Living donor liver transplantation

Characterization of hepatic steatosis using controlled attenuation parameter and MRI-derived proton density fat fraction in living donor liver transplantation

BACKGROUND

The increasingly favorable outcomes of live donor liver transplant warrant development of screening techniques to expand current donor pool. Transient elastography (TE) with controlled attenuation parameter (CAP) is accessible and has promising diagnostic performance in non-obese individuals. Here, we demonstrate its utility in grading donor steatosis for risk assessment in living liver donors (LLD).

STUDY DESIGN

In a prospective study of LLD and recipients, accuracy was determined using MRI-derived proton density fat fraction (PDFF) as reference.

RESULTS

One hundred and one LLD underwent TE, 95 of whom had available PDFF. Median CAP and MRI-PDFF were 233 dB/m (206-270) and 2.9% (2.3-4.0), respectively. A CAP threshold of 270 dB/m captured all steatosis which was present in 13 (13%) LLD (AUROC .942, 100% sensitivity and 83% specificity). Performance further improved when excluding obese LLD and limiting analysis to M-probe (AUROC .971 and .974, respectively, with 87% specificity). There was no difference in CAP and MRI-PDFF between LLD and nondonors (P = .26 and .21, respectively). Early allograft dysfunction was observed in one recipient (CAP 316, PDFF 9.5%), zero underwent retransplant, and one died from sepsis.

CONCLUSION

The specific role of CAP in living liver donation warrants further study, beginning with its use as screening tool across peripheral clinics.

Comparison of liver regeneration after partial hepatectomy and acetaminophen-induced acute liver failure: A global picture based on transcriptome analysis

Liver regenerates following surgical removal and after drug-induced liver injury (DILI). However, most of the mechanisms of liver regeneration were identified using partial hepatectomy (PHX) model rather than using DILI models. We compared mechanisms of liver regeneration following PHX and after acetaminophen (APAP) overdose, a DILI model, using transcriptomic approach. Kinetics of hepatocyte proliferation and global gene expression profiles were studied in male C57BL/6J mice either subjected to PHX or following APAP overdose. Liver regeneration was much more synchronized after PHX as compared to APAP overdose. Transcriptomics analysis revealed activation of common upstream regulators in both models including growth factors HGF, EGF and VEGF; and cytokines IL6 and TNFα. However, magnitude of activation and temporality was significantly differed between the two models. HGF and VEGF showed similar activation between PHX and APAP but activation of EGF was significantly stronger in the APAP model. Activation of IL6 and TNFα transcriptional programs was delayed but remarkably higher in APAP. These dissimilarities could be attributed to inherent differences in the two models including significant injury and inflammation exclusively in the APAP model. This study highlights need to study mechanisms of liver regeneration after DILI separately from the mechanisms of regeneration PHX.

Treatment of AECHB and Severe Hepatitis (Liver Failure)

This chapter describes the general treatment and immune principles and internal management for AECHB and HBV ACLF, including ICU monitoring, general supportive medications/nutrition/nursing, immune therapy, artificial liver supportive systems, hepatocyte/stem cell, and liver transplant, management for special populations, frequently clinical complications and the utilization of Chinese traditional medicines.

Early clinical indicators of severe hepatitis B include acratia, gastrointestinal symptoms, a daily increase in serum bilirubin >1 mg/dL, toxic intestinal paralysis, bleeding tendency and mild mind anomaly or character change, and the presence of other diseases inducing severe hepatitis. Laboratory indicators include T-Bil, PTA, cholinesterase, pre-albumin and albumin. The roles of immune indicators (such as IL-6, TNF-α, and fgl2), gene polymorphisms, HBV genotypes, and gene mutations as early clinical indicators.

Intensive Care Unit monitor patients with severe hepatitis include intracranial pressure, infection, blood dynamics, respiratory function, renal function, blood coagulation function, nutritional status and blood purification process. Nursing care should not only include routine care, but psychological and special care (complications).

Nutrition support and nursing care should be maintained throughout treatment for severe hepatitis. Common methods of evaluating nutritional status include direct human body measurement, creatinine height index (CHI) and subject global assessment of nutrition (SGA). Malnourished patients should receive enteral or parenteral nutrition support.

Immune therapies for severe hepatitis include promoting hepatocyte regeneration (e.g. with glucagon, hepatocyte growth factor and prostaglandin E1), glucocorticoid suppressive therapy, and targeting molecular blocking. Corticosteroid treatment should be early and sufficient, and adverse drug reactions monitored. Treatments currently being investigated are those targeting Toll-like receptors, NK cell/NK cell receptors, macrophage/immune coagulation system, CTLA-4/PD-1 and stem cell transplantation.

In addition to conventional drugs and radioiodine, corticosteroids and artificial liver treatment can also be considered for severe hepatitis patients with hyperthyreosis. Patients with gestational severe hepatitis require preventive therapy for fetal growth restriction, and it is necessary to choose the timing and method of fetal delivery. For patients with both diabetes and severe hepatitis, insulin is preferred to oral antidiabetic agents to control blood glucose concentration. Liver toxicity of corticosteroids and immune suppressors should be monitored during treatment for severe hepatitis in patients with connective tissue diseases including SLE, RA and sicca syndrome. Patient with connective tissue diseases should preferably be started after the antiviral treatment with nucleos(t)ide analogues.

