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Wang B, Zhou A, Wu Y, Pan Q, Wei X, Gao Y, Xiao W, Jin J, Zhou T, Luo Y, Zhan Z, Liu Y, Gao W, Liu Y, Xia Q. Establishment and validation of a predictive model of immune tolerance after pediatric liver transplantation: a multicenter cohort study. Int J Surg 2024; 110:5615-5626. [PMID: 38833360 PMCID: PMC11392161 DOI: 10.1097/js9.0000000000001671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/09/2024] [Indexed: 06/06/2024]
Abstract
JOURNAL/ijos/04.03/01279778-202409000-00031/figure1/v/2024-09-12T150105Z/r/image-jpeg
Background:
Side-effect of life-long immunosuppressants (IS) administration is a major obstacle for the long-term survival of pediatric liver transplantation (LT) recipients. Immunotolerance is the status that recipients discontinued IS with normal liver function and intrahepatic histology. So far, only a few clinical parameters were identified related with tolerance but failed to accurately discriminate tolerant recipients in clinical practice. Here, the authors aimed to provide a comprehensive view of pre-LT and post-LT risk factors associated with the achievement of tolerance after pediatric LT and established a tolerance predictive nomogram (ITPLT) with high accuracy and specificity.
Methods:
The authors enrolled 2228 pediatric recipients who received LT in Renji Hospital between October 2006 and December 2020. All participants survived over 3 years after transplantation with comprehensive and intact medical history and follow-up data. They were randomly assigned to training and validation cohorts in accordance with a ratio of 1:1. Univariate and multivariable Logistic regression were used to identify clinical factors associated with post-LT immune tolerance and establish a predictive model. The model was further validated in an independent external validation cohort from Tianjin First Central Hospital.
Results:
Among all participants, 6% recipients successfully tapered IS with intact allograft function. The most common reason for IS discontinuity was pneumonia. Univariate analysis identified 15 clinical factors associated with tolerance achievement, including age at LT, follow-up time, preoperative total bilirubin, creatinine, INR, CYP polymorphism, types of transplantation, massive postoperative ascites, episodes of acute rejection, and the severity of EBV and CMV infection. Using multivariable Logistic regression, the authors established the predictive ITPLT model for post-LT tolerance, which included seven easily accessible clinical factors (age at LT, CYP3A5 genotype, types of transplantation, post-LT massive ascites, preoperative INR, creatinine, and total bilirubin levels). Then, the authors visualized the model using nomogram. The c-statistics for predicting tolerance achievement in the training, internal validation, and external validation cohorts were 0.854, 0.787, and 0.746, respectively.
Conclusion:
Multiple pre-LT and post-LT clinical factors affected the process of immune remodeling after pediatric LT. The predictive ITPLT model, composed of seven easily accessible clinical factors, could comprehensively reveal the effect of these clinical parameters on immune remodeling and accurately identify tolerant recipients after pediatric LT. The application of ITPLT could facilitate the individualized IS strategy in the future.
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Affiliation(s)
- Bingran Wang
- Department of Liver Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Aiwei Zhou
- Department of Liver Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Yichi Wu
- Department of Liver Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Qi Pan
- Department of Liver Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Xinzhe Wei
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin
| | - Yunmu Gao
- Department of Liver Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Wanglong Xiao
- Department of Liver Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Jing Jin
- Department of Liver Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Tao Zhou
- Department of Liver Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Yi Luo
- Department of Liver Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
| | | | - Yongbo Liu
- Department of Liver Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
- Shanghai Institute of Transplantation
| | - Wei Gao
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin
| | - Yuan Liu
- Department of Liver Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
- Shanghai Immune Therapy Institute
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
- Shanghai Institute of Transplantation
- Shanghai Engineering Research Center of Transplantation and Immunology, Shanghai, People's Republic of China
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Fujiki M, Hashimoto K, Aucejo F, David Kwon CH, Eghtesad B, Miller C, Pinna A. Response to Comment on "Living Donor Liver Transplantation With Augmented Venous Outflow and Splenectomy: A Promised Land for Small Left Lobe Grafts". ANNALS OF SURGERY OPEN 2023; 4:e269. [PMID: 37600881 PMCID: PMC10431296 DOI: 10.1097/as9.0000000000000269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/02/2023] [Indexed: 03/19/2023] Open
Affiliation(s)
- Masato Fujiki
- From the Department of General Surgery, Transplant Center, Cleveland Clinic, Cleveland, OH
| | - Koji Hashimoto
- From the Department of General Surgery, Transplant Center, Cleveland Clinic, Cleveland, OH
