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Samanta A, Poddar U. Pediatric acute liver failure: Current perspective in etiology and management. Indian J Gastroenterol 2024; 43:349-360. [PMID: 38466551 DOI: 10.1007/s12664-024-01520-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/28/2023] [Indexed: 03/13/2024]
Abstract
Pediatric acute liver failure (PALF) is a catastrophic clinical condition with very high morbidity and mortality without early detection and intervention. It is characterized by the acute onset of massive hepatocellular injury that releases circulating inflammatory mediators, resulting in metabolic disturbances, coagulopathy, hepatic encephalopathy and multi-organ failure. The etiological spectrum is dominated by hepatotropic viruses, drug-induced liver injury, metabolic and genetic disorders and immune-mediated diseases. Unlike adults, indeterminate causes for acute liver failure constitute a considerable proportion of cases of acute liver failure in children in the west. The heterogeneity of age and etiology in PALF has led to difficulties in developing prognostic scoring. The recent guidelines emphasize prompt identification of PALF, age-appropriate evaluation for hepatic encephalopathy and laboratory evaluation with careful monitoring. Current therapy focuses on supporting the failing liver and other organs, pending either spontaneous recovery or liver transplantation. Targeted therapy is available for a select group of etiologies. Liver transplantation can be lifesaving and a plan for the same should be organized, whenever indicated. The aim of this review is to define PALF, understand its etiopathogenesis, address the challenges encountered during the management and update the latest advances in liver transplantation and non-transplant treatment options in PALF.
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Affiliation(s)
- Arghya Samanta
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India.
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2
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Vimalesvaran S, Verma A, Dhawan A. Pediatric Liver Transplantation: Selection Criteria and Post-transplant Medical Management. Indian J Pediatr 2024; 91:383-390. [PMID: 38150147 DOI: 10.1007/s12098-023-04963-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 11/10/2023] [Indexed: 12/28/2023]
Abstract
Pediatric liver transplantation remains the gold standard for life-threatening acute and chronic liver diseases and multiple liver-based inherited metabolic defects. Advances in surgical techniques, better perioperative care and immunosuppression regimes have resulted in excellent long-term graft and patient survival. The success of pediatric liver transplantation does however bring the additional challenge of long-term patient outcomes including graft hepatitis-related fibrosis and suboptimal biopsychosocial outcomes. In this review, authors will explore the current landscape of pediatric liver transplantation including indications, timing of referral for liver transplantation, surgical techniques and long-term outcomes such as recurrence of pre-transplant liver disease, idiopathic graft hepatitis and biopsychosocial outcomes. Ultimately, early identification and management of potential issues long-term helps ensure our recipients achieve a "meaningful survival".
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Affiliation(s)
- Sunitha Vimalesvaran
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, SE5 9RS, UK
| | - Anita Verma
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, SE5 9RS, UK
| | - Anil Dhawan
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, SE5 9RS, UK.
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3
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Lagasse E, Levin M. Future medicine: from molecular pathways to the collective intelligence of the body. Trends Mol Med 2023; 29:687-710. [PMID: 37481382 PMCID: PMC10527237 DOI: 10.1016/j.molmed.2023.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 07/24/2023]
Abstract
The remarkable anatomical homeostasis exhibited by complex living organisms suggests that they are inherently reprogrammable information-processing systems that offer numerous interfaces to their physiological and anatomical problem-solving capacities. We briefly review data suggesting that the multiscale competency of living forms affords a new path for biomedicine that exploits the innate collective intelligence of tissues and organs. The concept of tissue-level allostatic goal-directedness is already bearing fruit in clinical practice. We sketch a roadmap towards 'somatic psychiatry' by using advances in bioelectricity and behavioral neuroscience to design methods that induce self-repair of structure and function. Relaxing the assumption that cellular control mechanisms are static, exploiting powerful concepts from cybernetics, behavioral science, and developmental biology may spark definitive solutions to current biomedical challenges.
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Affiliation(s)
- Eric Lagasse
- McGowan Institute for Regenerative Medicine and Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Levin
- Allen Discovery Center, Tufts University, Medford, MA, USA; Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA, USA.
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4
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Fitzpatrick E, Filippi C, Jagadisan B, Shivapatham D, Anand H, Lyne M, Stroud KD, Newton R, DeLord M, Douiri A, Dhawan A. Intraperitoneal transplant of Hepatocytes co-Encapsulated with mesenchymal stromal cells in modified alginate microbeads for the treatment of acute Liver failure in Pediatric patients (HELP)-An open-label, single-arm Simon's two stage phase 1 study protocol. PLoS One 2023; 18:e0288185. [PMID: 37490429 PMCID: PMC10368261 DOI: 10.1371/journal.pone.0288185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 05/11/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Pediatric acute liver failure (PALF) carries a high mortality without liver transplantation (LT) in children. Liver transplantation, though lifesaving, is limited by timely donor organ availability, the risks of major surgery and complications of life-long immunosuppression. Hepatocyte transplantation (HT) improves synthetic and detoxification functions in small animal models. The encapsulation of hepatocytes in alginate protects it from the recipient immune system while the intraperitoneal route of administration allows large volumes to be infused. The safety and possibly short-term efficacy of encapsulated hepatocytes has been observed in a named patient use. A novel type of microbeads (HMB002) has been developed, using a modified alginate and mesenchymal stromal cells (MSCs). Its safety and medium-term efficacy need to be studied in the context of clinical study while optimizing the hepatocyte function and viability using modifications of the alginate and MSCs co-encapsulation. METHODS A single centre, non-randomised, open-label, single-arm Simon's two stage study will be conducted to evaluate the safety, biological activity and tolerability of transplantation of a single intraperitoneal dose of microbeads made from an optimum combination of a modified alginate, MSCs and hepatocytes in 17 patients less than 16 years of age with acute liver failure (Stage 1: 9 patients and Stage 2: 8 patient). Safety will be assessed by documenting moderate to severe (including life threatening and death) adverse events due to HMB002 in the first 52 weeks post-procedure. Tolerability will be assessed by observing the proportion of initiated infusions where >80% of infusion is received by the patient. Biological activity will be reflected in patient survival with native liver at 24 weeks post treatment. DISCUSSION HMB002, if safe and efficacious in acute liver failure, could be a bridge until the liver regenerates or a suitable organ becomes available. There are multiple advantages to using HT. HT, when delivered by the intraperitoneal route, is less invasive than LT. Hepatocytes from a single donor liver can be used to treat multiple patients. Cryopreserved cells provide an off-the-shelf emergency treatment in PALF. When encapsulated, alginate encapsulation of hepatocytes precludes the need for immunosuppression unlike in LT.
