Liver transplantation for fulminant hepatic failure

Liver Transplantation for Alcoholic Liver Disease and Hepatocellular Carcinoma

Hepatocellular carcinoma is one of the main important causes of cancer-related death and its mortality is increasingly worldwide. In Europe, alcohol abuse accounts for approximately half of all liver cancer cases and it will become the leading cause of hepatocellular carcinoma in the next future with the sharp decline of chronic viral hepatitis. The pathophysiology of alcohol-induced carcinogenesis involves acetaldehyde catabolism, oxidative stress and chronic liver inflammation. Genetic background plays also a significant role and specific patterns of gene mutations in alcohol-related hepatocellular carcinoma have been characterized. Survival is higher in patients who undergo specific surveillance programmes than in patients who do not. However, patients with alcohol cirrhosis present a significantly greater risk of liver decompensation than those with cirrhosis due to other aetiologies. Furthermore, the adherence to screening program can be suboptimal. Liver transplant for patients with Milan-in hepatocellular carcinoma represents the best possible treatment in case of tumour recurrence/progression despite loco-regional or surgical treatments. Long-term result after liver transplantation for alcohol related liver disease is good. However, cardiovascular disease and de novo malignancies can significantly hamper patients' survival and should be carefully considered by transplant team. In this review, we have focused on the evolution of alcohol-related hepatocellular carcinoma epidemiology and risk factors as well as on liver transplantation in alcoholic patients with and without hepatocellular carcinoma.

Hepatocellular Carcinoma and Liver Transplantation: State of the Art

Hepatocellular carcinoma (HCC) is an aggressive tumor that often occurs in chronic liver disease and cirrhosis. The incidence of HCC is growing worldwide. With respect to any other available treatment for liver cancer, liver transplantation (LT) has the highest potential to cure. LT allows for removal at once of both the tumor ("seed") and the damaged-hepatic tissue ("soil") where cancerogenesis and chronic liver disorders have progressed together. The Milan criteria (MC) have been applied worldwide to select patients with HCC for LT, yielding a 4-year survival rate of 75%. These criteria represent the benchmark for patient selection and are the basis for comparison with any other suggested criteria. However, MC are often considered to be too restrictive, and recent data show that between 25% and 50% of patients with HCC are currently transplanted beyond conventional indications. Consequently, any unrestricted expansion of selection criteria will increase the need for donor organs, lengthen waiting periods, increase drop-out rates, and impair outcomes on intention-to-treat analysis. Management of HCC recurrence after LT is challenging. There are a few reports available regarding the safety and efficacy of sorafenib for HCC recurrence after LT, but the data are heterogeneous. A multi-center prospective randomized controlled trial comparing placebo with sorafenib is advised. Alternatively, a meta-analysis of patient survival with sorafenib for HCC recurrence after LT could be helpful to characterize the therapeutic benefit and safety of sorafenib. Here, we review the use of LT for HCC, with particular emphasis on the selection criteria for transplantation in patients with HCC and management of HCC recurrence after LT.

Management of hepatocellular carcinoma: Enlightening the gray zones

Management of hepatocellular carcinoma (HCC) has been continuously evolving during recent years. HCC is a worldwide clinical and social issue and typically a complicates cirrhosis. The incidence of HCC is increasing, not only in the general population of patients with cirrhosis, but particularly in some subgroups of patients, like those with human immunodeficiency virus infection or thalassemia. Since a 3% annual HCC incidence has been estimated in cirrhosis, a bi-annual screening is generally suggested. The diagnostic criteria of HCC has recently had a dramatic evolution during recent years. HCC diagnosis is now made only on radiological criteria in the majority of the cases. In the context of cirrhosis, the universally accepted criteria for HCC diagnosis is contrast enhancement in arterial phase and washout in venous/late phase at imaging, the so called “typical pattern”. However, recently updated guidelines slightly differ in diagnostic criteria. Apart from liver transplantation, the only cure of both HCC and underlying liver cirrhosis, all the other treatments have to match with higher rate of HCC recurrence. The latter can be classified into curative (resection and percutaneous ablation) and palliative treatments. The aim of this paper was to review the current knowledge on management of HCC and to enlighten the areas of uncertainty.

Liver transplantation for fulminant hepatic failure: experience with more than 200 patients over a 17-year period

OBJECTIVE

To analyze outcomes after liver transplantation (LT) in patients with fulminant hepatic failure (FHF) with emphasis on pretransplant variables that can potentially help predict posttransplant outcome.