| | - Federico Aucejo
- From the Department of General Surgery, Transplant Center, Cleveland Clinic, Cleveland, OH
| | - Choon Hyuck David Kwon
- From the Department of General Surgery, Transplant Center, Cleveland Clinic, Cleveland, OH
| | - Bijan Eghtesad
- From the Department of General Surgery, Transplant Center, Cleveland Clinic, Cleveland, OH
| | - Charles Miller
- From the Department of General Surgery, Transplant Center, Cleveland Clinic, Cleveland, OH
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Qu W, Li X, Huang H, Xie C, Song H. Mechanisms of the ascites volume differences between patients receiving a left or right hemi-liver graft liver transplantation: From biofluidic analysis. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 226:107196. [PMID: 36367484 DOI: 10.1016/j.cmpb.2022.107196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND OBJECTIVE Post-transplant refractory ascites (RA) is common in patients receiving living donor liver transplantation (LDLT) using a left hemi-liver graft than in those using a right hemi-liver graft. However, there is currently no clear mechanism explaining the effect of grafts on ascites drainage. The purpose of this study is to analyze the values of blood flow parameters in the portal vein under different grafts using computational fluid dynamics (CFD) to interpret the relationship between portal pressure values with ascites drainage. METHODS In this work, ascites drainage was counted in 30 patients who underwent left-sided liver transplantation and 26 patients who underwent right-sided liver transplantation. The portal vein flow models of the transplanted liver under different flow rates were established based on computed tomography (CT) images and finite element theory. Ascites drainage and blood flow parameters were qualitatively compared. RESULTS The results show that the ascites drained from patients who received LDLT with a left hemi-liver is three times as that with a right hemi-liver. The simulation results show that the coefficient of the pressure-velocity curve of the left-liver is 1.7 times of the right-liver under the same hydrodynamic conditions, which qualitatively agrees with the clinical data. Moreover, the streamline of the transplanted left liver shows more vortexes compared with the right liver, which is a major reason for the left liver's higher pressure value. CONCLUSION This clinical phenomenon is reproduced and comprehensively explained by the hemodynamic parameters of the portal vein. This work establishes the relationship between portal pressure values and floating water drainage, and offers a new way for physicians to predict postoperative risks intuitively.
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Affiliation(s)
- Wei Qu
- Liver Transplantation Section, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China; Tsinghua University, Beijing 100084, China
| | - Xiaofan Li
- University of Science and Technology Beijing, Beijing 100083, China
| | - Hao Huang
- Liver Transplantation Section, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Chiyu Xie
- University of Science and Technology Beijing, Beijing 100083, China
| | - Hongqing Song
- University of Science and Technology Beijing, Beijing 100083, China.
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Ebada HE, Montasser MF, Abdelghaffar MF, Bahaa MM, Elbaset HSA, Sakr MA, Dabbous HM, Montasser IF, Hassan MS, Aboelmaaty ME, Elmeteini MS. Ascites post-living donor liver transplantation: Risk factors and outcome. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Iwaki K, Yagi S, Morita S, Hamaguchi Y, Masano Y, Yamamoto G, Ogawa E, Nagai K, Kamo N, Hata K, Taura K, Okajima H, Kaido T, Uemoto S. Impact of Graft Quality and Fluid Overload on Postoperative Massive Ascites After Living Donor Liver Transplantation. Transplant Proc 2019; 51:1779-1784. [PMID: 31301855 DOI: 10.1016/j.transproceed.2019.03.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 03/05/2019] [Accepted: 03/23/2019] [Indexed: 02/07/2023]
Abstract
After living donor liver transplantation, we encounter cases with massive ascites, which is difficult to manage. We analyzed the risk factors for massive ascites after living donor liver transplantation. The subjects were 100 adult recipients who underwent living donor liver transplantation at Kyoto University Hospital from 2013 to 2017. We retrospectively assessed patient, graft, operative factors, and percent fluid overload, which were defined as [(weight on the day - preoperative weight)/preoperative weight] × 100%. We defined the massive ascites group as having a14-day average ascites ≥ 2500 mL and the mild ascites group as having a 14-day average ascites < 2500 mL. Forty-seven patients were included in the massive group, and 53 patients were included in the mild group. There was no difference in short- and long-term survival. In multivariate analysis, the presence of preoperative ascites (P = .0008), 14-day average percent fluid overload ≥ 14.5% (P = .0095), graft-to-recipient weight ratio < 0.86 (P = .0253), and donors' age ≥ 47 years (P = .0466) were identified as independent risk factors for massive ascites after living donor liver transplantation. A liver graft with a small graft-to-recipient weight ratio or from an elderly donor, which may indicate poor graft quality, presence of preoperative ascites, and postoperative fluid overload were associated with massive ascites after living donor liver transplantation.
