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Kirchner A, Ronot M, Durand F, Dondero F, Lesurtel M, Francoz C, Roux O, Lebtahi R, Vilgrain V, Dioguardi Burgio M. CT Volumetry Can Be Used for Monitoring Liver Function Recovery in Auxiliary Partial Orthotopic Liver Transplantation. Transplantation 2023; 107:2406-2414. [PMID: 37095611 DOI: 10.1097/tp.0000000000004608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
BACKGROUND Scintigraphy with a 99m TC-trimethyl-Br-IDA tracer (TBIDA) is used to monitor liver function regeneration after auxiliary partial orthotopic liver transplantation (APOLT) for acute liver failure (ALF). As computed tomography (CT) is also regularly performed during patient follow-up, CT volumetry could be used as an alternative to monitor native liver recovery after APOLT for ALF. METHODS This was a retrospective cohort study of all patients who underwent APOLT (October 2006-July 2019). Collected data included liver graft and native liver CT volumetry measurements (expressed as fractions), TBIDA scintigraphy results, and biological and clinical data including immunosuppression therapy after APOLT. Four follow-up time points were defined (baseline, discontinuation of mycophenolate mofetil, beginning of tacrolimus reduction, and tacrolimus discontinuation) for analysis. RESULTS Twenty-four patients (7 men; median age 28.5 y old) were included. The main etiologies of ALF were acetaminophen intoxication (n = 12), hepatitis B virus (n = 5), and amanita phalloides intoxication (n = 3). The median native liver function fractions on scintigraphy at baseline, at discontinuation of mycophenolate mofetil, at tacrolimus reduction, and at tacrolimus discontinuation were 22.0% (interquartile range 14.0-30.8), 30.5% (21.5-49.0), 32.0% (28.0-62.0), and 93.0% (77.0-100.0), respectively. The corresponding median native liver volume fractions on CT were 12.8% (10.4-17.3), 20.5% (14.2-27.3), 24.7% (21.3-48.4), and 77.9% (62.5-96.9), respectively. Volume and function were strongly correlated (r = 0.918; 95% confidence interval, 0.878-0.945; P < 0.01). Median time-to-immunosuppression discontinuation was 25.0 (17.0-35.0) mo. Estimated time-to-immunosuppression discontinuation was shorter in patients with acetaminophen-induced ALF (22 versus 35 mo; P = 0.035). CONCLUSIONS In patients who receive APOLT for ALF, CT-based liver volumetry closely parallels native liver function recovery evaluated on TBIDA scintigraphy.
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Affiliation(s)
| | - Maxime Ronot
- Department of Radiology, Hôpital Beaujon, Clichy, France
- Université Paris Cité, Inserm, Centre de recherche sur l'inflammation, F-75018 Paris, France
| | | | - Federica Dondero
- Department of HPB Surgery and Liver Transplantation, Hôpital Beaujon, Clichy, France
| | - Mickael Lesurtel
- Department of HPB Surgery and Liver Transplantation, Hôpital Beaujon, Clichy, France
| | - Claire Francoz
- Department of Hepatology, Hôpital Beaujon, Clichy, France
| | - Olivier Roux
- Department of Hepatology, Hôpital Beaujon, Clichy, France
| | - Rachida Lebtahi
- Department of Nuclear Medicine, Hôpital Beaujon, Clichy, France
| | - Valérie Vilgrain
- Department of Radiology, Hôpital Beaujon, Clichy, France
- Université Paris Cité, Inserm, Centre de recherche sur l'inflammation, F-75018 Paris, France
| | - Marco Dioguardi Burgio
- Department of Radiology, Hôpital Beaujon, Clichy, France
- Université Paris Cité, Inserm, Centre de recherche sur l'inflammation, F-75018 Paris, France
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2
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Pakkala AK, Chaubal G, Nanavati A, Hatimi H, Sinha R, Mandot A, Sanglodkar U, Chaubal A, Chaksota H, Shah S. Auxiliary Partial Orthotopic Liver Transplant as a Rescue Procedure for Acute Liver Failure with Extra-Small-for-Size Grafts: A Report of 2 Cases. EXP CLIN TRANSPLANT 2023; 21:701-704. [PMID: 37698404 DOI: 10.6002/ect.2023.0197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
Auxiliary partial orthotopic liver transplant is a complex technique whereby a partial liver graft is transplanted in the orthotopic position, leaving behind a portion of the native liver. In acute liver failure, auxiliary partial orthotopic liver transplant serves as a rescue therapy and bridge for the native liver to regenerate. Auxiliary partial orthotopic liver transplant was initially considered a technically challenging procedure with inferior results versus orthotopic liver transplant. However, advancements in surgical techniques have led to improved results with auxiliary partial orthotopic liver transplant. Auxiliary partial orthotopic liver transplant is now increasingly accepted as a valid treatment option for acute liver failure. We present 2 cases of acute liver failure treated with auxiliary partial orthotopic liver transplant using an extra-small-for-size graft. The first case was a 12-year-old female patient who presented with druginduced acute liver failure and required an auxiliary partial orthotopic liver transplant with an extra-small left lobe graft (graft-to-recipient weight ratio of 0.45). The second case was a 23-year-old male patient with acute liver failure of unknown etiology who underwent an auxiliary partial orthotopic liver transplant with a small right lobe graft (graft-torecipient weight ratio of 0.5). In both cases, computed tomography liver volumetry was performed to determine the appropriate graft size for the recipient. Both patients underwent successful auxiliary partial orthotopic liver transplants, with good postoperative recovery. Follow-up examinations showed satisfactory liver function without evidence of graft failure or rejection. Auxiliary partial orthotopic liver transplant using extra-small grafts can be an effective treatment option for acute liver failure when no other suitable option exists, including as a rescue procedure for small grafts. However, careful patient selection and surgical planning are essential to ensure successful outcomes.
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Affiliation(s)
- Amith Kumar Pakkala
- From the Department of Multiorgan Transplant and HPB Surgery, Global Hospitals, Mumbai, India
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3
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Shingina A, Mukhtar N, Wakim-Fleming J, Alqahtani S, Wong RJ, Limketkai BN, Larson AM, Grant L. Acute Liver Failure Guidelines. Am J Gastroenterol 2023; 118:1128-1153. [PMID: 37377263 DOI: 10.14309/ajg.0000000000002340] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/04/2023] [Indexed: 06/29/2023]
Abstract
Acute liver failure (ALF) is a rare, acute, potentially reversible condition resulting in severe liver impairment and rapid clinical deterioration in patients without preexisting liver disease. Due to the rarity of this condition, published studies are limited by the use of retrospective or prospective cohorts and lack of randomized controlled trials. Current guidelines represent the suggested approach to the identification, treatment, and management of ALF and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence was reviewed using the Grading of Recommendations, Assessment, Development and Evaluation process to develop recommendations. When no robust evidence was available, expert opinions were summarized using Key Concepts. Considering the variety of clinical presentations of ALF, individualization of care should be applied in specific clinical scenarios.
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Affiliation(s)
- Alexandra Shingina
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nizar Mukhtar
- Department of Gastroenterology, Kaiser Permanente, San Francisco, California, USA
| | - Jamilé Wakim-Fleming
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland Ohio, USA
| | - Saleh Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
- Liver Transplantation Unit, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | | | - Anne M Larson
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
| | - Lafaine Grant
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
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4
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Zhang B, Han B, Gao F, Fu X, Tian Y. Fk506 Inhibit liver regeneration in HOC model Rat. Transplant Proc 2023; 55:637-642. [PMID: 37019811 DOI: 10.1016/j.transproceed.2023.02.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 02/24/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Studies have shown that lymphocytes support hepatic oval cell (HOC)-dependent liver regeneration and FK506(Tacrolimus) is known as an immunosuppressor. Therefore, we studied the role of FK506 in HOC activation and/or proliferation to guide the clinical use of FK506. METHODS Thirty male Lewis rats were randomly divided into 4 groups: (A) intervene in activation (n = 8), (B) intervene in proliferation (n = 8), (C) control HOC model (n = 8), and (D) pure partial hepatectomy (PH) (n = 6). The HOC model was established by 2AAF(2-acetylaminofluorene)/PH in groups A to C. FK506 (at a dose of 1 mg/kg/d) was given subcutaneously in group A except on operation day, and not until day 8 post-operation (PO) in group B. Half of the animals were euthanized on days 10 and 14 PO, respectively. The remnant liver was weighed and stained by hematoxylin and eosin and immunohistochemical staining of proliferating cell nuclear antigen and epithelial cell adhesion molecule enabled HOC proliferation analysis. RESULTS FK506 intervention exacerbated liver damage and hindered the recovery of the HOC model rat. Weight gain was severely retarded or even negative. Liver weight and the liver body weight ratio were lower than control group. HE and immunohistochemistry showed pooer proliferation of hepatocytes and fewer HOC numbers in group A. CONCLUSION FK506 inhibited HOC activation by affecting T and NK cells, ultimately blocking liver regeneration. Poor liver regeneration after auxiliary liver transplantation might be associated with the inhibition of HOC activation and proliferation caused by FK506 treatment.