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Affiliation(s)
- Emer Fitzpatrick
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, United Kingdom
- King's College London, London, United Kingdom
| | - Celine Filippi
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, United Kingdom
- King's College London, London, United Kingdom
| | - Barath Jagadisan
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, United Kingdom
- King's College London, London, United Kingdom
| | - Dharshene Shivapatham
- Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Hanish Anand
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, United Kingdom
| | - Mike Lyne
- Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Katherine-Daisy Stroud
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, United Kingdom
| | - Rebecca Newton
- King's Health Partners Clinical Trials Office, London, United Kingdom
| | - Marc DeLord
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | - Abdel Douiri
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | - Anil Dhawan
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, United Kingdom
- King's College London, London, United Kingdom
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5
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Cellular Therapies in Pediatric Liver Diseases. Cells 2022; 11:cells11162483. [PMID: 36010561 PMCID: PMC9406752 DOI: 10.3390/cells11162483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/30/2022] [Accepted: 08/06/2022] [Indexed: 11/16/2022] Open
Abstract
Liver transplantation is the gold standard for the treatment of pediatric end-stage liver disease and liver based metabolic disorders. Although liver transplant is successful, its wider application is limited by shortage of donor organs, surgical complications, need for life long immunosuppressive medication and its associated complications. Cellular therapies such as hepatocytes and mesenchymal stromal cells (MSCs) are currently emerging as an attractive alternative to liver transplantation. The aim of this review is to present the existing world experience in hepatocyte and MSC transplantation and the potential for future effective applications of these modalities of treatment.
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6
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Vimalesvaran S, Dhawan A. Liver transplantation for pediatric inherited metabolic liver diseases. World J Hepatol 2021; 13:1351-1366. [PMID: 34786171 PMCID: PMC8568579 DOI: 10.4254/wjh.v13.i10.1351] [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: 05/04/2021] [Revised: 06/23/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) remains the gold standard treatment for end stage liver disease in the pediatric population. For liver based metabolic disorders (LBMDs), the decision for LT is predicated on a different set of paradigms. With improved outcomes post-transplantation, LT is no longer merely life saving, but has the potential to also significantly improve quality of life. This review summarizes the clinical presentation, medical treatment and indications for LT for some of the common LBMDs. We also provide a practical update on the dilemmas and controversies surrounding the indications for transplantation, surgical considerations and prognosis and long terms outcomes for pediatric LT in LBMDs. Important progress has been made in understanding these diseases in recent years and with that we outline some of the new therapies that have emerged.
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Affiliation(s)
- Sunitha Vimalesvaran
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London SE5 9RS, United Kingdom
| | - Anil Dhawan
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London SE5 9RS, United Kingdom
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7
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Quadros J, Piedade C, Lopes MF. Auxiliary liver transplantation for management of acute liver failure in children - Systematic review. Transplant Rev (Orlando) 2021; 35:100631. [PMID: 34098491 DOI: 10.1016/j.trre.2021.100631] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/27/2021] [Accepted: 05/27/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Liver transplantation (LT) remains the standard of care in the treatment of acute pediatric liver failure (PALF) for the replacement of a severely damaged native liver in patients who are unlikely to recover. However, this is burdened by the consequences of long-term immunosuppression. Auxiliary partial liver orthotopic transplantation (APOLT) has emerged as a possible improved approach, by providing a graft that assures liver function until the regeneration of the native liver occurs, and then allows for possible progression to immunosuppression withdrawal. No previous systematic review has assessed APOLT for PALF. The aim of this work is to provide information on survival, postoperative complications, and withdrawal of immunosuppression after APOLT for PALF. METHODS The study was carried out according to the recommendations of the preferred report items for systematic reviews and meta-analyzes (PRISMA). We searched several electronic databases until October 31st, 2020, using the search terms "acute liver failure", "auxiliary liver transplant" and the MESH term "liver failure, acute". All types of clinical publications that presented results on APOLT for PALF, in English or Portuguese, and restricted to humans and for children under 18 years old were included. The following exclusion criteria were applied: "follow-up time <6 months", "does not report complications" and "does not report immunosuppression regimen (double vs triple)". Demographic data, clinical characteristics at the time of surgery and postoperative results were analyzed. RESULTS A total of 14 references (including 45 patients) were selected, including 3 case series (6-20 patients) and 11 case reports. Of the 45 subjects, 33 (73.3%) were male and 12 (26.7%) female. In most cases (n = 30; 66.7%), the cause of PALF was undetermined. All patients underwent APOLT. Their median age was 9 (range 0.6-17) years. In the postoperative period, the immunosuppression regimen was double in 34 (75.6%) and triple in 11 (24.4%) individuals. The main postoperative complications were rejection and infection. Over a follow-up period of 6 months to 14 years, 10 (22.2%) patients died. The main cause of death was sepsis (70%). Six (13.3%) patients were retransplanted. Of the survivors (n = 35), 68.6% achieved complete withdrawal from the immunosuppression regimen. CONCLUSION Based on current published evidence, APOLT for the treatment of PALF is a safe option, with an acceptable rate of complications and mortality. It has the great advantage of providing an immunosuppression-free life in the majority (68.6%) of survivors.