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Affiliation(s)
- Kentaro Iwaki
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan
| | - Shintaro Yagi
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan.
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuhei Hamaguchi
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan
| | - Yuki Masano
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan
| | - Gen Yamamoto
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan
| | - Eri Ogawa
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan
| | - Kazuyuki Nagai
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan
| | - Naoko Kamo
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan
| | - Koichiro Hata
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan
| | - Kojiro Taura
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan
| | - Toshimi Kaido
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan
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Sato K, Ohira M, Shimizu S, Imaoka Y, Hashimoto S, Tahara H, Kobayashi T, Kuroda S, Ide K, Tanaka Y, Ohdan H. Risk Factors for Refractory Ascites After Living Donor Liver Transplant. Transplant Proc 2019; 51:1516-1519. [PMID: 31155185 DOI: 10.1016/j.transproceed.2019.01.120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/28/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Refractory ascites after liver transplant commonly occurs in living donor liver transplant (LDLT). Refractory ascites is associated with postoperative complications and poor prognosis. This study sought to determine the risk factors of refractory ascites and discuss their perioperative management. METHODS A retrospective study of 122 living donor liver transplant recipients between 2008 and 2017 was performed to analyze the risk factors, incidence, and characteristics of refractory ascites. Refractory ascites post LDLT was defined as the production of ascites fluid >1000 mL/d on postoperative day 14 or required repeated drainage. RESULTS A total of 24 patients (19.6%) developed refractory ascites. The 1-year survival rate was significantly worse in the refractory ascites group compared with the nonrefractory ascites group (P < .001). In a univariate analysis, patients with refractory ascites had a higher Model for End-Stage Liver Disease (MELD) score, donor age, presence of left lobe graft, ascites at laparotomy, portal venous pressure just after surgery, cold ischemia time, and absence of hepatocellular carcinoma compared with patients without refractory ascites. Multivariate proportional regression analyses revealed that MELD score ≥20, left lobe graft, donor age 50 years or older, and ascites at laparotomy ≥350 mL were independently associated with refractory ascites. Postoperative complications, such as bleeding (P < .001), sepsis (P < .001), and bloodstream infection within 30 days after LDLT (P < .00), were significantly higher in the refractory ascites group. CONCLUSION Refractory ascites is associated with reduced 1-year survival and increased postoperative complications. Four factors including MELD score ≥20, donor age 50 years or older, presence of left graft, and ascites at laparotomy ≥350 mL were independent predictors for refractory ascites.
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Affiliation(s)
- Koki Sato
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masahiro Ohira
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Seiichi Shimizu
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuki Imaoka
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinji Hashimoto
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroyuki Tahara
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shintaro Kuroda
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kentaro Ide
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuka Tanaka
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
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Lan X, Zhang H, Li HY, Chen KF, Liu F, Wei YG, Li B. Feasibility of using marginal liver grafts in living donor liver transplantation. World J Gastroenterol 2018; 24:2441-2456. [PMID: 29930466 PMCID: PMC6010938 DOI: 10.3748/wjg.v24.i23.2441] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/04/2018] [Accepted: 05/18/2018] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) is one of the most effective treatments for end-stage liver disease caused by related risk factors when liver resection is contraindicated. Additionally, despite the decrease in the prevalence of hepatitis B virus (HBV) over the past two decades, the absolute number of HBsAg-positive people has increased, leading to an increase in HBV-related liver cirrhosis and hepatocellular carcinoma. Consequently, a large demand exists for LT. While the wait time for patients on the donor list is, to some degree, shorter due to the development of living donor liver transplantation (LDLT), there is still a shortage of liver grafts. Furthermore, recipients often suffer from emergent conditions, such as liver dysfunction or even hepatic encephalopathy, which can lead to a limited choice in grafts. To expand the pool of available liver grafts, one option is the use of organs that were previously considered “unusable” by many, which are often labeled “marginal” organs. Many previous studies have reported on the possibilities of using marginal grafts in orthotopic LT; however, there is still a lack of discussion on this topic, especially regarding the feasibility of using marginal grafts in LDLT. Therefore, the present review aimed to summarize the feasibility of using marginal liver grafts for LDLT and discuss the possibility of expanding the application of these grafts.
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Affiliation(s)
- Xiang Lan
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hua Zhang
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hong-Yu Li
- Department of Pancreatic Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Ke-Fei Chen
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Fei Liu
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yong-Gang Wei
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bo Li
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
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Prediction of the Development of Persistent Massive Ascites After Living Donor Liver Transplantation Using a Perioperative Risk Score. Transplantation 2018; 102:e275-e281. [DOI: 10.1097/tp.0000000000002174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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