SUMMARY BACKGROUND DATA

FHF is a formidable clinical problem associated with a high mortality rate. While LT is the treatment of choice for irreversible FHF, few investigations have examined pretransplant variables that can potentially predict outcome after LT.

METHODS

A retrospective review was undertaken of all patients undergoing LT for FHF at a single transplant center. The median follow-up was 41 months. Thirty-five variables were analyzed by univariate and multivariate analysis to determine their impact on patient and graft survival.

RESULTS

Two hundred four patients (60% female, median age 20.2 years) required urgent LT for FHF. Before LT, the majority of patients were comatose (76%), on hemodialysis (16%), and ICU-bound. The 1- and 5-year survival rates were 73% and 67% (patient) and 63% and 57% (graft). The primary cause of patient death was sepsis, and the primary cause of graft failure was primary graft nonfunction. Univariate analysis of pre-LT variables revealed that 19 variables predicted survival. From these results, multivariate analysis determined that the serum creatinine was the single most important prognosticator of patient survival.

CONCLUSIONS

This study, representing one of the largest published series on LT for FHF, demonstrates a long-term survival of nearly 70% and develops a clinically applicable and readily measurable set of pretransplant factors that determine posttransplant outcome.

Assessing the eligibility for liver transplantation of patients with fulminant hepatitis

The spleen to liver volume (S/L) ratio of 13 patients with fulminant hepatitis was determined using X-ray computed tomography (CT), and the correlation between S/L ratio and prognosis was evaluated. The S/L ratio of 6 patients who died was greater than 0.16, whereas that of the remaining 7 patients who survived was less than 0.15. These findings suggest that determining the S/L ratio using CT may be useful for assessing the eligibility of patients with fulminant hepatitis for liver transplantation.

Renal dysfunction associated with liver transplantation

It has been known for some time that a variety of liver diseases affect kidney function, but renal dysfunction associated with orthotopic liver transplantation has received scant attention. Although the mechanisms mediating these abnormalities are incompletely defined, advances in the understanding of renal pathophysiology after liver transplantation have made it possible to develop new treatment strategies. Aggressive and early intervention to diagnose and treat renal complications associated with liver transplantation should be the goal for transplant centres.

Orthotopic liver transplantation in fulminant and subfulminant hepatitis. The Paul Brousse experience

OBJECTIVE

The authors report on the experience of orthotopic liver transplantation in fulminant hepatitis at Paul Brousse Hospital.

SUMMARY BACKGROUND DATA

Liver transplantation is a breakthrough in the treatment of patients with fulminant hepatitis. However, the indications, the timing for transplantation, the type of transplantation, and the use of ABO incompatible grafts in this setting still are debated.

METHODS

Transplantation was indicated in patients with confusion or coma and factor V less than 20%, younger than 30 years of age, and confusion or coma and factor V less than 30% older than 30 years of age.

RESULTS

Among 139 patients who met the aforementioned criteria for transplantation, 1 recovered, 22 died before transplantation, and 116 underwent transplants with a 1-year survival of 68%. Survival was 83% in patients with grade 1 and 2 comas at transplantation versus 56% (p < 0.001) in those with grade 3 comas; it was 51% versus 81% (p < 0.001) in those transplanted with high risk (ABO-incompatible, split, or steatotic) and low-risk grafts, respectively. In a multivariate analysis, steatotic and partial grafts were predictive of poorer patient survival, and ABO incompatibility was predictive of poorer graft survival.

CONCLUSIONS

Orthotopic liver transplantation is an effective treatment in fulminant hepatitis. Use of high-risk grafts permitted transplantation of 83% of patients, but was responsible for higher mortality.

Liver transplantation after severe poisoning due to amatoxin-containing Lepiota--report of three cases

Four cases of severe Lepiota poisoning, including three which developed toxic fulminant hepatitis treated by orthotopic hepatic transplantation, are reported here. The toxicity of the Lepiota is discussed as well as the indications for hepatic transplantation in poisonings due to amatoxin-containing mushrooms.

Liver transplantation for severe Lepiota helveola poisoning

Orthotopic liver transplantation in patients with fulminant hepatic failure secondary to Lepiota helveola poisoning has not, to our knowledge, been reported. Our recent experience with liver transplantation in a 27-year-old woman with acute hepatic failure secondary to this poisoning is described. The indications for orthotopic liver transplantation are discussed.

