Auxiliary partial orthotopic liver transplantation for acute liver failure in children

Postoperative imaging findings in children with auxiliary partial orthotopic liver transplant (APOLT)

Auxiliary partial orthotopic liver transplant (APOLT) is a treatment technique for people who have acute hepatic failure secondary to fulminant hepatic failure and might ultimately recover normal liver function. This surgical procedure is complicated, involving the placement of a liver graft while maintaining viability of the remaining native portion of the liver. This method allows the native liver to recover hepatic function, therefore eliminating the need for long-term immunosuppression, as is typically needed in post-transplant settings. Postoperative imaging in these cases can be challenging given the complex anatomy, specifically the vascular anastomosis. Therefore it is important for radiologists and clinicians to be aware of the anatomy as well as the variable imaging appearances of the liver. We review the imaging findings in children who have undergone auxiliary partial orthotopic liver transplant (APOLT).

Adult living-related liver donation for acute liver failure: is it ethically appropriate?

Acute liver failure (ALF) results in the annual death of approximately 3.5 per million people in the United States. Unfortunately, given the marked shortage of cadaveric liver donations and the ethical questions that plague utilization of living donor liver transplantation (LDLT) for ALF, many patients with ALF die before a liver is allocated to them. In this review, we discuss how the consistent utilization of LDLT for ALF could decrease the mortality rate of ALF. Additionally, we examine a key underlying issue: is LDLT for ALF ethically appropriate?

Mental and physical quality of life in actual living liver donors versus potential living liver donors: a prospective, controlled, multicenter study

In a quasi-experimental design, we investigated the quality of life (QOL) in actual liver donors (n = 43) and potential liver donors (n = 33) before and 3 months after liver transplantation. This is the first study in this field combining a prospective design with an adequate control group. Potential donors served as a control group because they also had a relative in need of a liver transplant and were as emotionally involved with the recipient as actual donors, but they were not subjected to the donor operation. Groups did not differ in age, gender, marital status, donor-recipient relationship, urgency of transplantation, or recipient group (adult versus child). Actual donors showed decreased physical QOL, whereas potential donors were not affected. However, for both groups, a decrease in anxiety was found. Furthermore, actual donors showed a better mental QOL postoperatively than potential donors. The recipients of these 2 groups did not differ with respect to postoperative complications. Furthermore, the groups did not report a different caregiver burden, but actual donors showed higher self-esteem. Because of the surgery, the worsening of physical symptoms in actual donors was expected. It is remarkable, however, that although actual donors still showed a limited physical QOL 3 months after the operation, in both groups, a similar reduction in anxiety could be observed, and actual donors even demonstrated a better mental QOL postoperatively than potential donors. The latter might be due to a psychological benefit that actual donors derived from the fact that they were able to help the recipients.

Psychological strain in urgent indications for living donor liver transplantation

The ethical soundness of living donor liver transplantation (LDLT) in urgent indications is still under discussion. The aim of the survey was to investigate the psychological distress of donors in cases of hepatocellular carcinoma (HCC) or acute liver failure (ALF). In a prospective multicenter study (n = 123), health-related quality of life (QOL), anxiety, and depression were measured. The psychological distress of donors was correlated to the degree of urgency of the recipients' indication, which was classified as nonurgent, HCC, or ALF. During the donor evaluation prior to LDLT, the donors with recipients for HCC and ALF demonstrated significantly reduced mental QOL in comparison to donors for a nonurgent indication and to the German normative sample. Compared to healthy controls, anxiety and depression were significantly increased in donors for ALF. Three months after the transplantation, scores for mental QOL as well as for anxiety and depression improved and were within the normal range for the whole group as well as for the ALF donors. In conclusion, the psychological burden was temporary in nature. Our findings can be considered as arguments for the current practice to address family members as donors in cases of HCC and ALF.