An artificial liver can improve patients’ liver function; remove endotoxins, blood ammonia and other toxins; correct amino acid metabolism and coagulation disorders; and reverse internal environment imbalances. Non-bioartificial livers are suitable for patients with early and middle stage severe hepatitis; for late-stage patients waiting for liver transplantation; and for transplanted patients with rejection reaction or transplant failure. The type of artificial liver should be determined by each patient’s condition and previous treatment purpose, and patients should be closely monitored for adverse reactions and complications. Bio- and hybrid artificial livers are still under development.

MELD score is the international standard for choosing liver transplantation. Surgical methods mainly include the in situ classic type and the piggyback type; transplantation includes no liver prophase, no liver phase or new liver phase. Preoperative preparation, management of intraoperative and postoperative complications and postoperative long-term treatment are keys to success.

Severe hepatitis belongs to the categories of “acute jaundice”, “scourge jaundice”, and “hot liver” in traditional Chinese medicine. Treatment methods include Chinese traditional medicines, acupuncture and acupoint injection, external application of drugs, umbilical compress therapy, drip, blow nose therapy, earpins, and clysis. Dietary care is also an important part of traditional Chinese medicine treatment.

Long-term outcome and recurrence of hepatitis B virus following liver transplantation from hepatitis B surface antigen-positive donors in a Chinese population

Due to the severe shortage of the donor pool in China, a large number of patients are waiting for a suitable liver, or even worse lose the opportunity of transplantation. Reasonable use of hepatitis B surface antigen-positive (HBsAg-positive) donors is one possible strategy to increase the donor pool but the long-term outcome in a Chinese population is unknown. To evaluate the safety of using of HBsAg-positive donor for liver transplantation, we set up a multicentric retrospective study from 1 January 2007 to 31 December 2012. A total of 8632 patients underwent liver transplantation during the period and 282 (2.97%) received a liver from a HBsAg-positive donor. A total of 259 cases in both the case and control groups were matched. The incidence of postoperative liver dysfunction, early-stage and long-term complications and the 1-, 3- and 5-year patient survival (78.92% vs 85.65%, 60.41% vs 69.14%, 58.08% vs 69.14%, respectively) showed no difference between the two groups (P value > 0.05). However, the 1-, 3- and 5-year HBV recurrence for patients received the HBsAg-positive donor was higher compared with controls (5.85% vs 1.97%, 11.63% vs 4.46%, 17.94% vs 4.46%, respectively, P value = 0.016). Our results showed the use of HBsAg-positive donors is feasible and postoperative antiviral therapy should be managed.

Incisional hernia in recipients of adult to adult living donor liver transplantation

BACKGROUND

After receiving a living donor liver transplant (LDLT), an incisional hernia is a potentially serious complication that can affect the patient's quality of life. In the present study we evaluated surgical hernia repair after LDLT.

MATERIALS AND METHODS

Medical records of patients who underwent surgery to repair an incisional hernia after LDLT in Turgut Ozal Medical Center between October 2006 and January 2010 were evaluated in this retrospective study. A reverse-T incision was made for liver transplantation. The hernias were repaired with onlay polypropylene mesh. Age, gender, post-transplant relaparatomy, the type, the result of surgery for the incisional hernia, and risk factors for developing incisional hernia were evaluated.

RESULTS

An incisional hernia developed in 44 of 173 (25.4%) patients after LDLT. Incisional hernia repair was performed in 14 of 173 patients (8.1%) who underwent LDLT from October 2006 to January 2010. Relaparatomy was associated with incisional hernia (p = 0.0002). The mean age at the time of the incisional hernia repair was 51 years, and 79% of the patients were men. The median follow-up period was 19.2 (13-36) months after the hernia repair. Three patients with intestinal incarceration underwent emergency surgery to repair the hernia. Partial small bowel resection was required in one patient. Postoperative complications included seroma formation in one patient and wound infection in another. There was no recurrence of hernia during the follow-up period.

CONCLUSIONS

The incidence of incisional hernia after LDLT was 25.4% in this study. Relaparatomy increases the probability of developing incisional hernia in recipients of LDLT. According to the results of the study, repair of an incisional hernia with onlay mesh is a suitable option.

Blood glucose regulation during living-donor liver transplant surgery

OBJECTIVES

The goal of this study was to compare the effects of 2 different regimens on blood glucose levels of living-donor liver transplant.

MATERIALS AND METHODS

The study participants were randomly allocated to the dextrose in water plus insulin infusion group (group 1, n = 60) or the dextrose in water infusion group (group 2, n = 60) using a sealed envelope technique. Blood glucose levels were measured 3 times during each phase. When the blood glucose level of a patient exceeded the target level, extra insulin was administered via a different intravenous route. The following patient and procedural characteristics were recorded: age, sex, height, weight, body mass index, end-stage liver disease, Model for End-Stage Liver Disease score, total anesthesia time, total surgical time, and number of patients who received an extra bolus of insulin. The following laboratory data were measured pre- and postoperatively: hemoglobin, hematocrit, platelet count, prothrombin time, international normalized ratio, potassium, creatinine, total bilirubin, and albumin.

RESULTS

No hypoglycemia was noted. The recipients exhibited statistically significant differences in blood glucose levels during the dissection and neohepatic phases. Blood glucose levels at every time point were significantly different compared with the first dissection time point in group 1. Excluding the first and second anhepatic time points, blood glucose levels were significantly different as compared with the first dissection time point in group 2 (P < .05).