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5
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Menon J, Vij M, Sachan D, Rammohan A, Shanmugam N, Kaliamoorthy I, Rela M. Pediatric metabolic liver diseases: Evolving role of liver transplantation. World J Transplant 2021; 11:161-179. [PMID: 34164292 PMCID: PMC8218348 DOI: 10.5500/wjt.v11.i6.161] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/13/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023] Open
Abstract
Metabolic liver diseases (MLD) are the second most common indication for liver transplantation (LT) in children. This is based on the fact that the majority of enzymes involved in various metabolic pathways are present within the liver and LT can cure or at least control the disease manifestation. LT is also performed in metabolic disorders for end-stage liver disease, its sequelae including hepatocellular cancer. It is also performed for preventing metabolic crisis’, arresting progression of neurological dysfunction with a potential to reverse symptoms in some cases and for preventing damage to end organs like kidneys as in the case of primary hyperoxalosis and methyl malonic acidemia. Pathological findings in explant liver with patients with metabolic disease include unremarkable liver to steatosis, cholestasis, inflammation, variable amount of fibrosis, and cirrhosis. The outcome of LT in metabolic disorders is excellent except for patients with mitochondrial disorders where significant extrahepatic involvement leads to poor outcomes and hence considered a contraindication for LT. A major advantage of LT is that in the post-operative period most patients can discontinue the special formula which they were having prior to the transplant and this increases their well-being and improves growth parameters. Auxiliary partial orthotopic LT has been described for patients with noncirrhotic MLD where a segmental graft is implanted in an orthotopic position after partial resection of the native liver. The retained native liver can be the potential target for future gene therapy when it becomes a clinical reality.
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Affiliation(s)
- Jagadeesh Menon
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Mukul Vij
- Department of Pathology, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Deepti Sachan
- Department of Transfusion Medicine, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Naresh Shanmugam
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Ilankumaran Kaliamoorthy
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
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6
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Perdigoto DN, Tomé L, Diogo D, Ferrão J, Martins R, Oliveira P, Tralhão G, Furtado E. Auxiliary Liver Transplantation as a Transient Treatment for Acute Liver Failure: Two Cases. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:54-58. [PMID: 30675504 DOI: 10.1159/000487155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/25/2018] [Indexed: 12/30/2022]
Abstract
Introduction Acute liver failure is an uncommon condition associated with a high mortality. Most patients do not survive without liver transplantation. In the last decades, auxiliary liver transplantation has emerged as a therapeutic option. Clinical Case The authors present two cases of acute liver failure that required liver transplantation. Given the patients' young age and the preserved macroscopic liver pattern evaluated in surgery, auxiliary liver transplantation was executed using different surgical approaches. Afterwards, following confirmed full native liver regeneration, the patients were submitted to auxiliary liver hepatectomy, which was accomplished without complications. Conclusion Auxiliary liver transplantation can be regarded as an effective temporary treatment for acute liver failure in selected cases, allowing an immunosuppression-free life.
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Affiliation(s)
- David N Perdigoto
- Gastroenterology Department, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Luís Tomé
- Gastroenterology Department, Coimbra University and Hospital Centre, Coimbra, Portugal.,Adult and Paediatric Liver Transplantation Unit, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Dulce Diogo
- Adult and Paediatric Liver Transplantation Unit, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - José Ferrão
- Adult and Paediatric Liver Transplantation Unit, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Ricardo Martins
- Adult and Paediatric Liver Transplantation Unit, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Pedro Oliveira
- Adult and Paediatric Liver Transplantation Unit, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Guilherme Tralhão
- Adult and Paediatric Liver Transplantation Unit, Coimbra University and Hospital Centre, Coimbra, Portugal.,General Surgery Department, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Emanuel Furtado
- Adult and Paediatric Liver Transplantation Unit, Coimbra University and Hospital Centre, Coimbra, Portugal
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7
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Shrivastav M, Rammohan A, Reddy MS, Rela M. Auxiliary partial orthotopic liver transplantation for acute liver failure. Ann R Coll Surg Engl 2018; 101:e71-e72. [PMID: 30482030 DOI: 10.1308/rcsann.2018.0204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Auxiliary partial orthotopic liver transplantation (APOLT) in acute liver failure acts as a bridge to native liver regeneration with potential for immunosuppression free survival. While technical concerns limit its universal acceptance, the indications in acute liver failure also need to be examined for this procedure to ultimately succeed. CASE HISTORY We present the case of an eight-month-old girl with cryptogenic acute liver failure who underwent APOLT. She developed postoperative liver dysfunction, most likely owing to the persistence of the diseased native liver, ultimately leading to an orthotopic retransplantation. She remains well on follow-up review. CONCLUSIONS A tempered approach to selecting patients for APOLT (especially with regard to aetiology of acute liver failure) makes it a safe and effective alternative to orthotopic liver transplantation.
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Affiliation(s)
- M Shrivastav
- Institute of Liver Disease & Transplantation, Gleneagles Global Health City , Chennai , India.,Institute of Liver Disease & Transplantation, Dr.Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research , Chennai , India
| | - A Rammohan
- Institute of Liver Disease & Transplantation, Gleneagles Global Health City , Chennai , India.,Institute of Liver Disease & Transplantation, Dr.Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research , Chennai , India
| | - M S Reddy
- Institute of Liver Disease & Transplantation, Gleneagles Global Health City , Chennai , India.,Institute of Liver Disease & Transplantation, Dr.Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research , Chennai , India
| | - M Rela
- Institute of Liver Disease & Transplantation, Gleneagles Global Health City , Chennai , India.,Institute of Liver Disease & Transplantation, Dr.Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research , Chennai , India.,Institute of Liver Studies, King's College Hospital , London , UK
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8
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Selden C, Khalil M, Hodgson H. Three Dimensional Culture Upregulates Extracellular Matrix Protein Expression in Human Liver Cell Lines - a Step towards Mimicking the Liver in Vivo? Int J Artif Organs 2018. [DOI: 10.1177/039139880002301107] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extracellular matrix (ECM) in the liver affects the phenotype of both hepatocytes and non-parenchymal cells. To be able to mimic in vivo liver function for extracorporeal hepatic support using human cell lines, a necessary step is to upregulate the function normally seen in monolayer culture. 3-D spheroid colonies were formed by culturing single HepG2 cells encapsulated in alginate beads. ECM expression in these cultures was compared to monolayer Hep G2 cultures. The following ECM proteins were detected immunohistochemically:- collagens I, III, V and VI, the glycoproteins fibronectin, tenascin and vitronectin, and the basement membrane protein laminin. In 3-D cultures, all proteins except tenascin were strongly expressed, as compared with weak or undetectable expression in monolayer cultures, even with 10-fold increases in the antibody concentration used. In conclusion, we have demonstrated that the 3-D environment created by alginate encapsulation of cell lines leads to cell behaviour mimicking that in vivo.
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Affiliation(s)
- C. Selden
- Department of Medicine, Royal Free and University College Medical School, London - UK
| | - M. Khalil
- Department of Medicine, Royal Free and University College Medical School, London - UK
| | - H. Hodgson
- Department of Medicine, Royal Free and University College Medical School, London - UK
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9
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Kohli R, Cortes M, Heaton ND, Dhawan A. Liver transplantation in children: state of the art and future perspectives. Arch Dis Child 2018; 103:192-198. [PMID: 28918383 DOI: 10.1136/archdischild-2015-310023] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 07/03/2017] [Accepted: 07/06/2017] [Indexed: 12/13/2022]
Abstract
In this review, we provide a state of the art of liver transplantation in children, as the procedure is now carried out for more than 30 years and most of our paediatric colleagues are managing these patients jointly with liver transplant centres. Our goal for this article is to enhance the understanding of the liver transplant process that a child and his family goes through while explaining the surgical advances and the associated complications that could happen in the immediate or long-term follow-up. We have deliberately introduced the theme that 'liver transplant is a disease' and 'not a cure', to emphasise the need for adherence with immunosuppression, a healthy lifestyle and lifelong medical follow-up.