Liver transplantation for acute liver failure: analysis of applicability

BACKGROUND

Liver transplantation has emerged as the most important advance in the therapy of acute liver failure. To assess the applicability of liver transplantation in this setting, the outcome of 62 patients with acute liver failure consecutively admitted to hospital was analyzed.

METHODS

Criteria for indicating liver transplantation were grade III-IV hepatic encephalopathy or progression of encephalopathy following a transient improvement. In subfulminant cases, liver transplantation was also indicated when no improvement was observed after a 3-day period of conservative treatment.

RESULTS

Thirteen (21%) of the 62 patients never met criteria for transplant indication; all of them were discharged after receiving conventional therapy. Twenty-one (34%) patients with criteria for indicating liver transplantation could not receive the transplant because of either contraindications (17 patients; only 1 being discharged from hospital) or death before donor organ availability (4 patients). Finally, 28 (45%) patients received a liver transplant and 22 were discharged from hospital.

CONCLUSIONS

The applicability of liver transplantation in acute liver failure is relatively low. Considering the high survival rate (79%) obtained in the patients with transplantations and the poor survival rate (6%) observed in those who could not be transplanted, efforts should be made to increase liver transplant applicability to improve the prognosis in acute liver failure.

Toga virus-like particles in acute liver failure attributed to sporadic non-A, non-B hepatitis and recurrence after liver transplantation

Toga virus-like particles (typically 60-70 nm: enveloped with small surface spikes) were detected in the native hepatectomy specimens in 7 of 18 patients grafted for acute liver failure attributed to sporadic non-A, non-B hepatitis and in 2 patients grafted for fulminant hepatitis attributed to anti-epileptic drug hepatotoxicity. These particles were not detected in the hepatectomies from 12 other patients grafted for other causes of acute liver failure, 12 for various chronic liver diseases, and 2 histologically normal livers. Acute hepatic failure, characterized histologically by severe haemorrhagic necrosis, developed 7 days after grafting in 5 patients, all in the non-A, non-B group with toga virus-like particles in native liver. Similar virus-like particles were detected in all grafts and were in greater abundance than in the native livers. The agent may be novel because pre- and post-grafting sera were negative for antibodies against representative panels of arboviruses and in first and second generation antibody tests for hepatitis C virus.

Auxiliary partial orthotopic liver transplantation (APOLT) for fulminant hepatic failure: first successful case report

Fulminant hepatic failure is a life-threatening event with a high mortality rate up to 80%. Orthotopic liver transplantation has markedly decreased this mortality rate and is therefore a well established procedure for hepatic failure. However, this treatment neglects the fact that patients surviving hepatic failure without liver transplantation experienced a complete morphologic and functional recovery of their own liver. Temporary support of liver function in such cases could therefore be desirable and adequate therapy. Auxiliary liver transplantation could fulfill this demand. However, the standard technique of auxiliary grafting, transplanting a graft in a heterotopic position, is burdened by problems such as elevated venous back-pressure, insufficient respectively competing portal blood supply for both livers with an unpredictable long-term outcome. In order to cope with these problems, we performed an auxiliary transplantation in an orthotopic position. To accomplish this procedure we had to reduce the size of both the recipient and the donor livers. We, thus, performed an auxiliary partial orthotopic liver transplant (APOLT). The first patient was a 33 year old female who was transplanted on November 25, 1989. She developed a HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome and fell into a deep coma. At the time of transplantation histologic examination of her own liver revealed 80% confluent necrosis. We resected segments 2 and 3 of the recipient liver and transplanted the whole left lobe of the donor liver into this position.(ABSTRACT TRUNCATED AT 250 WORDS)

Liver transplantation (1)

Advances in the management of both chronic and acute hepatic disease have been made possible and even mandated by the development of liver transplantation. The clinical use of transplantation has proceeded at a rapid pace since a Consensus Development Conference of the National Institutes of Health concluded in June 1983 that liver transplantation had become a service and not simply an experimental procedure.1

The liver can be transplanted as an extra (auxiliary) organ at an ectopic site, or in the orthotopic location after the removal of the host liver (Fig. 1 ). This article will focus primarily on the orthotopic procedure. However, there has been renewed interest in the auxiliary operation, which will be discussed separately.