CONCLUSIONS

We concluded that dextrose with water infusion alone may be more effective and result in safer blood glucose levels as compared with dextrose with water plus insulin infusion for living-donor liver transplant recipients. Exogenous continuous insulin administration may induce hyperglycemic attacks, especially during the neohepatic phase of living-donor liver transplant surgery. Further prospective studies that include homogeneous patient subgroups and diabetic recipients are needed to support the use of dextrose plus water infusion without insulin.

Surgically placed abdominal wall catheters on postoperative analgesia and outcomes after living liver donation

Living donor liver resections are associated with significant postoperative pain. Epidural analgesia is the gold standard for postoperative pain management, although it is often refused or contraindicated. Surgically placed abdominal wall catheters (AWCs) are a novel pain modality that can potentially provide pain relief for those patients who are unable to receive an epidural. A retrospective review was performed at a single center. Patients were categorized according to their postoperative pain modality: intravenous (IV) patient-controlled analgesia (PCA), AWCs with IV PCA, or patient-controlled epidural analgesia (PCEA). Pain scores, opioid consumption, and outcomes were compared for the first 3 postoperative days. Propensity score matches (PSMs) were performed to adjust for covariates and to confirm the primary analysis. The AWC group had significantly lower mean morphine-equivalent consumption on postoperative day 3 [18.1 mg, standard error (SE)=3.1 versus 28.2 mg, SE=3.0; P=0.02] and mean cumulative morphine-equivalent consumption (97.2 mg, SE=7.2 versus 121.0 mg, SE=9.1; P=0.04) in comparison with the IV PCA group; the difference in cumulative-morphine equivalent remained significant in the PSMs. AWC pain scores were higher than those in the PCEA group and were similar to the those in the IV PCA group. The AWC group had a lower incidence of pruritus and a shorter hospital stay in comparison with the PCEA group and had a lower incidence of sedation in comparison with both groups. Time to ambulation, nausea, and vomiting were comparable among all 3 groups. The PSMs confirmed all results except for a decrease in the length of stay in comparison with PCEA. AWCs may be an alternative to epidural analgesia after living donor liver resections. Randomized trials are needed to verify the benefits of AWCs, including the safety and adverse effects.

Urine--a waste or the future of regenerative medicine?

In recent years, urine has emerged as a source of urine cells. Two different types of cells can be isolated from urine: urine derived stem cells (USCs) and renal tubular cells called urine cells (UCs). USCs have great differentiation properties and can be potentially used in genitourinary tract regeneration. Within this paper, we attempt to demonstrate that such as easily accessible source of cells, collected during completely non-invasive procedures, can be better utilized. Cells derived from urine can be isolated, stored, and used for the creation of urine stem cell banks. In the future, urine holds great potential to become a main source of cells for tissue engineering and regenerative medicine.

Mesenchymal stem cells promote liver regeneration and prolong survival in small-for-size liver grafts: involvement of C-Jun N-terminal kinase, cyclin D1, and NF-κB

Background

The therapeutic potential of mesenchymal stem cells (MSCs) has been highlighted recently for treatment of acute or chronic liver injury, by possibly differentiating into hepatocyte-like cells, reducing inflammation, and enhancing tissue repair. Despite recent progress, exact mechanisms of action are not clearly elucidated. In this study, we attempted to explore whether and how MSCs protected hepatocytes and stimulated allograft regeneration in small-for-size liver transplantation (SFSLT).

Methods

SFSLT model was established with a 30% partial liver transplantation (30PLT) in rats. The differentiation potential and characteristics of bone marrow derived MSCs were explored in vitro. MSCs were infused transvenously immediately after graft implantation in therapy group. Expressions of apoptosis-, inflammatory-, anti-inflammatory-, and growth factor-related genes were measured by RT-PCR, activities of transcription factors AP-1 and NF-κB were analyzed by EMSA, and proliferative responses of the hepatic graft were evaluated by immunohistochemistry and western blot.

Results

MSCs were successfully induced into hepatocyte-like cells, osteoblasts and adipocytes in vitro. MSCs therapy could not only alleviate ischemia reperfusion injury and acute inflammation to promote liver regeneration, but also profoundly improve one week survival rate. It markedly up-regulated the mRNA expressions of HGF, Bcl-2, Bcl-XL, IL-6, IL-10, IP-10, and CXCR2, however, down-regulated TNF-α. Increased activities of AP-1 and NF-κB, as well as elevated expressions of p-c-Jun, cyclin D1, and proliferating cell nuclear antigen (PCNA), were also found in MSCs therapy group.

Conclusion

These data suggest that MSCs therapy promotes hepatocyte proliferation and prolongs survival in SFSLT by reducing ischemia reperfusion injury and acute inflammation, and sustaining early increased expressions of c-Jun N-terminal Kinase, Cyclin D1, and NF-κB.

Balanced approach can help initial outcomes: analysis of initial 50 cases of a new liver transplantation program in East Asia

Purpose

To evaluate patient triage pattern and outcomes according to types of liver transplantation as part of a new liver transplant program developed in an East Asian country with a limited number of deceased donors.

Methods

Medical records of initial 50 liver transplantations were reviewed retrospectively.