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Affiliation(s)
- Rohit Kohli
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Miriam Cortes
- Department of Adult and Pediatric Liver Transplant Surgery, Institute of Liver Studies, King's College Hospital, London, UK
| | - N D Heaton
- Department of Adult and Pediatric Liver Transplant Surgery, Institute of Liver Studies, King's College Hospital, London, UK
| | - Anil Dhawan
- Pediatrics Liver GI and Nutrition Centre and MowatLabs, King's College Hospital, London, UK
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10
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Regeneration and Cell Recruitment in an Improved Heterotopic Auxiliary Partial Liver Transplantation Model in the Rat. Transplantation 2017; 101:92-100. [PMID: 28009756 DOI: 10.1097/tp.0000000000001511] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Auxiliary partial liver transplantation (APLT) in humans is a therapeutic modality used especially to treat liver failure in children or congenital metabolic disease. Animal models of APLT have helped to explore therapeutic options. Though many groups have suggested improvements, standardizing the surgical procedure has been challenging. Additionally, the question of whether graft livers are reconstituted by recipient-derived cells after transplantation has been controversial. The aim of this study was to improve experimental APLT in rats and to assess cell recruitment in the liver grafts. METHODS To inhibit recipient liver regeneration and to promote graft regeneration, we treated recipients with retrorsine and added arterial anastomosis. Using green fluorescence protein transgenic rats as recipients, we examined liver resident cell recruitment within graft livers by immunofluorescence costaining. RESULTS In the improved APLT model, we achieved well-regenerated grafts that could maintain regeneration for at least 4 weeks. Regarding the cell recruitment, there was no evidence of recipient-derived hepatocyte, cholangiocyte, or hepatic stellate cell recruitment into the graft. Macrophages/monocytes, however, were consistently recruited into the graft and increased over time, which might be related to inflammatory responses. Very few endothelial cells showed colocalization of markers. CONCLUSIONS We have successfully established an improved rat APLT model with arterial anastomosis as a standard technique. Using this model, we have characterized cell recruitment into the regenerating grafts.
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11
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Cardoso FS, Marcelino P, Bagulho L, Karvellas CJ. Acute liver failure: An up-to-date approach. J Crit Care 2017; 39:25-30. [PMID: 28131021 DOI: 10.1016/j.jcrc.2017.01.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 01/05/2017] [Accepted: 01/09/2017] [Indexed: 12/14/2022]
Abstract
Acute liver failure is a rare but potentially devastating disease. Throughout the last few decades, acute liver failure outcomes have been improving in the context of the optimized overall management. This positive trend has been associated with the earlier recognition of this condition, the improvement of the intensive care unit management, and the developments in emergent liver transplantation. Accordingly, we aimed to review the current diagnostic and therapeutic approach to this syndrome, especially in the intensive care unit setting.
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Affiliation(s)
- Filipe S Cardoso
- Intensive Care Unit, Curry Cabral Hospital, Central Lisbon Hospital Center, Lisbon, Portugal.
| | - Paulo Marcelino
- Intensive Care Unit, Curry Cabral Hospital, Central Lisbon Hospital Center, Lisbon, Portugal
| | - Luís Bagulho
- Intensive Care Unit, Curry Cabral Hospital, Central Lisbon Hospital Center, Lisbon, Portugal
| | - Constantine J Karvellas
- Divisions of Gastroenterology (Liver Unit) and Critical Care, University of Alberta Hospital, Edmonton, Canada
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12
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Rela M, Kaliamoorthy I, Reddy MS. Current status of auxiliary partial orthotopic liver transplantation for acute liver failure. Liver Transpl 2016; 22:1265-74. [PMID: 27357489 DOI: 10.1002/lt.24509] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 05/14/2016] [Accepted: 06/09/2016] [Indexed: 12/11/2022]
Abstract
Auxiliary partial orthotopic liver transplantation (APOLT) is a technique of liver transplantation (LT) where a partial liver graft is implanted in an orthotopic position after leaving behind a part of the native liver. APOLT was previously considered technically challenging with results inferior to orthotopic liver transplantation. Results of this procedure have continued to improve with improving surgical techniques and a better understanding of the natural history of acute liver failure (ALF) and liver regeneration. The procedure is being increasingly accepted as a valid treatment option for ALF-especially in children. This article reviews the historical background to this operation, advances in the technique, and its current place in the management of ALF. Liver Transplantation 22 1265-1274 2016 AASLD.
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Affiliation(s)
- Mohamed Rela
- Institute of Liver Studies, King's College Hospital, London, United Kingdom.,Institute of Liver Disease and Transplantation, Global Hospital, Chennai, India.,National Foundation for Liver Research, Chennai, India
| | | | - Mettu Srinivas Reddy
- Institute of Liver Disease and Transplantation, Global Hospital, Chennai, India.,National Foundation for Liver Research, Chennai, India
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13
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Rathi S, Dhiman RK. Hepatobiliary Quiz Answers-19 (2016). J Clin Exp Hepatol 2016; 6:257-260. [PMID: 27746626 PMCID: PMC5052399 DOI: 10.1016/j.jceh.2016.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Radha K. Dhiman
- Address for correspondence: Radha K. Dhiman, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.Department of Hepatology, Postgraduate Institute of Medical Education and ResearchChandigarh160012India
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14
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Ai L, Liang X, Wang Z, Shen J, Yu F, Xie L, Pan Y, Lin H. A Comparison between splenic fossa and subhepatic fossa auxiliary partial heterotopic liver transplantation in a porcine model. Liver Transpl 2016; 22:812-21. [PMID: 26785299 PMCID: PMC5089560 DOI: 10.1002/lt.24397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 12/15/2015] [Accepted: 12/31/2015] [Indexed: 01/13/2023]
Abstract
To test the alternative possible locations for the placement of a liver graft and the relevant surgical technique issues, we developed a porcine model of auxiliary partial heterotopic liver transplantation (APHLT) and evaluated the difference between 2 styles of liver transplantation, either subhepatic fossa or splenic fossa APHLT, by comparing survival and biochemical indexes. Thirty-eight miniature pigs were randomly divided into 2 groups. A left hemihepatic graft without the middle hepatic vein (HV) was procured from the living donor. In group A (n = 9), an 8 mm diameter polytetrafluoroethylene (PTFE) graft approximately 2.5 cm long was connected to the left HV while another PTFE graft of the same size was connected to the left portal vein (PV). The liver graft was implanted in the right subhepatic fossa following splenectomy and right nephrectomy. In group B (n = 10), a PTFE graft of the same size was connected to the left HV while the liver graft was implanted in the splenic fossa following splenectomy and left nephrectomy. Survival rate and complications were observed at 2 weeks after transplantation. Data were collected from 5 animals in group A and 6 animals in group B that survived longer than 2 weeks. The liver function and renal function of the recipients returned to normal at 1 week after surgery in both groups. Eighty-eight percent (14/16) of the PTFE grafts remained patent at 2 weeks after surgery, but 44% of the PTFE grafts (7/16) developed mural thrombus. No significant differences in the survival rate and biochemistry were found between the 2 groups. In conclusion, the splenic fossa APHLT can achieve beneficial outcomes similar to the subhepatic fossa APHLT in miniature pigs, although it also has a high morbidity rate due to hepatic artery thrombosis, PV thrombosis, and PTEF graft mural thrombus formation. Liver Transplantation 22 812-821 2016 AASLD.