Routine Use of Auxiliary Partial Orthotopic Liver Transplantation for Children With Fulminant Hepatic Failure: Preliminary Report

Auxiliary partial orthotopic liver transplantation (APOLT) has been performed for both metabolic disorders and fulminant liver failure (FHF). When the native liver regenerates, the patients with FHF who undergo APOLT have a chance to withdraw immunosuppression. It may be most beneficial for children. This preliminary report describes our start to routinely offer APOLT as an option to standard OLT for children with FHF in 2005. Six children (ages 8 months to 8 years) received APOLT: 1 in 1996 and the others in 2005 and 2006. The donor ages ranged from 4 to 40 years. We used either a left lateral segment or a left lobe graft. The recipient left lobe, which was removed, showed submassive to massive necrosis at the time of transplantation. All children are alive and well. The first patient who received APOLT in 1996 is currently off immunosuppression with a fully recovered native liver; the grafted liver underwent complete atrophy. The 5 remaining subjects are receiving reduced levels of immunosuppression with close monitoring. Their serial liver biopsy specimens show slight to significant recovery. One developed hepatic artery thrombosis, requiring retransplantation. The native liver was retained at the time of retransplantation (redo APOLT). Other postoperative complications included a bile leak (n = 1), invasive mucomycosis of the arm (preexisting condition; n = 1), biliary stricture (n = 1), and acute cellular rejection (n = 3). Posttransplantation length of stay was 6 to 60 days (median, 15 days). In conclusion, APOLT can be safely performed in children with FHF displaying short-term outcomes comparable to standard transplantations.

Impact of liver transplantation on HRQOL in children less than 5 years old

Our primary goal was to assess health related quality of life (HRQOL) at transplantation and 1 yr after transplantation in pediatric liver transplant patients aged less than 5 years. We conducted a prospective longitudinal study of HRQOL in pediatric liver transplant recipients, aged less than 5 years to define the impact of liver transplantation on HRQOL and identify factors that predict HRQOL after transplantation. The infant toddler health status questionnaire (ITHQ) was completed at the time of listing for liver transplantation and at 6 and 12 months after liver transplantation. The primary outcome measures were the subscale scores that comprise ITHQ. The mean age (+/-s.e.m.) of the enrolled patients (n = 45) at transplantation was 1.4 (+/-1.2) yr. Thirty-eight (84%) of the enrolled patients completed the study. The highest mean baseline scores of 78.6 (+/-3.3) were for global mental health (GlobalMH). ITHQ subscale scores increased steadily after transplantation. The greatest increase was in the first 6 months after transplant. At 1 yr after transplantation, there were significant increases in all of the ITHQ subscale scores except for GlobalMH. ITHQ subscales were similar for patients who received LDLT compared with those who received cadaver donor liver transplantation (CDLT) at baseline and a year after transplant. Time elapsed as transplantation was a significant predictor of functional health in all of the models generated. Scores for general health (GH), global health (GGH), parental time-impact (PT) and parental time-emotion (PE) were higher for male children. Family cohesion (FC) improved with time elapsed since transplant and increased number of inpatient days. HRQOL improves after transplantation in all of our patients irrespective of the donor type. Functional health scores were higher in patients with normal serum bilirubin at 1 yr post-transplant. Assessment of HRQOL should be an integral part of care for liver transplant patients and their caregivers.

Outcome after pediatric liver transplantation impact of living donor transplantation on cost

OBJECTIVE

To compare the direct health care cost of living donor liver transplantation (LDLT) with that of cadaver donor liver transplantation (CDLT) in children and identify predictors of cost.

STUDY DESIGN

All 16 children who underwent LDLT from January 1997 through January 2002 at Cincinnati Children's Hospital Medical Center comprised the study population. They were matched for age, diagnosis, and nutritional status with 31 children who received CDLT during the same era. A historic cohort analysis was performed.

RESULTS

There was no difference in the 1-year mortality rates between both groups. Costs associated with graft retrieval contributed 15.3% and 31% of the initial transplant cost for LDLT and CDLT, respectively. Mean cost of care in the first year was 60.3% higher for LDLT than CDLT (P=.01). Multivariate analysis identified biliary complications and insurance status as predictors of cost for initial transplantation (R(2)=0.57), whereas biliary complications and pediatric end stage liver disease scores were identified as predictors of cost of care in the first year after transplantation (R(2)=0.77).

CONCLUSIONS

The comprehensive cost of LDLT in the first year after transplantation is higher than cadaveric transplantation. This must be balanced against the time spent and care needs of patients on the waiting list.