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Affiliation(s)
- Joana Quadros
- Faculty of Medicine, University of Coimbra, Portugal.
| | - Cláudia Piedade
- Department of Pediatric Surgery, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Portugal; Pediatric Liver Transplantation, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Maria Francelina Lopes
- Faculty of Medicine, University of Coimbra, Portugal; Department of Pediatric Surgery, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Portugal; Pediatric Liver Transplantation, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Portugal
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8
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Chartier ME, Deheragoda M, Gattens M, Dhawan A, Heaton N, Booth C, Hadžić N. Successful Auxiliary Liver Transplant Followed by Hematopoietic Stem Cell Transplantation in X-Linked Lymphoproliferative Disease Type 1. Liver Transpl 2021; 27:450-455. [PMID: 32949066 DOI: 10.1002/lt.25898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/03/2020] [Accepted: 08/09/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Marie-Eve Chartier
- Paediatric Centre for Hepatology, Gastroenterology and Nutrition, King's College Hospital, London, United Kingdom
| | - Maesha Deheragoda
- Liver Histopathology, King's College Hospital, London, United Kingdom
| | - Michael Gattens
- Department of Paediatric Haematology and Oncology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Anil Dhawan
- Paediatric Centre for Hepatology, Gastroenterology and Nutrition, King's College Hospital, London, United Kingdom
| | - Nigel Heaton
- Liver Transplantation, Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Claire Booth
- Department of Paediatric Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Nedim Hadžić
- Paediatric Centre for Hepatology, Gastroenterology and Nutrition, King's College Hospital, London, United Kingdom
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9
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Dhawan A, Chaijitraruch N, Fitzpatrick E, Bansal S, Filippi C, Lehec SC, Heaton ND, Kane P, Verma A, Hughes RD, Mitry RR. Alginate microencapsulated human hepatocytes for the treatment of acute liver failure in children. J Hepatol 2020; 72:877-884. [PMID: 31843649 DOI: 10.1016/j.jhep.2019.12.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Liver transplantation (LT) is the most effective treatment for patients with acute liver failure (ALF), but is limited by surgical risks and the need for life-long immunosuppression. Transplantation of microencapsulated human hepatocytes in alginate is an attractive option over whole liver replacement. The safety and efficacy of hepatocyte microbead transplantation have been shown in animal models. We report our experience of this therapy in children with ALF treated on a named-patient basis. METHODS Clinical grade human hepatocyte microbeads (HMBs) and empty microbeads were tested in immunocompetent healthy rats. Subsequently, 8 children with ALF, who were awaiting a suitable allograft for LT, received intraperitoneal transplantation of HMBs. We monitored complications of the procedure, assessing the host immune response and residual function of the retrieved HMBs, either after spontaneous native liver regeneration or at the time of LT. RESULTS Intraperitoneal transplantation of HMBs in healthy rats was safe and preserved synthetic and detoxification functions, without the need for immunosuppression. Subsequently, 8 children with ALF received HMBs (4 neonatal haemochromatosis, 2 viral infections and 2 children with unknown cause at time of infusion) at a median age of 14.5 days, range 1 day to 6 years. The procedure was well tolerated without complications. Of the 8 children, 4 avoided LT while 3 were successfully bridged to LT following the intervention. HMBs retrieved after infusions (at the time of LT) were structurally intact, free of host cell adherence and contained viable hepatocytes with preserved functions. CONCLUSION The results demonstrate the feasibility and safety of an HMB infusion in children with ALF. LAY SUMMARY Acute liver failure in children is a rare but devastating condition. Liver transplantation is the most effective treatment, but it has several important limitations. Liver cell (hepatocyte) transplantation is an attractive option, as many patients only require short-term liver support while their own liver recovers. Human hepatocytes encapsulated in alginate beads can perform the functions of the liver while alginate coating protects the cells from immune attack. Herein, we demonstrated that transplantation of these beads was safe and feasible in children with acute liver failure.
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Affiliation(s)
- Anil Dhawan
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London, United Kingdom; Dhawan Lab at the Mowat Labs, Institute of Liver Studies, King's College London at King's College Hospital, London, United Kingdom.
| | - Nataruks Chaijitraruch
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London, United Kingdom; Paediatric Gastroenterology and Hepatology, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Emer Fitzpatrick
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London, United Kingdom
| | - Sanjay Bansal
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London, United Kingdom
| | - Celine Filippi
- Dhawan Lab at the Mowat Labs, Institute of Liver Studies, King's College London at King's College Hospital, London, United Kingdom
| | - Sharon C Lehec
- Dhawan Lab at the Mowat Labs, Institute of Liver Studies, King's College London at King's College Hospital, London, United Kingdom
| | - Nigel D Heaton
- Liver Transplant Surgery, Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Pauline Kane
- Department of Radiology, King's College Hospital, London, United Kingdom
| | - Anita Verma
- Department of Infection Sciences and Microbiology, King's College Hospital, London, United Kingdom
| | - Robin D Hughes
- Dhawan Lab at the Mowat Labs, Institute of Liver Studies, King's College London at King's College Hospital, London, United Kingdom
| | - Ragai R Mitry
- Dhawan Lab at the Mowat Labs, Institute of Liver Studies, King's College London at King's College Hospital, London, United Kingdom
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10
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Rammohan A, Reddy MS, Narasimhan G, Rajalingam R, Kaliamoorthy I, Shanmugam N, Rela M. Auxiliary Partial Orthotopic Liver Transplantation for Selected Noncirrhotic Metabolic Liver Disease. Liver Transpl 2019; 25:111-118. [PMID: 30317682 DOI: 10.1002/lt.25352] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 10/04/2018] [Indexed: 12/11/2022]
Abstract
Auxiliary partial orthotopic liver transplantation (APOLT) in selected noncirrhotic metabolic liver diseases (NCMLDs) is a viable alternative to orthotopic liver transplantation (OLT) as it supplements the function of the native liver with the missing functional protein. APOLT for NCMLD is not universally accepted due to concerns of increased technical complications and longterm graft atrophy. Review of a prospectively collected database of all pediatric patients (age ≤16 years) who underwent liver transplantation for NCMLD from August 2009 up to June 2017 was performed. Patients were divided into 2 groups: group 1 underwent APOLT and group 2 underwent OLT. In total, 18 OLTs and 12 APOLTs were performed for NCMLDs during the study period. There was no significant difference in the age and weight of the recipients in both groups. All APOLT patients needed intraoperative portal flow modulation. Intraoperative peak and end of surgery lactate were significantly higher in the OLT group, and cold ischemia time was longer in the APOLT group. There were no differences in postoperative liver function tests apart from higher peak international normalized ratio in the OLT group. The incidence of postoperative complications, duration of hospital stay, and 1- and 5-year survivals were similar in both groups. In conclusion, we present the largest series of APOLT for NCMLD. APOLT is a safe and effective alternative to OLT and may even be better than OLT due to lesser physiological stress and the smoother postoperative period for selected patients with NCMLD.