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Affiliation(s)
- Lemin Ai
- Department of General SurgeryThe People's First Hospital of XiaoshanHangzhouZhejiang ProvincePeople's Republic of China
| | - Xiao Liang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of MedicineZhejiang UniversityHangzhouZhejiang ProvincePeople's Republic of China
| | - Zhifei Wang
- Department of General SurgeryZhejiang Province People's HospitalHangzhouZhejiang ProvincePeople's Republic of China
| | - Jie Shen
- Department of General SurgeryThe People's First Hospital of XiaoshanHangzhouZhejiang ProvincePeople's Republic of China
| | - Feiyan Yu
- Department of General SurgeryThe People's First Hospital of XiaoshanHangzhouZhejiang ProvincePeople's Republic of China
| | - Limei Xie
- Department of General SurgeryThe People's First Hospital of XiaoshanHangzhouZhejiang ProvincePeople's Republic of China
| | - Yongming Pan
- Laboratory Animal Research CenterZhejiang Chinese Medical UniversityHangzhouZhejiang ProvincePeople's Republic of China
| | - Hui Lin
- Department of General Surgery, Sir Run Run Shaw Hospital, School of MedicineZhejiang UniversityHangzhouZhejiang ProvincePeople's Republic of China
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15
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Weiner J, Griesemer A, Island E, Lobritto S, Martinez M, Selvaggi G, Lefkowitch J, Velasco M, Tryphonopoulos P, Emond J, Tzakis A, Kato T. Longterm outcomes of auxiliary partial orthotopic liver transplantation in preadolescent children with fulminant hepatic failure. Liver Transpl 2016; 22:485-94. [PMID: 26479577 DOI: 10.1002/lt.24361] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 09/22/2015] [Accepted: 09/29/2015] [Indexed: 02/07/2023]
Abstract
By preserving part of the native liver, auxiliary partial orthotopic liver transplantation (APOLT) provides the advantage of potential immunosuppression (ISP) withdrawal if the native liver recovers but has had limited acceptance, especially in the United States, due to technical complications and low rates of native liver regeneration. No previous study has evaluated APOLT specifically for preadolescent children with fulminant hepatic failure (FHF). This population might benefit especially based on greater capacity for liver regeneration. Data from 13 preadolescent children who underwent APOLT were compared to 13 matched controls who underwent orthotopic liver transplantation (OLT) for FHF from 1996 to 2013. There were no significant differences in patient demographics or survival between the 2 groups. However, all surviving OLT recipients (10/13) remain on ISP, while all but 1 surviving APOLT recipient (12/13) showed native liver regeneration, and the first 10 recipients (76.9%) are currently off ISP with 2 additional patients currently weaning. In our experience, APOLT produced excellent survival and high rates of native liver regeneration in preadolescent children with FHF. This represents the largest series to date to report such outcomes. Liberating these children from lifelong ISP without the downside of increased surgical morbidity makes APOLT an attractive alternative. In conclusion, we therefore propose that, with the availability of technical expertise and with the technical modifications above, APOLT for FHF should be strongly considered for preteenage children with FHF.
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Affiliation(s)
- Joshua Weiner
- Center for Liver Disease and Transplantation, New York Presbyterian-Columbia University Medical Center, New York, NY
| | - Adam Griesemer
- Center for Liver Disease and Transplantation, New York Presbyterian-Columbia University Medical Center, New York, NY
| | - Eddie Island
- Division of Transplant Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Steven Lobritto
- Center for Liver Disease and Transplantation, New York Presbyterian-Columbia University Medical Center, New York, NY
| | - Mercedes Martinez
- Center for Liver Disease and Transplantation, New York Presbyterian-Columbia University Medical Center, New York, NY
| | - Gennaro Selvaggi
- Miami Transplant Institute, University of Miami Health System, Miami, FL
| | - Jay Lefkowitch
- Center for Liver Disease and Transplantation, New York Presbyterian-Columbia University Medical Center, New York, NY
| | - Monica Velasco
- Center for Liver Disease and Transplantation, New York Presbyterian-Columbia University Medical Center, New York, NY
| | | | - Jean Emond
- Center for Liver Disease and Transplantation, New York Presbyterian-Columbia University Medical Center, New York, NY
| | - Andreas Tzakis
- Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston, FL
| | - Tomoaki Kato
- Center for Liver Disease and Transplantation, New York Presbyterian-Columbia University Medical Center, New York, NY
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16
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Donnelly MC, Hayes PC, Simpson KJ. The changing face of liver transplantation for acute liver failure: Assessment of current status and implications for future practice. Liver Transpl 2016; 22:527-35. [PMID: 26823231 DOI: 10.1002/lt.24403] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 01/01/2016] [Accepted: 01/15/2016] [Indexed: 02/07/2023]
Abstract
The etiology and outcomes of acute liver failure (ALF) have changed since the definition of this disease entity in the 1970s. In particular, the role of emergency liver transplantation has evolved over time, with the development of prognostic scoring systems to facilitate listing of appropriate patients, and a better understanding of transplant benefit in patients with ALF. This review examines the changing etiology of ALF, transplant benefit, outcomes following transplantation, and future alternatives to emergency liver transplantation in this devastating condition.
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Affiliation(s)
- Mhairi C Donnelly
- Department of Hepatology, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Scottish Liver Transplantation Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Peter C Hayes
- Department of Hepatology, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Scottish Liver Transplantation Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Kenneth J Simpson
- Department of Hepatology, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Scottish Liver Transplantation Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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17
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Duan WD, Wang XT, Wang HG, Ji WB, Li H, Dong JH. Auxiliary partial liver transplantation for acute liver failure using "high risk" grafts: Case report. World J Gastroenterol 2016; 22:1919-1924. [PMID: 26855552 PMCID: PMC4724624 DOI: 10.3748/wjg.v22.i5.1919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 09/11/2015] [Accepted: 11/09/2015] [Indexed: 02/06/2023] Open
Abstract
Acute liver failure (ALF) is a reversible disorder that is associated with an abrupt loss of hepatic mass, rapidly progressive encephalopathy and devastating complications. Despite its high mortality, an emergency liver transplantation nowadays forms an integral part in ALF management and has substantially improved the outcomes of ALF. Here, we report the case of a 32-year-old female patient who was admitted with grade IV hepatic encephalopathy (coma) following drug-induced ALF. We performed an emergency auxiliary partial orthotopic liver transplantation with a “high risk” graft (liver macrovesicular steatosis approximately 40%) from a living donor. The patient was discharged on postoperative day 57 with normal liver function. Weaning from immunosuppression was achieved 9 mo after transplantation. A follow-up using CT scan showed a remarkable increase in native liver volume and gradual loss of the graft. More than 6 years after the transplantation, the female now has a 4-year-old child and has returned to work full-time without any neurological sequelae.
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18
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19
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Ringers J, Bloemenkamp K, Francisco N, Blok JJ, Arbous MS, van Hoek B. Auxiliary or orthotopic liver transplantation for acute fatty liver of pregnancy: case series and review of the literature. BJOG 2015; 123:1394-1398. [PMID: 26449726 DOI: 10.1111/1471-0528.13707] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2015] [Indexed: 12/17/2022]
Affiliation(s)
- J Ringers
- Department of Transplant Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Kwm Bloemenkamp
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands
| | - N Francisco
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - J J Blok
- Department of Transplant Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - M S Arbous
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - B van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
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20
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Garcia J, Oliveira A, de Pinho PG, Freitas V, Carvalho A, Baptista P, Pereira E, de Lourdes Bastos M, Carvalho F. Determination of amatoxins and phallotoxins in Amanita phalloides mushrooms from northeastern Portugal by HPLC-DAD-MS. Mycologia 2015; 107:679-687. [PMID: 25911698 DOI: 10.3852/14-253] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 03/23/2015] [Indexed: 09/01/2023]
Abstract
Amanita phalloides is a toxic mushroom responsible for the majority of deaths occurring after mushrooms ingestion, mainly due to amatoxins. In the present study the contents and distribution of the major amatoxins and phallotoxins in different tissues of A. phalloides from two different sites of Portugal were analyzed by liquid chromatography (LC) coupled to diode array (DAD) and mass spectrometry (MS) detection. The main toxins were separated by LC and its chemical structures confirmed by MS. α-Amanitin contents in caps, stipe and volva tissues were quantified by RP-HPLC. The results show that caps have the highest content of amatoxins, whereas the volva was richest in phallotoxins. Moreover variability in the toxins composition from different geographic sites was also observed. This study provides for the first time the content of toxins in A. phalloides from Portugal.