Results

Twenty-nine patients underwent deceased donor liver transplantation (DDLT) and 21 patients underwent living donor liver transplantation (LDLT). Mean model for end-stage liver disease scores of recipients of DDLT and LDLT were 24.9 ± 11.6 and 13.1 ± 5.4, respectively (P < 0.0001). Twenty-eight patients had HCCs and 17 of them (60.7%) underwent LDLT, which was 80.9% of LDLTs. There were 2 cases of perioperative mortality; each was from DDLT and LDLT, respectively. Median follow-up was 18 months. Overall patient and graft survival rates at 6 months, 1 and 2 years were 95.7%, 93.4%, and 89.8%, respectively. There was no significant difference in survival between DDLT and LDLT. Overall recurrence-free survival rates of hepatocellular carcinoma (HCC) patients at 6 month, 1, and 2 years were 96.3%, 96.3%, and 90.3%, respectively. There was no significant difference in recurrence-free survival between DDLT and LDLT.

Conclusion

As a new liver transplant program with limited resource and waiting list, patients with critical condition could undergo DDLT whereas relatively stable patients with HCCs were mostly directed to LDLT. We recommend a balanced approach between DDLT and LDLT for initiating liver transplant programs.

Impact of intra-operative cholangiography and parenchymal resection to donor liver function in living donor liver transplantation

BACKGROUND

Living donor liver transplantation (LDLT) has been widely accepted over the past decade, and hepatic dysfunction often occurs in the donor in the early stage after liver donation. The present study aimed to evaluate the effect of intra-operative cholangiography (IOC) and parenchymal resection on liver function of donors in LDLT, and to assess the role of IOC in influencing the biliary complications and improving the overall outcome.

METHODS

Data from 40 patients who had donated their right lobes for LDLT were analyzed. Total bilirubin (TB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT) at different time points were compared, and the follow-up data and the biliary complications were also analyzed.

RESULTS

The ALT and AST values were significantly increased after IOC (P<0.001) and parenchymal resection (P<0.001). However, the median values of TB, ALP and GGT were not significantly influenced by IOC (P>0.05) or parenchymal resection (P>0.05). The biochemical changes caused by IOC or parenchymal resection were not correlated with the degree of post-operative liver injury or the recovery of liver function. The liver functions of the donors after operation were stable, and none of the donors suffered from biliary stenosis or leakage during the follow-up.

CONCLUSIONS

IOC and parenchymal resection may induce a transient increase in liver enzymes of donors in LDLT, but do not affect the recovery of liver function after operation. Moreover, the routine IOC is helpful to clarify the division line of the hepatic duct, thus reducing the biliary complication rate.

Donor quality of life up to two years after living donor liver transplantation: a prospective study

BACKGROUND

There is a lack of longer-term prospective data on living liver donors' quality of life (QOL). This is the first prospective study examining QOL up to 2 years after donation.

METHODS

A consecutive sample of living donors (n=40) was compared with a sample of potential donors (n=27) with respect to QOL, anxiety, and depression. Performing mixed-effects model analysis, both groups were assessed before transplantation, with and without simultaneous donation (T0), and at three postoperative data points: 3 months (T1), 1 year (T2), and 2 years (T3). Subsequently, both groups were compared with reference data of the general population and healthy individuals.

RESULTS

At T1, living donors' physical QOL was impaired. At T2 and T3, physical QOL was slightly lower than the preoperative level but within the range of healthy individuals in both living donors and potential donors. Neither mental QOL nor depression showed significant changes across time, while anxiety decreased in both groups. Subgroup analysis of adult-to-adult (AA) donors and adult-to-pediatric (AP) donors revealed different trajectories of mental QOL, anxiety, and depression. AP donors experienced more preoperative psychological strain, which improved after donation, whereas AA donors showed unchanged anxiety and depression, and a slight decrease in mental QOL 2 years after surgery. Two AA donors, whose recipients had died, reported persisting depressive symptoms after donation.

CONCLUSIONS

One and two years after donation, QOL is not substantially impaired in the majority of donors. Future research needs to provide an even longer prospective follow-up and should more rigorously explore risk factors for a negative donor outcome.

Establishment of a simple living donor liver transplantation dog model using a two-step nonvenous bypass hepatectomy

AIM

Dogs are an ideal model for studying living donor liver transplantation (LDLT). However, due to their poor tolerance to congestion and acidosis during portal vein blockage, current LDLT dog models with long operation times have high mortality. To address the issue, we designed a novel simplified operation with two-step nonvenous bypass (NVB) hepatectomy.

METHODS

Eighty dogs were evenly randomized to the living liver donor (LLD) or the recipient (LLR) groups. A standard lobectomy of I, II, and III lobes was performed in the LLD group. In the LLR group, first only I, II, and III lobes were resected using NVB; the residual lobes were resected off just after donor lobes were implanted.

RESULTS

For the LLD group, the operation time was 172.67 ± 20.98 minutes, amount of blood loss was 71.39 ± 13.59 mL, and 2-week survival rate was 85.00%. For the LLR group, the operation time was 251.61 ± 22.87 minutes, amount of blood loss was 220.00 ± 96.40 mL, amount of blood transfusion was 163.89 ± 44.74 mL, and 48-hour survival rate was 77.14%. In the LLR group, the mean arterial and central venous pressures decreased after organ implantion, but gradually recovered to normal levels after surgery. The liver function biochemical parameters recovered to preoperational levels after 14 days in the LLD group; in the LLR group, they gradually increased during 48 hours after operation.

CONCLUSION

The present method with two-step NVB hepatectomy can be used efficiently and safely for establishing LDLT dog model.