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Affiliation(s)
- Ashwin Rammohan
- The Institute of Liver Disease & Transplantation, Global Hospitals & Health City, Chennai, India.,The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research, Chennai, India
| | - Mettu S Reddy
- The Institute of Liver Disease & Transplantation, Global Hospitals & Health City, Chennai, India.,The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research, Chennai, India
| | - Gomathy Narasimhan
- The Institute of Liver Disease & Transplantation, Global Hospitals & Health City, Chennai, India.,The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research, Chennai, India
| | - Rajesh Rajalingam
- The Institute of Liver Disease & Transplantation, Global Hospitals & Health City, Chennai, India.,The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research, Chennai, India
| | - Ilankumaran Kaliamoorthy
- The Institute of Liver Disease & Transplantation, Global Hospitals & Health City, Chennai, India.,The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research, Chennai, India
| | - Naresh Shanmugam
- The Institute of Liver Disease & Transplantation, Global Hospitals & Health City, Chennai, India.,The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research, Chennai, India
| | - Mohamed Rela
- The Institute of Liver Disease & Transplantation, Global Hospitals & Health City, Chennai, India.,The 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, United Kingdom
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11
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Acute Liver Failure in Children. PEDIATRIC HEPATOLOGY AND LIVER TRANSPLANTATION 2019. [PMCID: PMC7122201 DOI: 10.1007/978-3-319-96400-3_8] [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
“Acute liver failure” (ALF) and “fulminant liver failure” are terms used interchangeably to describe severe and sudden onset of liver cell dysfunction leading on to synthetic and detoxification failure across all age groups. Considerable variations exist between ALF in children and adults, in terms of aetiology and prognosis. Encephalopathy is not essential to make a diagnosis of ALF in children but when present has a bad prognosis. Early recognition of ALF and initiation of supportive management improve the outcome. Liver transplantation remains the only definitive treatment when supportive medical management fails.
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12
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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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13
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Szymczak M, Kaliciński P, Kowalewski G, Broniszczak D, Markiewicz-Kijewska M, Ismail H, Stefanowicz M, Kowalski A, Teisseyre J, Jankowska I, Patkowski W. Acute liver failure in children-Is living donor liver transplantation justified? PLoS One 2018; 13:e0193327. [PMID: 29474400 PMCID: PMC5825073 DOI: 10.1371/journal.pone.0193327] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/08/2018] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Living donor liver transplantation (LDLT) in patients with acute liver failure (ALF) has become an acceptable alternative to transplantation from deceased donors (DDLT). The aim of this study was to analyze outcomes of LDLT in pediatric patients with ALF based on our center's experience. MATERIAL AND METHODS We enrolled 63 children (at our institution) with ALF who underwent liver transplantation between 1997 and 2016. Among them 24 (38%) underwent a LDLT and 39 (62%) received a DDLT. Retrospectively analyzed patient clinical data included: time lapse between qualification for transplantation and transplant surgery, graft characteristics, postoperative complications, long-term results post-transplantation, and living donor morbidity. Overall, we have made a comparison of clinical results between LDLT and DDLT groups. RESULTS Follow-up periods ranged from 12 to 182 months (median 109 months) for LDLT patients and 12 to 183 months (median 72 months) for DDLT patients. The median waiting time for a transplant was shorter in LDLT group than in DDLT group. There was not a single case of primary non-function (PNF) in the LDLT group and 20 out of 24 patients (83.3%) had good early graft function; 3 patients (12.5%) in the LDLT group died within 2 months of transplantation but there was no late mortality. In comparison, 4 out of 39 patients (10.2%) had PNF in DDLT group while 20 patients (51.2%) had good early graft function; 8 patients (20.5%) died early within 2 months and 2 patients (5.1%) died late after transplantation. The LDLT group had a shorter cold ischemia time (CIT) of 4 hours in comparison to 9.2 hours in the DDLT group (p<0.0001). CONCLUSIONS LDLT is a lifesaving procedure for pediatric patients with ALF. Our experience showed that it may be performed with very good results, and with very low morbidity and no mortality among living donors when performed by experienced teams following strict procedures.
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Affiliation(s)
- Marek Szymczak
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Piotr Kaliciński
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Grzegorz Kowalewski
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Dorota Broniszczak
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | | | - Hor Ismail
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Marek Stefanowicz
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Adam Kowalski
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Joanna Teisseyre
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Irena Jankowska
- Department of Gastroenterology, Hepatology and Immunology, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Waldemar Patkowski
- Department of General, Transplant and Liver Surgery, Warsaw Medical University, Warsaw, Poland
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14
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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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15
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Abstract
Although there have been advances made in the diagnosis and management of pediatric acute liver failure, there is still no consensus regarding the definition or standardized evaluation, and an inability to predict outcomes, specifically irreversible brain injury, in many patients exists. Much of the research surrounding pediatric acute liver failure in the last several years has centered on the development of predictive scoring systems to enhance diagnosis and treatment decisions. In this article, we will discuss our current understanding of liver failure and updated management strategies in children with acute liver failure.
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Affiliation(s)
- Sara Kathryn Smith
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of California, San Francisco, Box 0136, San Francisco, CA, 94143, USA
| | - Philip Rosenthal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of California, San Francisco, Box 0136, San Francisco, CA, 94143, USA
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16
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Wang SF, Chen XP, Chen ZS, Wei L, Dong SL, Guo H, Jiang JP, Teng WH, Huang ZY, Zhang WG. Left Lobe Auxiliary Liver Transplantation for End-stage Hepatitis B Liver Cirrhosis. Am J Transplant 2017; 17:1606-1612. [PMID: 27888553 DOI: 10.1111/ajt.14143] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 11/10/2016] [Accepted: 11/19/2016] [Indexed: 01/25/2023]
Abstract
Auxiliary liver transplantation (ALT) for hepatitis B virus (HBV)-related liver cirrhosis previously showed poor results, because the native liver was a significant source of HBV recurrence and the graft could be rapidly destroyed by HBV infection in an immunosuppressive condition. Four patients with HBV-related liver cirrhosis were unable to undergo orthotopic liver transplantation because the only available grafts of left lobe were too small. Under entecavir-based anti-HBV treatment, they underwent ALT in which the recipient left liver was removed and the small left lobe graft was implanted in the corresponding space. The mean graft weight/recipient weight was 0.49% (range, 0.38%-0.55%). One year after transplantation, the graft sizes were increased to 273% and the remnant livers were decreased to 44%. Serum HBV DNA was persistently undetectable. Periodic graft biopsy showed no signs of tissue injury and negative immunostaining for hepatitis B surface antigen and hepatitis B core antigen. After a mean follow-up period of 21 months, all patients live well with normal graft function. Our study suggests that ALT for HBV-related liver cirrhosis is feasible under entecavir-based anti-HBV treatment. Successful application of small left livers in end-stage liver cirrhosis may significantly increase the pool of left liver grafts for adult patients.