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Affiliation(s)
- Juliana Garcia
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, Faculty of Medicine & Health Sciences, University of Nottingham, Royal Derby Hospital Centre, Derby, NG7 2UH, United Kingdom
| | - Ana Oliveira
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, Faculty of Medicine & Health Sciences, University of Nottingham, Royal Derby Hospital Centre, Derby, NG7 2UH, United Kingdom
| | - Paula Guedes de Pinho
- UCBIO-REQUIMTE/Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Victor Freitas
- Centro de Investigação em Química, Departamento de Química, Faculdade de Ciências, Universidade do Porto, Porto, Portugal
| | - Alexandra Carvalho
- Institute of Computational Chemistry and Department of Chemistry, University of Girona, 17071 Girona, Spain
| | - Paula Baptista
- CIMO/School of Agriculture, Polytechnic Institute of Bragança, Campus de Santa Apolónia, Apartado 1172, 5301-854 Bragança, Portugal
| | - Eric Pereira
- CIMO/School of Agriculture, Polytechnic Institute of Bragança, Campus de Santa Apolónia, Apartado 1172, 5301-854 Bragança, Portugal
| | - Maria de Lourdes Bastos
- UCBIO-REQUIMTE/Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Félix Carvalho
- UCBIO-REQUIMTE/Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
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21
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Rajput I, Prasad KR, Bellamy MC, Davies M, Attia MS, Lodge JPA. Subtotal hepatectomy and whole graft auxiliary transplantation for acetaminophen-associated acute liver failure. HPB (Oxford) 2014; 16:220-8. [PMID: 23870048 PMCID: PMC3945847 DOI: 10.1111/hpb.12124] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 03/17/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND An acetominophen overdose (AOD) is the leading cause of acute liver failure (ALF) in the UK and USA. For patients who meet the King's College Hospital criteria, (mortality risk > 85%), an emergency orthotopic liver transplantation (OLT) is conventionally performed with subsequent life-long immunosuppression. A new technique was developed in 1998 for AOD-induced ALF where a subtotal hepatectomy (right hepatic trisectionectomy) and whole graft auxiliary liver transplant (WGALT) was performed with complete withdrawal of immunosupression during the first year post-operatively. RESULTS During 1998-2010, 68 patients were listed for an emergency transplantation for AOD ALF at our institution: 28 died waiting, 16 underwent OLT and 24 a subtotal hepatectomy with WGALT. Eight OLT (50%) and 16 WGALT remain alive (67%); actuarial survival at 5 years OLT 50%, WGALT 63%, P = 0.37. All patients who had successful WGALT are off immunosuppression. Poor prognostic factors in the WGALT group included higher donor age (40.4 versus 53.9, P = 0.043), requirements for a blood transfusion (4.3 versus 7.6, P = 0.0043) and recipient weight (63.1 versus 54 kg, P = 0.036). CONCLUSION Although OLT remains standard practice for AOD-induced ALF, life-long immunosuppression is required. A favourable survival rate using a subtotal hepatectomy and WGALT has been demonstrated, and importantly, all successful patients have undergone complete immunosuppression withdrawal. This technique is advocated for patients who have acetominophen hepatotoxicity requiring liver transplantation.
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Affiliation(s)
- Ibrahim Rajput
- HPB and Transplant Unit, St. James's University HospitalLeeds, UK
| | | | - Mark C Bellamy
- Department of Anaesthesia, St. James's University HospitalLeeds, UK
| | - Mervyn Davies
- Department of Hepatology, St. James's University HospitalLeeds, UK
| | - Magdy S Attia
- HPB and Transplant Unit, St. James's University HospitalLeeds, UK
| | - J Peter A Lodge
- HPB and Transplant Unit, St. James's University HospitalLeeds, UK
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22
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Abstract
Acute liver failure (ALF) is a condition wherein the previously healthy liver rapidly deteriorates, resulting in jaundice, encephalopathy, and coagulopathy. There are approximately 2000 cases per year of ALF in the United States. Viral causes (fulminant viral hepatitis [FVH]) are the predominant cause of ALF in developing countries. Given the ease of spread of viral hepatitis and the high morbidity and mortality associated with ALF, a systematic approach to the diagnosis and treatment of FVH is required. In this review, the authors describe the viral causes of ALF and review the intensive care unit management of patients with FVH.
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MESH Headings
- Acetylcysteine/therapeutic use
- Adult
- Brain Edema/etiology
- Brain Edema/virology
- Developing Countries
- Female
- Hepatectomy
- Hepatitis, Viral, Human/complications
- Hepatitis, Viral, Human/drug therapy
- Hepatitis, Viral, Human/prevention & control
- Herpesviridae/pathogenicity
- Humans
- Hypothermia, Induced/adverse effects
- Hypothermia, Induced/standards
- Immunocompromised Host
- Intensive Care Units
- Intubation, Intratracheal
- Liver Failure, Acute/etiology
- Liver Failure, Acute/therapy
- Liver Failure, Acute/virology
- Liver Transplantation
- Pregnancy
- Pregnancy Complications, Infectious/virology
- Prognosis
- Viral Hepatitis Vaccines/administration & dosage
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Affiliation(s)
- Saumya Jayakumar
- Faculty of Medicine and Dentistry, Division of Gastroenterology, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
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23
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Ohno Y, Mita A, Ikegami T, Masuda Y, Urata K, Nakazawa Y, Kobayashi A, Terada M, Ikeda S, Miyagawa S. Temporary auxiliary partial orthotopic liver transplantation using a small graft for familial amyloid polyneuropathy. Am J Transplant 2012; 12:2211-9. [PMID: 22500969 DOI: 10.1111/j.1600-6143.2012.04061.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Donor shortage is a major issue in liver transplantation. We have successfully performed temporary auxiliary partial orthotopic liver transplantation (APOLT) using a small volume graft procured from a living donor for recipients with familial amyloid polyneuropathy (FAP). The aim of this study was to evaluate this procedure by comparing it with standard living donor liver transplantation (LDLT). We compared 13 recipients undergoing this procedure with 23 recipients undergoing a standard LDLT for the treatment of FAP. The estimated donor graft volume and the graft volume/recipient's standard liver volume ratio were significantly smaller in the temporary APOLT group than in the standard LDLT group. Postoperative complications were comparable, although the hospital stay was longer in the temporary APOLT group. All the patients safely underwent a remnant native liver resection about 2 months after their first operation in the temporary APOLT group. No symptoms related to FAP developed before the remnant liver resection, and no significant differences in graft and patient survival were observed between the two groups. We successfully performed temporary APOLT using a small volume liver graft without postoperative liver failure for FAP. Temporary APOLT for FAP might be a useful alternative procedure for expanding the donor pool for LDLT.
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Affiliation(s)
- Y Ohno
- Department of Surgery, Division of Transplantation, Shinshu University School of Medicine, Matsumoto, Japan
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24
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Integrating repopulation and regeneration of the auxiliarily transplanted small liver graft: the solution for organ shortage and immunosuppression. Med Hypotheses 2012; 79:241-5. [PMID: 22608859 DOI: 10.1016/j.mehy.2012.04.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 04/27/2012] [Indexed: 01/17/2023]
Abstract
Cirrhosis is a common yet generally irreversible medical condition which would cause damaged liver function and regeneration after resection. When the disease progressed to end stage, liver transplantation, cadaveric or live donor, would be the only way to eliminate the disease. But both have their confinements, such as organ shortage, detriments to the donors, and immunosuppression. Now that the techniques of auxiliary transplantation are in practice, and the phenomenon of graft repopulated by cells of host origin has been observed, and that elevated blood inflow would stimulate the regenerative response, the combination of the three might give rise to a non-immunogeneic customized liver. We hypotheses that it can be achieved through a auxiliary transplantation of a extremely small but normal graft combined with progressive portal control on the portal inflow of the native liver to induce atrophy of the cirrhotic liver and the regeneration of the graft, as well as postoperative administration of bone marrow mobilizing agents and reduced administration of immunosuppressants to initiate repopulation. This will not only solve the issue of organ shortage as one organ can be shared by more, and in case of live donor, less detriments would occur due to reduced size needed; but diminish, even eliminate the adverse effect caused by immunosuppression as well.
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25
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Abstract
PURPOSE OF REVIEW Auxiliary liver transplantation (ALT) has developed as a technique for treating patients with acute liver failure. The surgical techniques of ALT have been refined and current patient survival appears to be similar to that observed with conventional liver replacement for acute liver failure. RECENT FINDINGS Our understanding of liver regeneration has improved with experience and it is possible to identify patient and disease groups that are more likely to regenerate and wean off immunosuppression after ALT. Withdrawal of immunosuppression is possible in at least two thirds of survivors up to 4 years post transplant. Young patients have most to gain in the long term from immunosuppression withdrawal. Documentation of liver regeneration should be performed by liver histology, nuclear medicine scanning and CT volumetry. Weaning should be gradual to allow for graft atrophy to avoid complications. ALT has also been utilised for the management of inborn errors of metabolism based in the liver and for other rare problems and these will be briefly addressed in the review. SUMMARY Auxiliary liver transplantation should be considered for the treatment of children with acute liver failure satisfying current criteria for liver transplantation.
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26
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Ford RM, Sakaria SS, Subramanian RM. Critical care management of patients before liver transplantation. Transplant Rev (Orlando) 2010; 24:190-206. [PMID: 20688502 DOI: 10.1016/j.trre.2010.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 05/26/2010] [Accepted: 05/28/2010] [Indexed: 02/07/2023]
Abstract
The critical care management of patients before liver transplantation is aimed at optimizing hepatic and extrahepatic organ function before the transplant operation, with a goal to favorably influence perioperative and postoperative graft and patient outcomes. Critical illness in liver disease can present in the context of acute liver failure or acute on chronic liver failure. The differing pathophysiologic processes underlying these 2 types of liver failure necessitate specific approaches to their intensive care management. In their extreme presentations, both types of liver failure present as multiorgan system failure; and therefore, the critical care management of these entities requires a systematic multiorgan system approach to address hepatic and extrahepatic organ dysfunction. This review provides a multiorgan system-based description of critical care management of acute liver failure and acute on chronic liver failure before liver transplantation.