Revisiting the safety of living liver donors by reassessing 441 donor hepatectomies: is a larger hepatectomy complication-prone?

Donor safety is of paramount importance in performing living donor liver transplantation (LDLT). We retrospectively reviewed donor medical records to confirm whether larger donor hepatectomy is absolutely complication-prone. A total of 441 living donor hepatectomies were performed between October 1996 and July 2012 in our institute, which were divided into three eras (Era I, October 1996 to March 2004; Era II, April 2004 to March 2008; Era III, April 2008 to July 2012) and the incidences of postoperative complications were compared among the three types of hepatectomy-right hepatectomy (RH), left hepatectomy (LH) and left lateral segmentectomy (LLS). Although severe complications (Clavien's grade 3 or more) frequently occurred in RH in Eras I and II (15.4% and 10.7%, respectively), the incidence in Era III decreased to the comparable level observed in LH and LLS (5.4% in RH, 2.3% in LH and 5.3% in LLS). The incidence of postoperative complications did not relate to the type of hepatectomy selected in the latest era. Since most complications after hepatectomy were considered preventable, step-by-step meticulous surgical procedures are a prerequisite for further assuring donor safety irrespective of the type of hepatectomy selected.

Factors associated with blood transfusion in donor hepatectomy: results from 2344 donors at a large single center

BACKGROUND

The safety of healthy living donors undergoing hepatic resection for living-donor liver transplantation is of paramount concern. Although blood transfusions have been associated with morbidity and mortality after hepatectomy, there is limited information about the risk factors associated with blood transfusion in living liver donors.

METHODS

We retrospectively analyzed 2344 donors who underwent a hepatectomy for living-donor liver transplantation. Logistic regression analysis was performed to determine blood transfusion predictors in living-donor hepatectomy.

RESULTS

Of these donors, 48 (2.0%) and 97 (4.1%) were transfused with packed red blood cell (PRBC) and fresh-frozen plasma (FFP), respectively. The amount of PRBC and FFP administered to donors transfused with blood products were 1.9±0.8 and 3.7±2.5 units, respectively. In multivariate logistic regression analysis, a low preoperative hemoglobin level was found to be an independent predictor of PRBC transfusion in donor hepatectomy (odds ratio=0.585; 95% confidence interval=0.451-0.758; P<0.001). A high graft-to-donor weight ratio predicted an FFP transfusion in donor hepatectomy (odds ratio=2.997; 95% confidence interval=1.226-7.327; P=0.016).

CONCLUSIONS

These results indicate that, in donor hepatectomy, the preoperative hemoglobin value and graft-to-donor weight ratio can provide useful information on the probability of PRBC and FFP transfusion, respectively.

Spheroid culture for enhanced differentiation of human embryonic stem cells to hepatocyte-like cells

Stem cell-derived hepatocyte-like cells hold great potential for the treatment of liver disease and for drug toxicity screening. The success of these applications hinges on the generation of differentiated cells with high liver specific activities. Many protocols have been developed to guide human embryonic stem cells (hESCs) to differentiate to the hepatic lineage. Here we report cultivation of hESCs as three-dimensional aggregates that enhances their differentiation to hepatocyte-like cells. Differentiation was first carried out in monolayer culture for 20 days. Subsequently cells were allowed to self-aggregate into spheroids. Significantly higher expression of liver-specific transcripts and proteins, including Albumin, phosphoenolpyruvate carboxykinase, and asialoglycoprotein receptor 1 was observed. The differentiated phenotype was sustained for more than 2 weeks in the three-dimensional spheroid culture system, significantly longer than in monolayer culture. Cells in spheroids exhibit morphological and ultrastructural characteristics of primary hepatocytes by scanning and transmission electron microscopy in addition to mature functions, such as biliary excretion of metabolic products and cytochrome P450 activities. This three-dimensional spheroid culture system may be appropriate for generating high quality, functional hepatocyte-like cells from ESCs.

Current issues in pediatric liver transplantation

Pediatric patients with ESLD requiring liver transplantation often have a multitude of comorbidities ranging from pulmonary hypertension to renal and cardiovascular insufficiency that impairs our ability to safely care for these critically ill children. As organ allocation techniques advance, many of these patients may be healthier on arrival to the operating room. However, postoperative surgical complications and immunosuppressive regimens still daunt us. As we continue to care for these challenging patients, hopefully, advances in ESLD management and technology will dramatically improve outcomes in the future.

Impact of venous-systemic oxygen persufflation with nitric oxide gas on steatotic grafts after partial orthotopic liver transplantation in rats

BACKGROUND

Steatotic livers are associated with poor graft function after transplantation. We investigated the effects of venous-systemic oxygen persufflation with nitric oxide gas (VSOP-NO) on steatotic partial livers after transplantation.

METHODS

Steatotic livers induced by fasting for 2 days and subsequent refeeding for 3 days with a fat-free, carbohydrate-rich diet were reduced in size by 50% and transplanted into Lewis rats after 3 hr of cold storage in histidine-tryptophan-ketoglutarate solution. Gaseous oxygen with nitric oxide (40 ppm) was insufflated into the grafts through the suprahepatic vena cava during cold storage (VSOP-NO group; n=20). Transplantation of cold-static stored steatotic and normal grafts served as controls (Steatotic-Control and Normal-Control, respectively; n=20 for each group).

