- Unit of Liver Transplantation, Department of Surgery, Virgen de las Nieves University Hospital, Granada, Spain
| | - T Villegas Herrera
- Unit of Liver Transplantation, Department of Surgery, Virgen de las Nieves University Hospital, Granada, Spain
| | - J M Villar Del Moral
- Unit of Liver Transplantation, Department of Surgery, Virgen de las Nieves University Hospital, Granada, Spain
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Kulik U, Lehner F, Klempnauer J, Borlak J. Primary non-function is frequently associated with fatty liver allografts and high mortality after re-transplantation. Liver Int 2017; 37:1219-1228. [PMID: 28267886 DOI: 10.1111/liv.13404] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 02/27/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The shortage of liver donations demands the use of suboptimal grafts with steatosis being a frequent finding. Although ≤30% macrovesicular steatosis is considered to be safe the risk for primary non-function (PNF) and outcome after re-transplantation (re-OLT) is unknown. METHODS Among 1205 orthotopic liver transplantations performed at our institution the frequency, survival and reason of re-OLT were evaluated. PNF (group A) cases and those with initial transplant function but subsequent need for re-OLT (group B) were analysed. Histopathology and clinical judgement determined the cause of PNF and included an assessment of hepatic steatosis. Additionally, survival of fatty liver allografts (group C) not requiring re-OLT was considered in Kaplan-Meier and multivariate regression analysis. RESULTS A total of 77 high urgency re-OLTs were identified and included 39 PNF cases. Nearly 70% of PNF cases were due to primary fatty liver allografts. The 3-month in-hospital mortality for PNF cases after re-OLT was 46% and the mean survival after re-OLT was 0.5 years as compared to 5.2 and 5.1 years for group B, C, respectively, (P<.008). In multivariate Cox regression analysis only hepatic steatosis was associated with an inferior survival (HR 4.272, P=.002). The MELD score, donor BMI, age, cold ischaemic time, ICU stay, serum sodium and transaminases did not influence overall survival. CONCLUSIONS Our study highlights fatty liver allografts to be a major cause for PNF with excessive mortality after re-transplantation. The findings demand the development of new methods to predict risk for PNF of fatty liver allografts.
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Affiliation(s)
- Ulf Kulik
- Department of General-, Visceral- and Transplantation Surgery, Hannover, Germany
| | - Frank Lehner
- Department of General-, Visceral- and Transplantation Surgery, Hannover, Germany
| | - Jürgen Klempnauer
- Department of General-, Visceral- and Transplantation Surgery, Hannover, Germany
| | - Jürgen Borlak
- Centre for Pharmacology and Toxicology, Hannover Medical School, Hannover, Germany
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14
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Choe J, Mulligan DC. Liver retransplantation: Recurrent primary sclerosing cholangitis may provide better outcomes. Liver Transpl 2017; 23:730-732. [PMID: 28425147 DOI: 10.1002/lt.24777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 04/17/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Jennie Choe
- Section of Transplantation and Immunology, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT
| | - David C Mulligan
- Section of Transplantation and Immunology, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT
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15
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Henson JB, Patel YA, King LY, Zheng J, Chow SC, Muir AJ. Outcomes of liver retransplantation in patients with primary sclerosing cholangitis. Liver Transpl 2017; 23:769-780. [PMID: 28027592 PMCID: PMC5865072 DOI: 10.1002/lt.24703] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 12/08/2016] [Indexed: 01/13/2023]
Abstract
Liver retransplantation in patients with primary sclerosing cholangitis (PSC) has not been well studied. The aims of this study were to characterize patients with PSC listed for and undergoing retransplantation and to describe the outcomes in these patients. The United Network for Organ Sharing/Organ Procurement and Transplantation Network database was used to identify all primary liver transplantations and subsequent relistings and first retransplantations in adults with PSC between 1987 and 2015. A total of 5080 adults underwent primary transplantation for PSC during this period, and of the 1803 who experienced graft failure (GF), 762 were relisted, and 636 underwent retransplantation. Younger patients and patients with GF due to vascular thrombosis or biliary complications were more likely to be relisted, whereas those with Medicaid insurance or GF due to infection were less likely. Both 5-year graft and patient survival after retransplantation were inferior to primary transplantation (P < 0.001). Five-year survival after retransplantation for disease recurrence (REC), however, was similar to primary transplantation (graft survival, P = 0.45; patient survival, P = 0.09) and superior to other indications for retransplantation (graft and patient survival, P < 0.001). On multivariate analysis, mechanical ventilation, creatinine, bilirubin, albumin, advanced donor age, and a living donor were associated with poorer outcomes after retransplantation. In conclusion, although survival after liver retransplantation in patients with PSC was overall inferior to primary transplantation, outcomes after retransplantation for PSC REC were similar to primary transplantation at 5 years. Retransplantation may therefore represent a treatment option with the potential for excellent outcomes in patients with REC of PSC in the appropriate clinical circumstances. Liver Transplantation 23 769-780 2017 AASLD.