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Affiliation(s)
- S-F Wang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Ministry of Health, Key Laboratory of Organ Transplantation, Wuhan, China.,Ministry of Education, Key Laboratory of Organ Transplantation, Wuhan, China
| | - X-P Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Ministry of Health, Key Laboratory of Organ Transplantation, Wuhan, China.,Ministry of Education, Key Laboratory of Organ Transplantation, Wuhan, China
| | - Z-S Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Ministry of Health, Key Laboratory of Organ Transplantation, Wuhan, China.,Ministry of Education, Key Laboratory of Organ Transplantation, Wuhan, China
| | - L Wei
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - S-L Dong
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - H Guo
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Ministry of Health, Key Laboratory of Organ Transplantation, Wuhan, China.,Ministry of Education, Key Laboratory of Organ Transplantation, Wuhan, China
| | - J-P Jiang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - W-H Teng
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Z-Y Huang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - W-G Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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17
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Abstract
Even though auxiliary partial orthotopic liver transplantation (APOLT) as a technique was popularized in the late 80s, its role in metabolic liver disease remains controversial. The slow progress in gene therapy research, high incidence of technical complications, and the problem of long term graft atrophy have been roadblocks to its wider application. Better understanding of reciprocal dynamics of portal flow and regeneration between the graft and native liver along with multiple refinements in surgical technique have improved the outcomes of this operation, making it a safe alternative to orthotopic liver transplantation for patients with a wide range of noncirrhotic metabolic liver diseases (NCMLD). The ability to perform APOLT safely has also opened up a range of exciting indications in the setting of NCMLD. This article reviews the current status of APOLT for NCMLD, technical refinements which have improved outcomes and novel indications, which have rekindled fresh interest in this procedure.
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18
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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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19
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Cortes M, Vilca-Melendez H, Heaton N. The use of temporary portocaval shunt as a technical aid in auxiliary orthotopic liver transplantation. Liver Transpl 2016; 22:1607-1609. [PMID: 27357622 DOI: 10.1002/lt.24510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/19/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Miriam Cortes
- Institute of Liver Studies Liver Transplant Surgery, King's College Hospital, London, United Kingdom
| | - Hector Vilca-Melendez
- Institute of Liver Studies Liver Transplant Surgery, King's College Hospital, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies Liver Transplant Surgery, King's College Hospital, London, United Kingdom.
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20
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Jain V, Dhawan A. Prognostic modeling in pediatric acute liver failure. Liver Transpl 2016; 22:1418-30. [PMID: 27343006 DOI: 10.1002/lt.24501] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/12/2016] [Accepted: 06/16/2016] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) is the only proven treatment for pediatric acute liver failure (PALF). However, over a period of time, spontaneous native liver survival is increasingly reported, making us wonder if we are overtransplanting children with acute liver failure (ALF). An effective prognostic model for PALF would help direct appropriate organ allocation. Only patients who would die would undergo LT, and those who would spontaneously recover would avoid unnecessary LT. Deriving and validating such a model for PALF, however, encompasses numerous challenges. In particular, the heterogeneity of age and etiology in PALF, as well as a lack of understanding of the natural history of the disease, contributed by the availability of LT has led to difficulties in prognostic model development. Several prognostic laboratory variables have been identified, and the incorporation of these variables into scoring systems has been attempted. A reliable targeted prognostic model for ALF in Wilson's disease has been established and externally validated. The roles of physiological, immunological, and metabolomic parameters in prognosis are being investigated. This review discusses the challenges with prognostic modeling in PALF and describes predictive methods that are currently available and in development for the future. Liver Transplantation 22 1418-1430 2016 AASLD.
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Affiliation(s)
- Vandana Jain
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK.
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21
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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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22
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Ayyala RS, Martinez M, Lobritto SJ, Kato T, Ruzal-Shapiro C. Postoperative imaging findings in children with auxiliary partial orthotopic liver transplant (APOLT). Pediatr Radiol 2016; 46:1209-17. [PMID: 26867605 DOI: 10.1007/s00247-016-3541-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 11/22/2015] [Accepted: 01/11/2016] [Indexed: 11/29/2022]
Abstract
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).
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Affiliation(s)
- Rama S Ayyala
- Department of Radiology, Columbia University Medical Center, Morgan Stanley Children's Hospital, 3959 Broadway, CHONY 3N, New York, NY, 10032, USA.
| | - Mercedes Martinez
- Center for Liver Disease and Transplantation, Columbia University Medical Center, Morgan Stanley Children's Hospital, 3959 Broadway, CHONY 7, Rm 723, New York, NY, 10032, USA
| | - Steven J Lobritto
- Center for Liver Disease and Transplantation, Columbia University Medical Center, Morgan Stanley Children's Hospital, 3959 Broadway, CHONY 7, Rm 723, New York, NY, 10032, USA
| | - Tomoaki Kato
- Division of Abdominal Organ Transplantation, Columbia University Medical Center, Morgan Stanley Children's Hospital, 622 West 168th Street, PH 14, Suite 105, New York, NY, 10032, USA
| | - Carrie Ruzal-Shapiro
- Department of Radiology, Columbia University Medical Center, Morgan Stanley Children's Hospital, 3959 Broadway, CHONY 3N, New York, NY, 10032, USA
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23
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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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24
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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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25
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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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26
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Early Application of Auxiliary Partial Orthotopic Liver Transplantation in Murine Model of Wilson Disease. Transplantation 2016; 99:2317-24. [PMID: 26018347 DOI: 10.1097/tp.0000000000000787] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Liver transplantation (LT) is the only option of treatment for Wilson disease (WD) when chelation therapy fails, but it is limited due to the shortage of donor. Auxiliary partial orthotopic LT (APOLT) has been performed successfully in end-stage WD patients, which expands the donor pool. METHODS Atp7bmice were used as experimental model of WD. Eight- and 20-week-old mice were used as different timepoints to perform APOLT. Serum copper, tissue copper, serum ceruloplasmin (CP), and liver histological examination were observed after operation. RESULTS Hepatic and serum copper levels in Atp7b mice decreased after APOLT, and copper metabolism disorder of WD mice was relieved at both early and late stages. The progression of pathology in the native liver was delayed only when transplantation was performed at an early stage. CONCLUSIONS Auxiliary partial orthotopic LT can significantly improve copper metabolism disorder in the Atp7b mice, and early transplantation may prevent the disease progression.