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Affiliation(s)
- Ryan M Ford
- Division of Gastroenterology and Hepatology, Emory University School of Medicine, Atlanta, GA, USA
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27
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Abstract
Acute liver failure is a rare disorder with high mortality and resource cost. In the developing world, viral causes predominate, with hepatitis E infection recognised as a common cause in many countries. In the USA and much of western Europe, the incidence of virally induced disease has declined substantially in the past few years, with most cases now arising from drug-induced liver injury, often from paracetamol. However, a large proportion of cases are of unknown origin. Acute liver failure can be associated with rapidly progressive multiorgan failure and devastating complications; however, outcomes have been improved by use of emergency liver transplantation. An evidence base for practice is emerging for supportive care, and a better understanding of the pathophysiology of the disorder, especially in relation to hepatic encephalopathy, will probably soon lead to further improvements in survival rates.
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MESH Headings
- Acetaminophen/adverse effects
- Ammonia/metabolism
- Analgesics, Non-Narcotic/adverse effects
- Chemical and Drug Induced Liver Injury/epidemiology
- Chemical and Drug Induced Liver Injury/etiology
- Emergency Treatment/methods
- Europe/epidemiology
- Global Health
- Hepatic Encephalopathy/epidemiology
- Hepatic Encephalopathy/etiology
- Hepatitis, Viral, Human/complications
- Hepatocytes/transplantation
- Humans
- Liver Failure, Acute/chemically induced
- Liver Failure, Acute/classification
- Liver Failure, Acute/epidemiology
- Liver Failure, Acute/etiology
- Liver Failure, Acute/mortality
- Liver Failure, Acute/physiopathology
- Liver Failure, Acute/surgery
- Liver Failure, Acute/virology
- Liver Transplantation
- Patient Selection
- Prognosis
- Severity of Illness Index
- Survival Rate
- Time Factors
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Affiliation(s)
- William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, King's College Hospital, London, UK.
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28
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Abstract
Fulminant hepatic failure is a life-threatening condition that can lead to rapid deterioration and death if timely treatment is not instituted. Many patients recover with supportive care. Patients with deteriorating signs and laboratory parameters require prompt assessment and listing for liver transplantation. Outcome following transplantation is a function of severity of illness before transplantation, timeliness of liver transplantation and graft quality and function. With appropriate immunosuppression and close follow-up most patients can lead near normal lives following liver transplantation.
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Affiliation(s)
- Ajai Khanna
- Abdominal Transplant and Hepatobiliary Surgery, Department of Surgery, University of California San Diego School of Medicine, 200 West Arbor Drive, San Diego, CA 92103-8401, USA.
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29
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Kobayashi T, Sato Y, Yamamoto S, Takeishi T, Oya H, Hideki N, Kokai H, Kurosaki I, Hatakeyama K. Auxiliary Partial Orthotopic Living Donor Liver Transplantation for Fulminant Hepatic Failure With Flat Electroencephalogram: A Case Report. Transplant Proc 2010; 42:990-3. [DOI: 10.1016/j.transproceed.2010.03.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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30
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Abstract
OBJECTIVE The aim of this study is to present the largest experience of auxiliary liver transplantation for acute liver failure (ALF) in children over the past 19 years. METHODS Between 1990 and 2009, a total of 128 liver transplants were performed on children with ALF. Of these, 20 received auxiliary liver transplants (19 were cadaveric and 1 living graft). The recipient median age was 12 years (range: 1 -16). Indications for auxiliary partial orthotopic liver transplantation were seronegative non-A non-B hepatitis in 16 children, drug induced in 2, and 1 autoimmune hepatitis and 1 mushroom poisoning. The median waiting time for transplantation was 2 days (range: 1-9). After native liver partial hepatectomy, 20 grafts were implanted orthotopically and included 8 right lobes, 8 left lateral segments, 3 left lobes, and 1 whole liver. Regeneration of the native liver was assessed by radiologic, nuclear medicine imaging, and histology. Follow-up imaging and biopsies were performed at intervals of 3 to 6 months and yearly. RESULTS Patient survival was 85% at 1, 5, and 10 years. There were 3 deaths at a median of 9 days (range: 8-52) post-transplantation. There was 1 retransplant for chronic rejection 15 months post-transplantation. There were no biliary or vascular complications. Of 17 survivors, 14 (82%) have successfully regenerated their native liver and so far 11 children (65% of the survivors) have been withdrawn from immunosuppression at a median time of 23 months (range: 4-106) after transplantation. CONCLUSION Auxiliary partial orthotopic liver transplantation should be considered in children presenting with ALF who fulfill criteria for liver transplantation.
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31
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Polak WG, Peeters PM, Slooff MJ. The evolution of surgical techniques in clinical liver transplantation. A review. Clin Transplant 2009; 23:546-64. [DOI: 10.1111/j.1399-0012.2009.00994.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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32
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33
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22 Levertransplantatie. LEVERZIEKTEN 2009. [PMCID: PMC7121307 DOI: 10.1007/978-90-313-7437-3_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In 1963 verrichtte Thomas Starzl in Denver de eerste levertransplantatie bij de mens. In 1966 werden in Nederland de eerste twee (auxiliaire, zie par. 22.3.6) levertransplantaties verricht in Leiden en Arnhem, in 1968 startte Cambridge. Helaas resulteerden de eerste levertransplantaties niet in langetermijnoverleving als gevolg van niet-optimale operatietechniek, matige immuunsuppressie en onbekendheid met complicaties.
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34
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Abstract
Acute liver failure (ALF) is defined by the presence of hepatic encephalopathy due to severe liver damage in patients without pre-existing liver disease. Although the mortality of ALF without liver transplantation is over 80%, the survival rates of ALF patients have improved considerably with the advent of liver transplantation, up to 60-80% in the last decade. Living donor liver transplantation (LDLT), which has mainly evolved in Asian countries where organ availability from deceased donors is extremely scarce, has also improved the survival rate of ALF patients. According to recent reports, the overall survival rate of adult ALF patients who underwent LDLT is 60% to 90%. Although there is still controversy regarding the graft type, the optimal graft volume, and ethical issues of defining the indications for LDLT in ALF patients with respect to donor risk, LDLT has become an established treatment option for ALF in areas where the use of deceased donors organs is severely restricted.
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Affiliation(s)
- Nobuhisa Akamatsu
- Department of Hepato-biliary-pancreatic Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
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35
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Haberal M, Sevmis S, Karakayali H, Ozcay F, Moray G, Arslan G. Long-term survival in a patient after heterotopic segmental auxiliary liver transplantation. Pediatr Transplant 2008; 12:816-20. [PMID: 18972619 DOI: 10.1111/j.1399-3046.2007.00823.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Auxiliary liver transplantation has been used mostly for patients with acute liver failure, but between 1980 and 2000, it has gained wider application for patients with both acute and chronic liver diseases. It is particularly applicable in patients in whom there is specific indication for removing the native liver. However, to date, very few patients have survived auxiliary liver transplantation in the long term. In this report, we describe a patient with normal liver function following heterotopic segmental auxiliary liver transplantation whom we followed for nine yr.
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Affiliation(s)
- Mehmet Haberal
- Department of General Surgery and Transplantation, Baskent University Faculty of Medicine, Ankara, Turkey.
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Ding GKA, Buckley NA. Evidence and consequences of spectrum bias in studies of criteria for liver transplant in paracetamol hepatotoxicity. QJM 2008; 101:723-9. [PMID: 18606611 DOI: 10.1093/qjmed/hcn077] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE In severe paracetamol hepatotoxicity, orthotopic liver transplant (OLT) is a standard treatment in patients judged to have a hopeless prognosis. The most commonly used criteria to make this decision are the King's College Criteria (KCC). We aimed to compare the expected survival for patients who meet the KCC and do not receive transplant and those who receive OLT. METHODS A systematic review of studies of survival in patients who met the KCC according to whether they were transplanted. Data from these studies was extrapolated to compare long-term survival with and without adjustment for Quality of Life. RESULTS The survival of patients meeting KCC and undergoing transplant has not been specifically studied. UK data on transplants for acute liver failure indicate 1 and 10 year survival rates of 65 and 44%, respectively. Survival in those without transplant was documented in 15 studies. The average long-term survival rate was 24.9%. Survival was worse in studies originating in the King's unit (13.8 vs. 30.0%). It was apparent that this may be due to spectrum bias occurring in this much larger unit. There was clear evidence that those with the best prognosis were preferentially transplanted at the Kings liver unit, indicating the criteria may perform significantly worse at predicting death without transplant than previously estimated. Even so, for a 20-year-old meeting KCC, the best estimate of life expectancy with transplant (13.5 years) is no better than without (13.4 years). Adjustment for quality of life made OLT clearly a worse option. CONCLUSION Criteria for OLT that have a much higher positive predictive value (for death without transplant) are required. Such studies must be conducted only on those who would be considered suitable for transplant. Non-orthotopic liver transplant may be a preferred option in such circumstances, although much more data on survival after this procedure are required.