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Affiliation(s)
| | - Yuval A. Patel
- Division of Gastroenterology, Department of Medicine, Durham, NC
| | - Lindsay Y. King
- Division of Gastroenterology, Department of Medicine, Durham, NC
| | | | - Shein-Chung Chow
- Department of Biostatistics, Durham, NC,Duke Clinical Research Institute, Durham, NC
| | - Andrew J. Muir
- Division of Gastroenterology, Department of Medicine, Durham, NC,Duke Clinical Research Institute, Durham, NC
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16
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Liver Transplantation With Older Donors: A Comparison With Younger Donors in a Context of Organ Shortage. Transplantation 2017; 100:2410-2415. [PMID: 27780188 DOI: 10.1097/tp.0000000000001401] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Older liver grafts have been considered in the past decade due to organ shortage. The aim was to compare outcomes after liver transplantation with either younger or older donors. METHODS Patients transplanted in our center between 2004 and 2014 with younger donors (younger than 60 years; n = 253) were compared with older donors (older than 75 years; n = 157). Multiorgan transplantations, split grafts, or non-heart-beating donors were not included. RESULTS Donors in the older group were mostly women deceased from stroke, and only 3 patients had experienced cardiac arrest. Liver tests were significantly better in the older group than in the younger group. There was no difference regarding cold ischemia time, model for end-stage liver disease score, and steatosis. There was no significant difference regarding primary nonfunction and dysfunction, hepatic artery and biliary complications, and retransplantation rates. Graft survival was not different (65% and 64% in the older and younger groups, P = 0.692). Within the older group, hepatitis C infection, retransplantation, and emergency transplantation were associated with poor graft survival. CONCLUSIONS Provided normal liver tests and the absence of cardiac arrest in donors, older liver grafts (>75 years) may be safely attributed to non-hepatitis C-infected recipients in the setting of a first and nonurgent transplantation.
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Abstract
Hepatic retransplantation has been surgically challenging since the beginning of liver transplant. Outcomes have improved over time, but patient survival with retransplant continues to be significantly worse than that of primary transplant. Many studies have focused on factors to predict outcomes. Models have been developed to help predict risk, but the decision for retransplant must be a multidisciplinary transplant team decision. The question of "when is too much?" can be guided by recipient and donor factors but is an ethical decision that must be made by the liver transplant team.
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Affiliation(s)
- Jennifer Berumen
- Department of Abdominal Transplantation and Hepatobiliary Surgery, University of California, San Diego, La Jolla, CA 92037, USA.
| | - Alan Hemming
- Department of Abdominal Transplantation and Hepatobiliary Surgery, University of California, San Diego, La Jolla, CA 92037, USA
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Bittermann T, Shaked A, Goldberg DS. When Living Donor Liver Allografts Fail: Exploring the Outcomes of Retransplantation Using Deceased Donors. Am J Transplant 2017; 17:1097-1102. [PMID: 27596956 DOI: 10.1111/ajt.14037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/24/2016] [Accepted: 09/01/2016] [Indexed: 01/25/2023]
Abstract
Outcomes of retransplantation after initial living donor liver transplantation (LDLT) are poorly understood. The aim of this study is to better understand the indications, timing, and outcomes of retransplantation after initial LDLT when compared to after initial deceased donor transplantation (DDLT). From 2002 to 2013, 209 retransplant recipients after initial LDLT and 2893 after initial DDLT were identified in Organ Procurement and Transplantation Network/United Network for Organ Sharing. Multivariable logistic models evaluated the association between initial transplant type and 1-year mortality. The most frequent reason for early graft failure (≤14 days) in LDLT recipients was vascular thrombosis (63.6%) versus primary graft failure in initial DDLT recipients (59.1%). LDLT recipients were more often acutely and/or critically ill with a greater proportion of Status 1 (42.6% vs. 27.3%; p < 0.001) and intensive care unit (52.2% vs. 39.9%; p = 0.001) recipients at the time of retransplantation. There was no difference in adjusted 1-year mortality between retransplant recipients after initial LDLT versus DDLT (odds ratio 0.74; 95% confidence interval 0.51-1.08). The proportion of recipients who ultimately required retransplantation for a third time was not different between the two groups (4.8%). Retransplantation outcomes after LDLT are not different from other retransplant procedures, despite recipients having greater acuity of illness and different indications.
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Affiliation(s)
- T Bittermann
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA
| | - A Shaked
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA
| | - D S Goldberg
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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