RESULTS

The graft microcirculation and portal venous flow were increased by VSOP-NO compared with Steatotic-Control (P<0.001 for both). Serum alanine aminotransferase and interleukin-6 levels were lower in VSOP-NO versus Steatotic-Control group (P=0.03 for both). Messenger RNA expression for inducible nitric oxide synthase, which was increased in Steatotic-Control livers 3 hr after transplantation (P=0.02 vs. that at 1 hr), was suppressed by VSOP-NO. Although serum nitrite levels were decreased 1 hr after transplantation in Steatotic-Control (P=0.06 vs. Normal-Control), the VSOP-NO group showed increased levels comparable to Normal-Control. In livers 24 hr after transplantation, moderate vacuolization of hepatocytes by histology with the immunohistochemical expression of nitrotyrosine, indicative of nitrative stress, was found in Steatotic-Control, whereas these findings were less apparent in VSOP-NO-treated livers.

CONCLUSIONS

Application of VSOP-NO for steatotic partial livers reduces hepatocellular damage and improves graft viability and microcirculation after transplantation.

Suppression of liver regeneration affects hepatic graft survival in small-for-size liver transplantation in rats

AIM

  Small-for-size liver transplantation (SFSLT) often results in hepatic graft failure and decreased survival. The present study was aimed to investigate the possible mechanism of hepatic graft failure in SFSLT in rats.

METHODS

  Rat models of full-size orthotopic liver transplantation, 50% partial liver transplantation and 30% partial liver transplantation were established. Proliferative responses of the hepatic graft were evaluated by immunohistochemical staining and western blotting. Apoptosis-, inflammatory-, anti-inflammatory- and growth factor-related genes were screened by quantitative reverse transcription polymerase chain reaction. Activities of transcription factors of AP-1 and nuclear factor (NF)-κB were analyzed by electrophoretic mobility shift assay.

RESULTS

  A 30% partial liver transplant not only resulted in marked structural damages to the hepatic graft, but also showed the lowest 7-day survival rate. In addition, sup pressed expressions of proliferating cell nuclear antigen (PCNA) and cyclin D1 by immunohistochemical staining and decreased expressions of cyclin D1 and p-c-Jun by western blotting were detected. Downregulated expressions of Bcl-2, Bcl-XL, interleukin (IL)-6, IL-10, IP-10 and CXCR2, upregulated expression of tumor necrosis factor-α, and decreased levels of AP-1 and NF-κB were also found following 30% partial liver transplantation after reperfusion.

CONCLUSION

  Liver regeneration is remarkably suppressed in SFSLT. The significant changes of intra-graft gene expression described above indicated that ischemia reperfusion injury would be severe in 30% partial liver transplantation. The capability of liver regeneration secondary to ischemia reperfusion injury might determine hepatic graft survival in SFSLT.

Prevention of poor psychosocial outcomes in living organ donors: from description to theory-driven intervention development and initial feasibility testing

CONTEXT

Although some living donors experience psychological, somatic, and interpersonal difficulties after donation, interventions to prevent such outcomes have not been developed or evaluated.

OBJECTIVE

To (1) summarize empirical evidence on psychosocial outcomes after donation, (2) describe a theoretical framework to guide development of an intervention to prevent poor outcomes, and (3) describe development and initial evaluation of feasibility and acceptability of the intervention.

METHODS

Based on a narrative literature review suggesting that individuals ambivalent about donation are at risk for poor psychosocial outcomes after donation, the intervention targeted this risk factor. Intervention structure and content drew on motivational interviewing principles in order to assist prospective donors to resolve ambivalence. Data were collected on donors' characteristics at our institution to determine whether they constituted a representative population in which to evaluate the intervention. Study participants were then recruited to assess the feasibility and acceptability of the intervention. They were required to have scores greater than 0 on the Simmons Ambivalence Scale (indicating at least some ambivalence about donation).

RESULTS

Our population was similar to the national living donor population on most demographic and donation-related characteristics. Eight individuals who had been approved to donate either a kidney or liver segment were enrolled for pilot testing of the intervention. All successfully completed the 2-session telephone-based intervention before scheduled donation surgery. Participants' ratings of acceptability and satisfaction were high. Open-ended comments indicated that the intervention addressed participants' thoughts and concerns about the decision to donate.

CONCLUSIONS

The intervention is feasible, acceptable, and appears relevant to donor concerns. A clinical trial to evaluate the efficacy of the intervention is warranted.

Innovations in organ donation

The growing disparity between organ availability for transplantation and the number of patients in need has challenged the donation and transplantation community of practice to develop innovative processes, ideas, and techniques to bridge the gaps. Advances in the sharing of best practices in the donation community have contributed greatly over the last 8 years. Broader sharing of updated guidelines for declaration of brain death in conjunction with improvements in deceased donor management have increased opportunities for organ donation. New techniques for organ preservation and organ resuscitation have allowed for better utilization of the potential donor pool. This review will highlight processes, ideas, and techniques in organ donation.

Posttransplant mortality risk assessment for adult-to-adult right-lobe living donor liver recipients with benign end-stage liver disease

OBJECTIVE

A model for living donor liver transplantation (LDLT) outcomes, in concert with pretransplant disease severity assessment, would facilitate informed decision-making on both sides considering donation and transplantation. So far, however, few of studies have focused on models specifically for adult-to-adult right-lobe LDLT recipients with benign end-stage liver diseases. Therefore, we aimed to develop such a prognostic model based on easily obtainable and objective pretransplant characteristics.