Temporary organ substitution by hemoperfusion through suspension of active donor hepatocytes in a total complex of intensive therapy in patients with acute hepatic insufficiency

The results of intensive therapy and temporary organ substitution by hemoperfusion through a suspension of active hepatocytes in 126 patients suffering from acute hepatic insufficiency (AHI) induced by virus B hepatitis, virus non-A, non-B hepatitis, acute toxic hepatitis, active liver cirrhosis, sepsis leptospirosis long-term subhepatic jaundice are presented in this paper. Hepatic encephalopathia confirmed both clinically and electroencephalographically was registered in all the patients. The patients were subdivided into two groups: a complex of commonly used curative measures according to the intensive therapy for AHI was applied in Group A (67 patients); in Group B (59 patients), alongside with the above measures, temporary organ substitution by hemoperfusion through a suspension of active porky hepatocytes was also performed. The lethality in Group A made up 59% and that in Group B was 37%.

Thiopental infusion in the treatment of intracranial hypertension complicating fulminant hepatic failure

Intracranial hypertension complicating fulminant hepatic failure has a mortality in excess of 90% in the presence of renal failure if not rapidly responsive to mannitol and ultrafiltration. Based on data which suggest that barbiturates can be of value in controlling the intracranial hypertension of head injury, intravenous thiopental was assessed in 13 patients with fulminant hepatic failure. All had developed acute renal failure complicated by intracranial hypertension unresponsive to other modes of therapy and were likely by all published criteria to have little chance of survival. The dosage of thiopental was adjusted incrementally until intracranial pressure, measured by extradural transducers, fell to within normal limits or adverse hemodynamic changes occurred. The intracranial pressure was reduced, in each case, by 185 to 500 mg (median: 250 mg) thiopental given over 15 min, and in eight cases continuing infusion achieved stable normal intracranial pressure and cerebral perfusion pressure. Five of the patients made a complete recovery and there were only three deaths from intracranial hypertension. Side effects were few and included minor hypotension controlled by dose reduction. The response of otherwise intractable intracranial hypertension and the 38% survival rate was remarkable for a group of patients with such a poor prognosis.

Liver transplantation: an update for physicians

End-stage irreversible liver disease, previously treated only by partially-effective, symptomatic measures, can now be reversed by successful liver transplantation at reasonable cost and with comparatively little increase in resources. Three Australian liver transplant programs are now established with results comparable to those of more experienced overseas centres. New organ-preservation techniques and reduced-size orthotopic transplantation in children should significantly increase donor organ availability. Orthotopic liver transplantation should be considered as a therapeutic option once a patient has been diagnosed as suffering from intractable, non-malignant chronic liver disease.

Hepatic encephalopathy

Hepatic encephalopathy (HE) is a complex reversible syndrome that can progress to coma. Recently, behavioral and electrophysiologic ameliorations of HE have been reported to occur in animal models of fulminant hepatic failure (FHF) and, in uncontrolled studies, in a majority of patients with FHF or cirrhosis following the intravenous administration of the benzodiazepine (BZ) receptor antagonist, flumazenil. These observations, while not excluding a role for other mechanisms in the mediation of HE, raise the possibility that an endogenous BZ receptor ligand with agonist properties may contribute to the manifestations of HE by allosterically potentiating GABA-mediated neurotransmission.

Toga-like virus as a cause of fulminant hepatitis attributed to sporadic non-A, non-B

Virus-like particles (60-70 nm) with spiked surfaces budding into cell vacuoles and rod-shaped inclusions were detected in nuclei of hepatocytes from a British patient transplanted for sporadic non-A, non-B fulminant hepatitis (NANB-FHF), probably contracted in Kenya. Identical particles were seen in two successive grafts (days 2 and 10) at regrafting for recurrent FHF. Ultrastructural features resembled those of the RNA-containing arbovirus, Rift Valley fever virus, but serological markers against a representative panel for arboviruses (Togaviruses) and transmission in mice proved negative. The particles shared features with the different arboviruses seen in the hepatectomy specimen of a second patient with NANB-FHF, and in both patients an insect vector was implicated in the clinical history. The particles were identical in size to those of a third patient with NANB-FHF, who had remained in the United Kingdom. These findings, together with the recent report of isolation of an RNA-containing virus resembling the Togaviridae, in parenteral NANB, suggest that several exotic virus-like agents resembling the arboviruses may be involved in the aetiology of NANB, including in the sporadic forms of FHF in the United Kingdom.