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27
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Shanmugam NP, Al-Lawati T, Kelgeri C, Rela M, Koca T, Dereci S, Karahan N, Akcam M, Revanna KG, Chandran S, Saiprasad, Kasaragod A. Auxiliary liver transplantation for acute liver failure. Indian Pediatr 2016; 53:67-9. [DOI: 10.1007/s13312-016-0795-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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28
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Hackl C, Schlitt HJ, Melter M, Knoppke B, Loss M. Current developments in pediatric liver transplantation. World J Hepatol 2015; 7:1509-1520. [PMID: 26085910 PMCID: PMC4462689 DOI: 10.4254/wjh.v7.i11.1509] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 12/18/2014] [Accepted: 03/20/2015] [Indexed: 02/06/2023] Open
Abstract
In 1953, the pioneer of human orthotopic liver transplantation (LT), Thomas E Starzl, was the first to attempt an orthotopic liver transplant into a 3 years old patient suffering from biliary atresia. Thus, the first LT in humans was attempted in a disease, which, up until today, remains the main indication for pediatric LT (pLT). During the last sixty years, refinements in diagnostics and surgical technique, the introduction of new immunosuppressive medications and improvements in perioperative pediatric care have established LT as routine procedure for childhood acute and chronic liver failure as well as inherited liver diseases. In contrast to adult recipients, pLT differs greatly in indications for LT, allocation practice, surgical technique, immunosuppression and post-operative life-long aftercare. Many aspects are focus of ongoing preclinical and clinical research. The present review gives an overview of current developments and the clinical outcome of pLT, with a focus on alternatives to full-size deceased-donor organ transplantation.
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Rela M, Bharathan A, Palaniappan K, Cherian PT, Reddy MS. Portal flow modulation in auxiliary partial orthotopic liver transplantation. Pediatr Transplant 2015; 19:255-60. [PMID: 25692474 DOI: 10.1111/petr.12436] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2015] [Indexed: 12/14/2022]
Abstract
APOLT is a suitable technique of liver transplantation in patients with ALF and some types of MLD. Portal venous steal is a problem with this procedure that leads to graft dysfunction and failure. Modulation of the portal flow to the graft and native liver can help in preventing this problem. We discuss the pathophysiology of this complication, review available literature regarding its management, and describe our results using the technique of graded hemiportal banding to achieve adequate perfusion for the graft and native liver.
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Affiliation(s)
- Mohamed Rela
- Institute of Liver Disease & Transplantation, Global Hospital & Health City, National Foundation for Liver Research, Chennai, Tamil Nadu, India; Institute of Liver Studies, Kings College Hospital, Denmark Hill, London, UK
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Forbes SJ, Gupta S, Dhawan A. Cell therapy for liver disease: From liver transplantation to cell factory. J Hepatol 2015; 62:S157-69. [PMID: 25920085 DOI: 10.1016/j.jhep.2015.02.040] [Citation(s) in RCA: 200] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 02/20/2015] [Accepted: 02/27/2015] [Indexed: 02/08/2023]
Abstract
Work over several decades has laid solid foundations for the advancement of liver cell therapy. To date liver cell therapy in people has taken the form of hepatocyte transplantation for metabolic disorders with a hepatic basis, and for acute or chronic liver failure. Although clinical trials using various types of autologous cells have been implemented to promote liver regeneration or reduce liver fibrosis, clear evidence of therapeutic benefits have so far been lacking. Cell types that have shown efficacy in preclinical models include hepatocytes, liver sinusoidal endothelial cells, mesenchymal stem cells, endothelial progenitor cells, and macrophages. However, positive results in animal models have not always translated through to successful clinical therapies and more realistic preclinical models need to be developed. Studies defining the optimal repopulation by transplanted cells, including routes of cell transplantation, superior engraftment and proliferation of transplanted cells, as well as optimal immunosuppression regimens are required. Tissue engineering approaches to transplant cells in extrahepatic locations have also been proposed. The derivation of hepatocytes from pluripotent or reprogrammed cells raises hope that donor organ and cell shortages could be overcome in the future. Critical hurdles to be overcome include the production of hepatocytes from pluripotent cells with equal functional capacity to primary hepatocytes and long-term phenotypic stability in vivo.
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Affiliation(s)
- Stuart J Forbes
- MRC Centre for Regenerative Medicine, Scottish Centre for Regenerative Medicine, 5 Little France Drive, Edinburgh EH16 4UU, United Kingdom.