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Affiliation(s)
- G K A Ding
- Australian National University Medical School, ACT, Australia
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Schleimer K, Stippel D, Kasper HU, Allwissner R, Yavuzyasar S, Hölscher A, Beckurts K. Competition Between Native Liver and Graft in Auxiliary Liver Transplantation in a Rat Model. Transplant Proc 2008; 40:967-70. [DOI: 10.1016/j.transproceed.2008.03.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Emergency Subtotal Hepatectomy: A New Concept for Acetaminophen-Induced Acute Liver Failure. Ann Surg 2008; 247:238-49. [DOI: 10.1097/sla.0b013e31816401ec] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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39
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Diagnosis and Management of Liver Failure in the Adult. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50078-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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40
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Ringers J, Dubbeld J, Baranski AG, Coenraad M, Sarton E, Schaapherder AFM, van Hoek B. Reuse of auxiliary liver grafts in second recipients with chronic liver disease. Am J Transplant 2007; 7:2615-8. [PMID: 17927609 DOI: 10.1111/j.1600-6143.2007.01959.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We describe the first cases of reuse of auxiliary liver grafts for orthotopic transplantation in chronic liver disease. A reduced liver graft (segments 2, 3, half of 4) was first transplanted auxiliary for acute liver failure using a new technique. After regeneration of both native liver and graft, the auxiliary graft was removed and immunosuppression discontinued in the first recipients. After informed consent of donors and recipients, both auxiliary grafts were then orthotopically transplanted into second recipients. Both grafts function normally. Reuse of auxiliary grafts may help to reduce the shortage or liver grafts available for transplantation.
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Affiliation(s)
- J Ringers
- Department of Transplant Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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41
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Lee SG, Ahn CS, Kim KH. Which types of graft to use in patients with acute liver failure? (A) Auxiliary liver transplant (B) Living donor liver transplantation (C) The whole liver. (B) I prefer living donor liver transplantation. J Hepatol 2007; 46:574-8. [PMID: 17316870 DOI: 10.1016/j.jhep.2007.01.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- S G Lee
- Hepato-Biliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, SongPa-gu, Poongap-2dong 388-1, Seoul 138-736, Republic of Korea.
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Jaeck D, Pessaux P, Wolf P. Which types of graft to use in patients with acute liver failure? (A) Auxiliary liver transplant (B) Living donor liver transplantation (C) The whole liver. (A) I prefer auxiliary liver transplant. J Hepatol 2007; 46:570-3. [PMID: 17313991 DOI: 10.1016/j.jhep.2007.01.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Daniel Jaeck
- Centre de Chirurgie Viscérale et de Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Université Louis Pasteur, Avenue Molière, 67098 Strasbourg, France.
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43
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Lange R, Rauen U, Janssen H, Erhard J, de Groot H. Temporary heterotopic auxiliary liver transplantation with arterialization of the portal vein as treatment of acute liver failure. Transpl Int 2007; 20:473-4. [PMID: 17263787 DOI: 10.1111/j.1432-2277.2007.00452.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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44
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Ringers J, Baranski AG, Dubbeld J, Sarton E, Veenendaal RA, Schaapherder AFM, van der Linden E, Terpstra OT, van Hoek B. A novel technique for auxiliary partial liver transplantation with reno-portal anastomosis and avoidance of the hepatoduodenal ligament. Am J Transplant 2006; 6:2802-8. [PMID: 17049066 DOI: 10.1111/j.1600-6143.2006.01538.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Auxiliary liver transplantation (ALT) is a treatment for acute liver failure when regeneration of the native liver is possible or for metabolic disorders. In selected cases ALT and orthotopic liver transplantation (OLT) have similar survival when ALT is performed in the orthotopic position (auxiliary partial orthotopic liver transplantation, APOLT). Drawback of ALT with portal vein to portal vein anastomosis is the frequent occurrence of thrombosis, compromising both graft and native liver, and the necessity of a significant resection. To avoid division of portal flow we performed ALT with an end-to-end anastomosis between the graft portal vein and the left renal vein of the recipient (reno-portal ALT, REPALT). The hepatic artery was anastomosed to the aorta using an iliac arterial graft conduit. The bile duct was anastomosed to the stomach. In the two cases presented here excellent immediate graft function occurred with rapid regeneration of the graft and without early vascular complications.
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Affiliation(s)
- J Ringers
- Department of Transplant Surgery, Leiden Univ ersity Medical Center, Leiden, The Netherlands
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45
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Fernández-Rodríguez OM, Palenciano CG, Ríos A, Martínez L, Arance M, Segura B, Martín-Gil R, Conesa C, Sansano T, Acosta F, Ramírez P, Parrilla P. Hemodynamic Assessment During Auxiliary Heterotopic Liver Transplantation With Portal Vein Arterialization in a Swine Model: Preliminary Report of 10 Transplants. Transplant Proc 2006; 38:2603-5. [PMID: 17098014 DOI: 10.1016/j.transproceed.2006.08.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
UNLABELLED Portal vein arterialization (PVA) is a technical variation of auxiliary heterotopic liver transplantation (AHLT) that is rarely studied but that simplifies the AHLT surgical technique because it does not act on the portal area. The objective of this study was to analyze the hemodynamic consequences of this auxiliary transplant in an experimental model. MATERIALS AND METHODS Ten AHLT-PVA were analyzed in a pig model. A PiCCO (Pulsion) monitor was used for the hemodynamic study of the recipient. The following were measured: cardiac index, (CI), systemic vascular resistance index, (SVRI), mean arterial pressure (MAP), global end-diastolic volume, central venous pressure, and intrathoracic blood volume. The measurements were taken at four times during transplant: at baseline, after inferior vena cava clamping, after graft reperfusion, and at closure. RESULTS After graft reperfusion there was a reduction in SVRI (968 +/- 168.03 vs 1686.25 +/- 290.66; P < .05) and in MAP, and there was an increase in CI. At the end of the transplant MAP and SVRI recovered (1254.2 +/- 225.79 vs 968 +/- 168.03; P < .05) but CI remained slightly high. The end-diastolic volume showed greater variation than central venous pressure, although this was only statistically significant at the inferior vena cava clamping phase (244.75 +/- 52.05 vs 333.37 +/- 170.13; P < .05). DISCUSSION Heterotopic liver transplantation with portal arterialization is well-tolerated hemodynamically. Graft reperfusion decreases SVRI and increases CI to compensate for this. This behavior, which in healthy recipients like ours is not a problem, could imply a contraindication in patients with a prior hyperdynamic state.
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Affiliation(s)
- O M Fernández-Rodríguez
- Unit of Experimental Surgery, Departament of Surgery, Arrixaca University Hospital, 30120 El Palmar, Murcia, Spain.
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46
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Schleimer K, Stippel DL, Kasper HU, Tawadros S, Suer C, Schomäcker K, Hölscher A, Beckurts KTE. Auxiliary liver transplantation with flow-regulated portal vein arterialization offers a successful therapeutic option in acute hepatic failure--investigations in heterotopic auxiliary rat liver transplantation. Transpl Int 2006; 19:581-8. [PMID: 16764637 DOI: 10.1111/j.1432-2277.2006.00291.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Heterotopic auxiliary liver transplantation (HALT) with portal vein arterialization (PVA) was proposed in acute hepatic failure (AHF). However, clinical results of PVA are controversial because of lacking standardized flow-regulation. In rats, we examined HALT with flow-regulated PVA in AHF. Group A: HALT with flow-regulated PVA and 85% resection of the native liver to induce AHF [acute experiments (n = 8), killing after 7 days (n = 8) and after 6 weeks (n = 11)]. Group B: 85% liver-resection (n = 10). The average blood-flow in the arterialized portal vein in HALT achieved normal values (1.7 +/- 0.4 ml/min/g liver-weight). After reperfusion, the diameters of the sinusoids (6.4 +/- 0.6 microm), the postsinusoidal venules (31.1 +/- 3.3 microm) and the intersinusoidal distance (17.9+/-0.7 microm) also achieved normal values. The functional sinusoidal density amounted to 335 +/- 48/cm. The 6-week survival was nine of 11 with excellent liver function (Quick's value: 110% +/- 7.8%). The hepatobiliary radioisotope scanning with (99mTc) ethyl hepatic iminodiacetic acid (EHIDA) showed no significant differences between the native livers and grafts. The hepatocellular morphology was regular, apart from low-grade necroses in two grafts. The grafts' sinusoidal endothelial cells did not show any morphological changes. In group B, however, all rats died from AHF within 6 days. HALT with flow-regulated PVA achieved good results regarding microcirculation, morphology and function and can reliably bridge AHF.