Liver transplantation

Liver transplantation has become an established form of therapy for patients with almost any type of irreversible and severe liver disease. The remarkable success of liver transplantation has resulted from recent advances in immunosuppressive therapy, surgical techniques, and patient selection. Additional progress has been made in the management of the complex postoperative medical complications that may occur. Indeed, liver transplantation has contributed significantly to an improved quantity and quality of life for many patients with liver disease.

The role of transplantation in liver disease

Liver transplantation is rapidly emerging as the most effective treatment pathway for a growing number of acute and chronic liver disease states. Indications and contraindications to transplant are undergoing continuous revision and clarification as experience is accrued in the expanding number of treatment centers. For some disorders such as primary biliary cirrhosis, sclerosing cholangitis, and chronic active hepatitis with cirrhosis, the role of transplantation in patient management is obvious. For other hepatic diseases such as primary hepatic neoplasm, clear definition of the role of transplantation is likely to await development of improved early diagnostic techniques and more effective chemotherapy regimens. Standardization of the technical aspects of liver transplant and recent advances in graft preservation have led to reduction in the logistical problems that previously plagued this complex therapy. Refinements in immunosuppression with the introduction of cyclosporine and monoclonal antibody therapy have extended chances for survival and contributed to considerable improvement in quality of life following transplant. Further extension of transplantation as a treatment option to individuals with liver disease will require the concerned effort of the primary care or referral physician in the early recognition and management of patients with liver disease.

Liver transplantation for alcoholic liver disease: a consideration of reasons for and against

Orthotopic liver transplantation is a clinical procedure that has been accepted widely as the treatment of choice for individuals with advanced chronic liver disease. As such, its application to the important clinical problem of alcoholic liver disease is inevitable. The arguments for and against liver transplantation for individuals with advanced alcoholic liver disease are presented.

Amanita poisoning: treatment and the role of liver transplantation

Fatal mushroom poisoning has long been recognized as a major health problem in western Europe and more recently in the United States. The majority of deaths are attributable to the genus Amanita. Amanita phalloides (death cap) has been found with increasing frequency across the United States and presents a significant health hazard in this country to those who pick and consume wild mushrooms. This article discusses the pharmacologic basis and clinical manifestations of Amanita intoxication. It outlines the rationale of various treatment modalities and, from these, summarizes a protocol that the authors believe will be useful to the clinician. In addition, two patients are presented who underwent successful orthotopic liver transplantation for fulminant hepatic failure secondary to Amanita poisoning. The role of liver transplantation both acutely and as treatment for chronic active hepatitis secondary to severe intoxication is discussed.

[Liver transplantation in adults: postoperative management and development during the first months]

Recent improvements in the results of orthotopic liver transplantation (OLT) have made this a well-accepted treatment for patients with severe hepatic failure. Current problems encountered following OLT are discussed. Immediate complications comprise surgical bleeding, primary graft non-function, and graft failure due to hepatic artery occlusion. Secondary complications are frequent. Surgical ones include biliary and vascular (hepatic artery thrombosis most often) problems, as well as intra-abdominal abscesses associated with gastrointestinal perforation, biliary leak, graft ischaemia or an infected haematoma. 40% of patients having undergone OLT will be reoperated on, 2/3 of them within 3 months. Non-surgical complications are mostly pulmonary. The risk of pneumonitis is increased by prolonged mechanical ventilation; it is always potentially disastrous in the immunosuppressed, transplanted patient. Hypertension is also often seen in the early postoperative period; it requires prompt treatment. Early renal impairment after OLT is common, and of better prognosis than late onset renal failure, which is generally associated with shock, graft failure, sepsis or use of nephrotoxic agents. Seizures, usually only one, occur in about 10% of patients; recovery is complete. Encephalopathy with intracranial oedema related to fulminant hepatitis has a worse prognosis, but survival figures are quite encouraging. Three type of rejection are described after OLT: 1) severe accelerated rejection (very rare), 2) acute rejection encountered in about 70% of patients over the first 3 months, and 3) late rejection, which can lead to the vanishing bile duct syndrome (VBDS). Diagnosis of rejection is made by liver biopsy. Prophylactic immunosuppression includes cyclosporin, methylprednisolone and azathioprine. Cyclosporin toxicity and drug interactions are reviewed. Treatment of acute rejection episodes comprises an initial bolus of high doses of corticoid drugs; if there is no response, antilymphocyte globulin or monoclonal antibodies may have to be used. Infection is the main cause of death following OLT. Early infections, mostly intra-abdominal and pulmonary, are bacterial or fungal. Vital (especially CMV) and other opportunistic infections occur generally after the second week. Retransplantation, carried out in 10 to 25% of patients, may be urgent in case of primary graft failure, or hepatic artery thrombosis associated with graft failure, or hepatic artery thrombosis associated with graft failure. Other indications are early graft rejection with severe hepatic dysfunction, chronic rejection with severe VBDS, and recurrence of the initial disease.