| | - Sanjeev Gupta
- Departments of Medicine and Pathology, Albert Einstein College of Medicine, Jack and Pearl Resnick Campus, 1300 Morris Park Avenue, Ullmann Building, Room 625, Bronx, NY 10461, United States
| | - Anil Dhawan
- Paediatric Liver GI and Nutrition Center and NIHR/Wellcome Cell Therapy Unit, King's College Hospital at King's College, London SE59RS, United Kingdom
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Qiao J, Han C, Zhang J, Wang Z, Meng X. A new rat model of auxiliary partial heterotopic liver transplantation with liver dual arterial blood supply. Exp Ther Med 2015; 9:367-371. [PMID: 25574199 PMCID: PMC4280989 DOI: 10.3892/etm.2014.2110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 10/16/2014] [Indexed: 01/23/2023] Open
Abstract
Auxiliary partial heterotopic liver transplantation (APHLT) with portal vein arterialization is a valuable procedure to be considered in the treatment of patients with acute liver failure and metabolic liver diseases. The aim of this study was to develop a new rat model of APHLT with liver dual arterial blood supply (LDABS). A total of 20 rats were used. The donor liver was resected, and the celiac trunk was reserved. Left and medial hepatic lobes accounting for 70% of the liver mass were removed en bloc and the suprahepatic caval vein was ligated simultaneously. Thus, 30% of the donor liver was obtained as the graft. Sleeve anastomosis of the graft portal vein and splenic artery were performed after narrowing the portal vein lumen through suturing. The right kidney of the recipient was removed, and sleeve anastomosis was performed between the celiac trunk of the graft and the right renal artery of the recipient. In addition, end-to-end anastomosis was performed between the infrahepatic caval vein of the graft and the right renal vein of the recipient. Following the reperfusion of the graft, the blood flow of the arterialized portal vein was controlled within the physiological range through suturing and narrowing under monitoring with an ultrasonic flowmeter. The bile duct of the graft was implanted into the duodenum of the recipient through an internal stent catheter. A 70% section of the native liver (left and medial hepatic lobes) was resected using bloodless hepatectomy. The mean operative duration was 154.5±16.4 min, and the warm and cold ischemia times of the graft were 8.1±1.1 min and 64.5±6.6 min, respectively. The blood flow of the arterialized portal vein to the graft was 1.8±0.3 ml/min/g liver weight. The success rate of model establishment (waking with post-surgical survival of >24 h) was 70% (7/10). Following successful model establishment, all rats survived 7 days post-surgery (100%; 7/7). The graft was found to be soft in texture and bright red in color following exploratory laparotomy. In conclusion, a new rat model of APHLT with LDABS without stent for vascular reconstruction was developed. This is a feasible and reliable rat model for liver transplantation study.
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Affiliation(s)
- Jianliang Qiao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China ; Department of General Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
| | - Chunlei Han
- Turku PET Centre, Turku University Hospital and University of Turku, Turku 20521, Finland
| | - Junjing Zhang
- Department of General Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
| | - Zhiyong Wang
- Department of General Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
| | - Xingkai Meng
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China ; Department of General Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
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Hibi T, Shinoda M, Itano O, Kitagawa Y. Current status of the organ replacement approach for malignancies and an overture for organ bioengineering and regenerative medicine. Organogenesis 2014; 10:241-9. [PMID: 24836922 DOI: 10.4161/org.29245] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Significant achievements in the organ replacement approach for malignancies over the last 2 decades opened new horizons, and the age of "Transplant Oncology" has dawned. The indications of liver transplantation for malignancies have been carefully expanded by a strict patient selection to assure comparable outcomes with non-malignant diseases. Currently, the Milan criteria, gold standard for hepatocellular carcinoma, are being challenged by high-volume centers worldwide. Neoadjuvant chemoradiation therapy and liver transplantation for unresectable hilar cholangiocarcinoma has been successful in specialized institutions. For other primary and metastatic liver tumors, clinical evidence to establish standardized criteria is lacking. Intestinal and multivisceral transplantation is an option for low-grade neoplasms deemed unresectable by conventional surgery. However, the procedure itself is in the adolescent stage. Solid organ transplantation for malignancies inevitably suffers from "triple distress," i.e., oncological, immunological, and technical. Organ bioengineering and regenerative medicine should serve as the "triple threat" therapy and revolutionize "Transplant Oncology."
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Affiliation(s)
- Taizo Hibi
- Department of Surgery; Keio University School of Medicine; Tokyo, Japan
| | - Masahiro Shinoda
- Department of Surgery; Keio University School of Medicine; Tokyo, Japan
| | - Osamu Itano
- Department of Surgery; Keio University School of Medicine; Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery; Keio University School of Medicine; Tokyo, Japan
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Wang DW, Yin YM, Yao YM. Advances in the management of acute liver failure. World J Gastroenterol 2013; 19:7069-7077. [PMID: 24222950 PMCID: PMC3819542 DOI: 10.3748/wjg.v19.i41.7069] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 08/05/2013] [Accepted: 09/13/2013] [Indexed: 02/06/2023] Open
Abstract
Acute liver failure (ALF) is an uncommon but dramatic clinical syndrome characterized by hepatic encephalopathy and a bleeding tendency due to abrupt loss of liver function caused by massive or submassive liver necrosis in a patient with a previously healthy liver. The causes of ALF encompass a wide variety of toxic, viral, metabolic, vascular and autoimmune insults to the liver, and identifying the correct cause can be difficult or even impossible. Many patients with ALF develop a cascade of serious complications involving almost every organ system, and death is mostly due to multi-organ failure, hemorrhage, infection, and intracranial hypertension. Fortunately, the outcome of ALF has been improved in the last 3 decades through the specific treatment for the disease of certain etiology, and the advanced intensive care management. For most severely affected patients who fail to recover after treatment, rapid evaluation for transfer to a transplantation center and consideration for liver transplantation is mandatory so that transplantation can be applied before contraindications develop. This review focuses on the recent advances in the understanding of various contributing etiologies, the administration of etiology-specific treatment to alleviate the liver injury, and the management of complications (e.g., encephalopathy, coagulopathy, cardiovascular instability, respiratory failure, renal failure, sepsis and metabolic disturbance) in patients with ALF. Assessment of the need for liver transplantation is also presented.
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Rela M. Technique of hepatic arterial anastomosis in living donor pediatric auxiliary partial orthotopic liver transplantation. Liver Transpl 2013; 19:1046-8. [PMID: 23825046 DOI: 10.1002/lt.23699] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 06/09/2013] [Indexed: 12/16/2022]
Affiliation(s)
- Mohamed Rela
- Institute of Liver Surgery and Transplantation, Global Hospital and Health City, Chennai, India; Institute of Liver Studies, King's College Hospital, London, United Kingdom
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35
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D'Agostino D, Diaz S, Sanchez MC, Boldrini G. Management and prognosis of acute liver failure in children. Curr Gastroenterol Rep 2012; 14:262-269. [PMID: 22528660 DOI: 10.1007/s11894-012-0260-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Although the etiologies of pediatric acute liver failure (ALF) are diverse, ultimate pathophysiologic pathways and management challenges for these disorders, usually lethal in the pre-transplant era, are similar. This review considers particularly the mechanisms of, and monitoring for, intracranial hypertension and coagulopathy; summarizes detailed advice for management of the ALF-associated failures of multiple body systems; and reviews the variety of prognostic scores available to guide management and assist in choosing the patients most apt to benefit from liver transplantation and the optimal timing for such transplantation.