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Affiliation(s)
- Karina Schleimer
- Department of Visceral and Vascular Surgery, University of Cologne, Cologne, Germany.
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47
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Fernández-Rodríguez OM, Ríos A, Navarro JL, Pons JA, Palenciano CG, Mota R, Berenguer JJ, Mulero F, Contreras J, Conesa C, Ramírez P, Fuente T, Parrilla P. Doppler ultrasonographic and scintigraphic assessment of an auxiliary heterotopic liver transplantation with portal vein arterialization in pigs. Transplant Proc 2006; 38:963-6. [PMID: 16647519 DOI: 10.1016/j.transproceed.2006.02.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Our aim was to evaluate liver graft integrity and function using scintigraphy and ultrasonography in a porcine model of auxiliary heterotopic liver transplantation with portal vein arterialization (AHLT-PVA). MATERIALS AND METHODS Using Doppler ultrasonography we evaluated eight AHLT-PVA by parenchymal echogenicity, portal and arterial anatomy, and portal and biliary system flow. Two types of scintigraphy were performed: microaggregated human albumin colloid scintigraphy and diisopropyl iminodiacetic acid (DISIDA) scintigraphy, both labeled with 99mTc. RESULTS The animals were distributed into two groups. The first group consisted of three animals with clinical suspicion of graft dysfunction, in which the ultrasonographic study revealed areas of parenchymal destructuring. In the scintigraphic study, heterogenous uptake was observed; there was no uptake in one animal. Necropsy of these three animals revealed areas of graft necrosis. The second group consisted of five animals with good clinical evolutions, in which the ultrasonographic study showed portal dilation, portal flow with arterial spiculations, and homogenous echogenicity of the hepatic parenchyma. The scintigraphic study revealed homogenous uptake by the graft and an elimination speed of the hepatobiliary agent similar to that of the native liver. CONCLUSIONS An heterogenous echostructure of the graft provided a sign of poor prognosis indicating necrosis in the same way as heterogenous uptake or nonuptake of radioisotope upon scintigraphy. Scintigraphy is a good method to evaluate biliary function and bile elimination. In an AHLT-PVA, the main ultrasound findings derived from arterialization were dilation of the portal system and portal flow with arterial spiculations.
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Affiliation(s)
- O M Fernández-Rodríguez
- Unit of Experimental Surgery, Department of Surgery, Arrixaca University Hospital, Murcia, Spain.
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Targhetta S, Villamil F, Inturri P, Pontisso P, Fagiuoli S, Cillo U, Cecchetto A, Gianni S, Naccarato R, Burra P. Protocol liver biopsies in long-term management of patients transplanted for hepatitis B-related liver disease. World J Gastroenterol 2006; 12:1706-12. [PMID: 16586538 PMCID: PMC4124344 DOI: 10.3748/wjg.v12.i11.1706] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the long-term histological outcome of patients transplanted for HBV-related liver disease and given HBIg prophylaxis indefinitely after LT.
METHODS: Forty-two consecutive patients transplanted for hepatitis B were prospectively studied. HBsAg, HBV-DNA and liver function tests were evaluated in the serum 3, 6 and 12 mo after LT and then yearly. LB was obtained 6 and 12 mo after LT and yearly thereafter. Chronic hepatitis (CH) B after LT was classified as minimal, mild, moderate or severe.
RESULTS: HBV recurred in 7/42 (16.6 %) patients after 6-96 mo of follow-up. A hundred and eighty-seven LB were evaluated. Four of 7 patients with graft reinfection, all with unknown HBV DNA status before LT, developed cirrhosis at 12-36 mo of follow-up. Of the 122 LB obtained from 28 HBsAg+/HCV- recipients with no HBV recurrence after LT, all biopsies were completely normal in only 2 patients (7.1 %), minimal/non-specific changes were observed in 18 (64.2 %), and at least 1 biopsy showed CH in the remaining 8 (28.5 %). Twenty-nine LB obtained from 7 patients transplanted for HBV-HCV cirrhosis and remaining HBsAg- after LT revealed recurrent CH-C. Actuarial survival was similar in patients with HBsAg+ or HBsAg- liver diseases.
CONCLUSION: Though protocol biopsies may enable the detection of graft dysfunction at an early stage, the risk of progression and the clinical significance of these findings remains to be determined.
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Affiliation(s)
- Stefano Targhetta
- Department of Surgical and Gastroenterological Sciences, Gastroenterology Section, University Hospital, University of Padua, Via Giustiniani 2, 35128 Padua, Italy
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49
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Du WB, Li LJ, Huang JR, Yang Q, Liu XL, Li J, Chen YM, Cao HC, Xu W, Fu SZ, Chen YG. Effects of artificial liver support system on patients with acute or chronic liver failure. Transplant Proc 2006; 37:4359-64. [PMID: 16387120 DOI: 10.1016/j.transproceed.2005.11.044] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS Acute on chronic liver failure (AoCLF) is associated with a high mortality rate. Artificial liver support system (ALSS) is useful to bridge patients with liver failure to liver transplantation or to regenerate their own livers. The aims of this prospective study were to investigate the effects of ALSS on clinical manifestations, liver function, and 30-day survival to probe the factors related to mortality in patients with AoCLF. METHODS In this study, 338 enrolled patients with AoCLF who received ALSS treatment for 1 to 8 sessions, were compared with 312 patients treated with conventional medications. RESULTS Clinical manifestations and liver functions were significantly improved, namely, decreased levels of serum transaminases, total bilirubin, and bile acid, as well as increased levels of serum albumin following ALSS treatment. The 30-day survival rates of the patients who received ALSS versus controls were 47.9% versus 34.6%, respectively (P = .01). The MELD score and the stage of hepatic encephalopathy were highly associated with mortality (P < .001), but the sessions of ALSS showed a positive relation to the 30-day survival (P < .05). CONCLUSIONS ALSS appears to be efficacious and safe for the treatment of patients with AoCLF. Both model for end-stage liver disease (MELD) score and hepatic encephalopathy are useful to predict the mortality of patients.
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Affiliation(s)
- W B Du
- Key Laboratory of Infectious Diseases, Ministry of Public Health of China, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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50
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Fernández OM, Ríos A, Sánchez A, Palenciano CG, Martínez L, Conesa C, Montoya M, Pons JA, Ramírez P, Parrilla P. Pathology findings in a model of auxiliary liver transplantation with portal vein arterialization in pigs. Transplant Proc 2006; 37:3939-42. [PMID: 16386591 DOI: 10.1016/j.transproceed.2005.10.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To determine the histological findings and temporal evolution that occur in auxiliary liver grafts as a consequence of arterialization of the portal vein (PVA). MATERIALS AND METHODS We evaluated 10 auxiliary heterotopic liver transplants with arterialization of the PVA. The histological study was performed using an optical microscope to process liver samples with staining using hematoxylin and eosin. A biopsy of native liver tissue was used as a control. RESULTS Two animals were excluded from the study, one due to ischemic necrosis of the graft and one that died 4 hours after transplant. All of the remaining eight animals underwent a histological study at 1 day, 7 days, and 14 days. The most significant histological findings were: (1) dilation of portal areas and sinusoids, which were detected at 24 hours and persisted; (2) thickening of the interlobular septum, which was observed after day 7 and progressively increased to day 14; (3) bile duct hyperplasia detected at the seventh day. CONCLUSIONS The consistent, early findings in a pig liver with PVA included vascular dilation of the portal area and the sinusoids, with bile duct hyperplasia extending progressively and the thickening of interlobular connective tissue septa with a generalized perilobular connective tissue reaction, which did not seem to alter the internal structure of the lobule, which showed histologically normal hepatocytes. The fibrous reaction may be the first stage in chronic hepatopathy. Further long-term studies are required in this model.
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Affiliation(s)
- O M Fernández
- Unit of Experimental Surgery, Department of Surgery, Arrixaca University Hospital, El Palmar, Murcia, Spain.
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