METHODS

With data retrospectively collected on 120 recipients, we used Cox proportional-hazards regression to analyze six donor characteristics and 33 pretransplant recipient variables for correlation with posttransplant mortality. In both a modeling set and a prospective validation set with 30 recipients, the performances of the new Cox model, MELD, and MELD-Na+ were assessed by measuring both calibration ability and discriminative power with the Hosmer-Lemeshow test and receiver operating characteristic analysis, respectively.

RESULTS

By univariate and multivariate analysis, donor age, serum total bilirubin, creatinine, and HBV-DNA level were significantly associated with posttransplant mortality. The Cox model, employing these four variables, yielded good calibration ability in the modeling set χ² = 2.465, p = 0.653) and the validation set χ² = 2.836, p = 0.586), and high discriminative power in the modeling set (c-statistic = 0.826, p = 0.001) and validation set (c-statistic = 0.816, p = 0.028). The calibration ability and discriminative power of MELD and MELD-Na+ in both sets were poor.

CONCLUSIONS

The newly derived Cox model was valuable in posttransplant mortality risk assessment for adult-to-adult right-lobe LDLT recipients with benign end-stage liver diseases.

Energy status of pig donor organs after ischemia is independent of donor type

BACKGROUND

Literature is controversial whether organs from living donors have a better graft function than brain dead (BD) and non-heart-beating donor organs. Success of transplantation has been correlated with high-energy phosphate (HEP) contents of the graft.

METHODS

HEP contents in heart, liver, kidney, and pancreas from living, BD, and donation after cardiac death in a pig model (n=6 per donor type) were evaluated systematically. BD was induced under general anesthesia by inflating a balloon in the epidural space. Ten hours after confirmation, organs were retrieved. Cardiac arrest was induced by 9V direct current. After 10min of ventricular fibrillation without cardiac output, mechanical and medical reanimation was performed for 30min before organ retrieval. In living donors, organs were explanted immediately. Freeze-clamped biopsies were taken before perfusion with Celsior solution (heart) or University of Wisconsin solution (abdominal organs) in BD and living donors or with Histidine-Tryptophan-Ketoglutaric solution (all organs) in non-heart-beating donors, after perfusion, and after cold ischemia (4h for heart, 6h for liver and pancreas, and 12h for kidney). HEPs (adenosine triphosphate, adenosine diphosphate, adenosine monophosphate, and phosphocreatine), xanthine, and hypoxanthine were measured by high-performance liquid chromatography. Energy charge and adenosine triphosphate-to-adenosine diphosphate ratio were calculated.

RESULTS

After ischemia, organs from different donor types showed no difference in energy status. In all organs, a decrease of HEP and an increase in hypoxanthine contents were observed during perfusion and ischemia, irrespective of the donor type.

CONCLUSION

Organs from BD or non-heart-beating donors do not differ from living donor organs in their energy status after average tolerable ischemia.

Methods to decrease blood loss and transfusion requirements for liver transplantation

BACKGROUND

Excessive blood loss and increased blood transfusion requirements may have significant impact on the short-term and long-term outcomes after liver transplantation.

OBJECTIVES

To compare the potential benefits and harms of different methods of decreasing blood loss and blood transfusion requirements during liver transplantation.

SEARCH METHODS

We searched The Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and metaRegister of Controlled Trials until September 2011.

SELECTION CRITERIA

We included all randomised clinical trials that were performed to compare various methods of decreasing blood loss and blood transfusion requirements during liver transplantation.

DATA COLLECTION AND ANALYSIS

Two authors independently identified the trials and extracted the data. We analysed the data with both the fixed-effect and the random-effects model using RevMan Analysis. For each outcome we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on available data analysis. We also conducted network meta-analysis.