Fulminant hepatic failure

These discussions are selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from transcriptions, they are prepared by Drs Homer A. Boushey, Professor of Medicine, and David G. Warnock, Associate Professor of Medicine, under the direction of Dr Lloyd H. Smith, Jr, Professor of Medicine and Associate Dean in the School of Medicine. Requests for reprints should be sent to the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, CA 94143.

Liver transplantation--the first 25 years

These discussions are selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from transcriptions, they are prepared by Drs Homer A. Boushey, Professor of Medicine, and David G. Warnock, Associate Professor of Medicine, under the direction of Dr Lloyd H. Smith, Jr, Professor of Medicine and Associate Dean in the School of Medicine. Requests for reprints should be sent to the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, CA 94143.

Orthotopic liver transplantation for fulminant and subacute hepatic failure

The fulminant hepatic failure (FHF) is a condition characterized by massive hepatocyte necrosis and one that is associated with severe liver and/or other organ-systems insufficiency leading to death in up to 85 per cent of the cases with medical treatment only. Although various expedients have been tried in order to save these patients, the necrosis is usually so massive that it is beyond regeneration. At present, the only hope lies with orthotopic liver transplantation (OLTx), which has become progressively more successful during the last few years. Various considerations pertaining to OLTx are discussed, as well as our series of 40 patients who were transplanted for FHF, with a survival of 57 per cent.

Postdilution hemofiltration in the management of acute hepatic failure: a pilot study

We conducted a pilot study to assess the feasibility and efficacy of postdilution hemofiltration (PDHF) in the management of acute hepatic failure. From January 1984 through May 1986, we encountered seven patients with acute hepatic failure and entered these consecutive patients in the study; three had non-A, non-B hepatitis and one each had type B hepatitis, fulminant Wilson's disease (hepatolenticular degeneration), acute allograft (liver) failure, and acute fatty liver of pregnancy. Two of these seven patients were unable to undergo PDHF because of a precarious hemodynamic status. Of the five patients treated with PDHF, four had amelioration of hepatic encephalopathy; in two of these patients, a close temporal relationship was noted between the improvement and the procedure. Four patients had appreciable thrombocytopenia related to PDHF and bleeding complications. Our preliminary results support a possible role for PDHF as a temporary artificial liver support system for patients with acute hepatic failure.

Orthotopic liver transplantation for fulminant and subacute hepatic failure

Fulminant and subacute hepatitis are conditions characterized by rapid liver failure, which can lead to death in 80 to more than 95% of the cases with medical supportive care only. The etiology can be viral, drug-, or other chemical-induced, metabolic, etc. Orthotopic liver transplantation emerged during the 1980s as a powerful means for dealing with these diseases. The existence of this therapeutic modality has brought about major changes in the diagnosis, patient selection, treatment, and outlook for fulminant/subacute liver failure. The authors present the results of orthotopic liver transplantation for the treatment of 47 cases of acute/subacute hepatic insufficiency at the University of Pittsburgh between March 1980 and July 1987. The results of this series demonstrate that liver transplantation is the most effective means for treating this condition.

Microbial structures in a patient with sporadic non-A, non-B fulminant hepatitis treated by liver transplantation

Double-shelled virus-like particles (60 nm) and long cytoplasmic tubular structures were found in the cytoplasm of hepatocytes from areas of collapsed and regenerating areas of hepatectomised liver in a 13-year-old boy who received a liver graft for fulminant hepatitis attributed to sporadic non-A, non-B hepatitis. The patient died on the ninth postoperative day from acute graft failure. Although virus-like particles were not found, instead, gram-negative rods were identified in the necrotic graft and the most likely cause of death was a gram-negative septicaemia with a Shwartzman-like reaction localized to the liver.