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Affiliation(s)
- Daniel D'Agostino
- Gastroenterology-Hepatology Division, Liver-Intestinal Transplantation Center, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
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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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Devictor D, Tissieres P, Durand P, Chevret L, Debray D. Acute liver failure in neonates, infants and children. Expert Rev Gastroenterol Hepatol 2011; 5:717-29. [PMID: 22017699 DOI: 10.1586/egh.11.57] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute liver failure (ALF) is a rare but devastating syndrome. ALF in children differs from that observed in adults in both the etiologic spectrum and the clinical picture. Specific therapy to promote liver recovery is often not available and the underlying cause of the liver failure is often not determined. Management requires a multidisciplinary approach and should focus on preventing or treating complications and arranging for early referral to a transplant center. Although liver transplantation has increased the chance of survival, children who have ALF still face an increased risk of death, both while on the waiting list and after emergency liver transplantation. This article will review the current knowledge of the epidemiology, pathobiology and treatment of ALF in neonates, infants and children, and discuss some recent controversies.
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Affiliation(s)
- Denis Devictor
- Neonatal and Pediatric Intensive Care Unit, Department of Pediatrics, APHP-Bicêtre Hospital, Paris 11-Sud University, 94275 Le Kremlin-Bicêtre, France.
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Shanmugam NP, Perumalla R, Gopinath RG, Olithselvan A, Varghese J, Kapoor D, Rela M. Auxiliary liver transplantation: a form of gene therapy in selective metabolic disorders. J Clin Exp Hepatol 2011; 1:118-20. [PMID: 25755324 PMCID: PMC3940636 DOI: 10.1016/s0973-6883(11)60132-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 09/26/2011] [Indexed: 12/12/2022] Open
Abstract
Auxiliary liver transplantation is an accepted form of therapy in acute liver failure and in certain metabolic disorders. We report India's first successful auxiliary liver transplantation for Crigler-Najjar syndrome type 1, showing that it is technically feasible and safe procedure. It is utmost important to select appropriate cases for auxiliary transplant for successful long-term outcome. The surgeon should also have an understanding of the portal flow dynamics, as steal phenomenon can occur, depriving blood blow to either graft or native liver. Though successful in animal models, gene therapy is still in experimental stage in humans and pace of progress has been disappointing. Auxiliary liver transplantation retains the native liver for future gene therapy. These children are young and are likely to have a long life expectancy, and withdrawal of immunosuppression would be a huge advantage.
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Affiliation(s)
| | | | | | | | | | | | - Mohmed Rela
- Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, Tamil Nadu, India
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Sundaram V, Shaikh OS. Acute liver failure: current practice and recent advances. Gastroenterol Clin North Am 2011; 40:523-39. [PMID: 21893272 DOI: 10.1016/j.gtc.2011.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
ALF is an important cause of liver-related morbidity and mortality. Advances in the management of ICH and SIRS, and cardiorespiratory, metabolic, and renal support have improved the outlook of such patients. Early transfer to a liver transplant center is essential. Routine use of NAC is recommended for patients with early hepatic encephalopathy, irrespective of the etiology. The role of hypothermia remains to be determined. Liver transplantation plays a critical role, particularly for those with advanced encephalopathy. Several detoxification and BAL support systems have been developed to serve as a bridge to transplantation or to spontaneous recovery. However, such systems lack sufficient reliability and efficacy to be applied routinely in clinical practice. Hepatocyte and stem cell transplantation may provide valuable adjunctive therapy in the future.
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Affiliation(s)
- Vinay Sundaram
- Department of Medicine, Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
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Devictor D, Tissieres P, Afanetti M, Debray D. Acute liver failure in children. Clin Res Hepatol Gastroenterol 2011; 35:430-7. [PMID: 21531191 DOI: 10.1016/j.clinre.2011.03.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 03/09/2011] [Indexed: 02/04/2023]
Abstract
The management of children with acute liver failure mandates a multidisciplinary approach and intense monitoring. In recent years, considerable progress has been made in developing specific and supportive medical measures, but clinical studies have mainly concerned adult patients. There are no specific medical therapies, except for a few metabolic diseases presenting with acute liver failure. Liver transplantation still remains the only definitive therapy in most instances. Recent clinical studies suggest that hepatocyte transplantation may be useful for bridging patients to liver transplantation, for providing metabolic support during liver failure and for replacing liver transplantation in certain metabolic liver diseases.
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Affiliation(s)
- Denis Devictor
- Neonatal, Pediatric Intensive Care Unit, Department of Pediatrics, AP-HP, Bicêtre Hospital, Paris 11-Sud University, 78, avenue Général-Leclerc, 94275 Le Kremlin-Bicêtre, France.
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Shanmugam NP, Dhawan A. Selection criteria for liver transplantation in paediatric acute liver failure: the saga continues. Pediatr Transplant 2011; 15:5-6. [PMID: 21241436 DOI: 10.1111/j.1399-3046.2010.01457.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abstract
Acute liver failure (ALF) is defined as a multisystem disorder of severe impairment of liver function, with or without encephalopathy, which is associated with hepatocellular necrosis (reflected as liver synthetic failure in patients with no recognized chronic liver disease), and can lead to death. ALF can be due to hepatotoxic drugs, natural toxins, autoimmune disease, severe bacterial infection and some neoplastic processes, or ALF can be idiopathic. In the pediatric group, the most frequent cause is viral agents; hepatitis A is the most common among these. The pathophysiologic changes in ALF consist of alterations in coagulation, elevated serum ammonia, hypoalbuminemia and hypoglycemia. In recent years, N-acetylcysteine has been utilized to treat this condition. Using this drug during the early stages of the disease has the potential to improve outcomes for the patient, including the avoidance liver transplantation. This article focuses on the criteria that help to identify ALF and emphasizes accessible alternative medical treatments.
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Affiliation(s)
- Norberto Sotelo
- Jefe del Servicio de Medicina Interna, Hospital Infantil del Estado de Sonora, Calle Reforma Numero 355 Norte, Colonia Ley 57, CP 83100, Hermosillo Sonora, Mexico
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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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