MAIN RESULTS

We included 33 trials involving 1913 patients. The sample size in the trials varied from 8 to 209 participants. The interventions included pharmacological interventions (aprotinin, tranexamic acid, epsilon amino caproic acid, antithrombin 3, recombinant factor (rFvIIa), oestrogen, prostaglandin, epinephrine), blood substitutes (blood components rather than whole blood, hydroxy-ethyl starch, thromboelastography), and cardiovascular interventions (low central venous pressure). All the trials were of high risk of bias. Primary outcomes were reported in at least two trials for the following comparisons: aprotinin versus control, tranexamic acid versus control, recombinant factor VIIa (rFVIIa) versus control, and tranexamic acid versus aprotinin. There were no significant differences in the 60-day mortality (3 trials; 6/161 (3.7%) in the aprotinin group versus 8/119 (6.7%) in the control group; RR 0.52; 95% CI 0.18 to 1.45), primary graft non-function (2 trials; 0/128 (0.0%) in the aprotinin group versus 4/89 (4.5%) in the control group; RR 0.15; 95% CI 0.02 to 1.25), retransplantation (3 trials; 2/256 (0.8%) in the aprotinin group versus 12/178 (6.7%) in the control group; RR 0.21; 95% CI 0.02 to 1.79), or thromboembolic episodes (3 trials; 4/161 (2.5%) in the aprotinin group versus 5/119 (4.2%) in the control group; RR 0.59; 95% CI 0.19 to 1.84) between the aprotinin and control groups. There were no significant differences in the 60-day mortality (3 trials; 4/83 (4.8%) in the tranexamic acid group versus 5/56 (8.9%) in the control group; RR 0.55; 95% CI 0.17 to 1.76), retransplantation (2 trials; 3/41 (7.3%) in the tranexamic acid group versus 3/36 (8.3%) in the control group; RR 0.79; 95% CI 0.18 to 3.48), or thromboembolic episodes (5 trials; 5/103 (4.9%) in the tranexamic acid group versus 1/76 (1.3%) in the control group; RR 2.20; 95% CI 0.38 to 12.64) between the tranexamic acid and control groups. There were no significant differences in the 60-day mortality (3 trials; 8/195 (4.1%) in the recombinant factor VIIa (rFVIIa) group versus 2/91 (2.2%) in the control group; RR 1.51; 95% CI 0.33 to 6.95), thromboembolic episodes (2 trials; 24/185 (13.0%) in the rFVIIa group versus 8/81 (9.9%) in the control group; RR 1.38; 95% CI 0.65 to 2.91), or serious adverse events (2 trials; 90/185 (48.6%) in the rFVIIa group versus 30/81 (37.0%) in the control group; RR 1.30; 95% CI 0.94 to 1.78) between the rFVIIa and control groups. There were no significant differences in the 60-day mortality (2 trials; 6/91 (6.6%) in the tranexamic acid group versus 1/87 (1.1%) in the aprotinin group; RR 4.12; 95% CI 0.71 to 23.76) or thromboembolic episodes (2 trials; 4/91 (4.4%) in the tranexamic acid group versus 2/87 (2.3%) in the aprotinin group; RR 1.97; 95% CI 0.37 to 10.37) between the tranexamic acid and aprotinin groups. The remaining outcomes in the above comparisons and the remaining comparisons included only only trial under the primary outcome or the outcome was not reported at all in the trials. There were no significant differences in the mortality, primary graft non-function, graft failure, retransplantation, thromboembolic episodes, or serious adverse events in any of these comparisons. However, the confidence intervals were wide, and it is not possible to reach any conclusion on the safety of the interventions. None of the trials reported the quality of life in patients.Secondary outcomes were reported in at least two trials for the following comparisons - aprotinin versus control, tranexamic acid versus control, rFVIIa versus control, thromboelastography versus control, and tranexamic acid versus aprotinin. There was significantly lower allogeneic blood transfusion requirements in the aprotinin group than the control group (8 trials; 185 patients in aprotinin group and 190 patients in control group; SMD -0.61; 95% CI -0.82 to -0.40). There were no significant differences in the allogeneic blood transfusion requirements between the tranexamic acid and control groups (4 trials; 93 patients in tranexamic acid group and 66 patients in control group; SMD -0.27; 95% CI -0.59 to 0.06); rFVIIa and control groups (2 trials; 141 patients in rFVIIa group and 80 patients in control group; SMD -0.05; 95% CI -0.32 to 0.23); thromboelastography and control groups (2 trials; 31 patients in thromboelastography group and 31 patients in control group; SMD -0.73; 95% CI -1.69 to 0.24); or between the tranexamic acid and aprotinin groups (3 trials; 101 patients in tranexamic acid group and 97 patients in aprotinin group; SMD -0.09; 95% CI -0.36 to 0.19). The remaining outcomes in the above comparisons and the remaining comparisons included only only trial under the primary outcome or the outcome was not reported at all in the trials. There were no significant differences in the blood loss, transfusion requirements, hospital stay, or intensive care unit stay in most of the comparisons.

AUTHORS' CONCLUSIONS

Aprotinin, recombinant factor VIIa, and thromboelastography groups may potentially reduce blood loss and transfusion requirements. However, risks of systematic errors (bias) and risks of random errors (play of chance) hamper the confidence in this conclusion. We need further well-designed randomised trials with low risk of systematic error and low risk of random errors before these interventions can be supported or refuted.

Evaluation of intraoperative brain natriuretic peptide as a predictor of 1-year mortality after liver transplantation

BACKGROUND

Although brain natriuretic peptide (BNP), a marker of cardiac dysfunction, has been known to predict postoperative mortality, little is known about the postoperative prognostic ability of BNP in liver transplantation (OLT) recipients. We aimed to determine whether intraoperative BNP level can predict 1-year all-cause mortality after OLT.

METHODS

We retrospectively investigated 525 OLT recipients. BNP and hemodynamic parameters were simultaneously measured 1 hour after induction of anesthesia. Cox regression analysis and receiver operating characteristic curve analysis were performed to determine clinical predictors and optimal cutoff values of post-OLT mortality.

RESULTS

The 1-year all-cause mortality rate was 9.7% (51/525). Median BNP concentration was significantly higher in nonsurvivors than in survivors (114 vs 56 pg/mL, P < .001). Significant factors in univariate Cox regression analysis were Child-Pugh score, model for end-stage liver disease (MELD) score, logBNP, hemoglobin, creatinine, heart rate, systolic pulmonary arterial pressure, and central venous pressure. In multivariate Cox regression analysis, independent predictors of posttransplant mortality were MELD score and logBNP. However, simultaneously measured hemodynamic parameters did not remain predictors. BNP levels greater than a cutoff of 136 pg/mL (specificity = 83.5%, negative predictive value = 93.6%) were associated with increased post-OLT mortality (log-rank test P < .001).

CONCLUSIONS

Intraoperative BNP level is an independent predictor of 1-year all-cause mortality after OLT with a high negative predictive value, suggesting that its measurement appears useful in identifying patients at low risk of post-OLT mortality.