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Schlegel A, Dutkowski P. Impact of Machine Perfusion on Biliary Complications after Liver Transplantation. Int J Mol Sci 2018; 19:ijms19113567. [PMID: 30424553 PMCID: PMC6274934 DOI: 10.3390/ijms19113567] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/01/2018] [Accepted: 11/05/2018] [Indexed: 12/13/2022] Open
Abstract
We describe in this review the different types of injuries caused to the biliary tree after liver transplantation. Furthermore, we explain underlying mechanisms and why oxygenated perfusion concepts could not only protect livers, but also repair high-risk grafts to prevent severe biliary complications and graft loss. Accordingly, we summarize experimental studies and clinical applications of machine liver perfusion with a focus on biliary complications after liver transplantation. Key points: (1) Acute inflammation with subsequent chronic ongoing liver inflammation and injury are the main triggers for cholangiocyte injury and biliary tree transformation, including non-anastomotic strictures; (2) Hypothermic oxygenated perfusion (HOPE) protects livers from initial oxidative injury at normothermic reperfusion after liver transplantation. This is a unique feature of a cold oxygenation approach, which is effective also end-ischemically, e.g., after cold storage, due to mitochondrial repair mechanisms. In contrast, normothermic oxygenated perfusion concepts protect by reducing cold ischemia, and are therefore most beneficial when applied instead of cold storage; (3) Due to less downstream activation of cholangiocytes, hypothermic oxygenated perfusion also significantly reduces the development of biliary strictures after liver transplantation.
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Affiliation(s)
- Andrea Schlegel
- Department of Surgery & Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland.
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham B15 2TH, UK.
- NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham B15 2TH, UK.
| | - Philipp Dutkowski
- Department of Surgery & Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland.
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den Dulk AC, Shi X, Verhoeven CJ, Dubbeld J, Claas FHJ, Wolterbeek R, Brand-Schaaf SH, Verspaget HW, Sarasqueta AF, van der Laan LJW, Metselaar HJ, van Hoek B, Kwekkeboom J, Roelen DL. Donor-specific anti-HLA antibodies are not associated with nonanastomotic biliary strictures but both are independent risk factors for graft loss after liver transplantation. Clin Transplant 2017; 32. [DOI: 10.1111/ctr.13163] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Anne Claire den Dulk
- Department of Gastroenterology and Hepatology; Leiden University Medical Center; Leiden The Netherlands
| | - Xiaolei Shi
- Department of Gastroenterology and Hepatology; Erasmus MC-University Medical Center; Rotterdam The Netherlands
| | | | - Jeroen Dubbeld
- Department of Transplant Surgery; Leiden University Medical Center; Leiden The Netherlands
| | - Frans H. J. Claas
- Department of Immunohematology and Blood Transfusion; Section Immunogenetics and Transplantation Immunology; Leiden University Medical Center; Leiden The Netherlands
| | - Ron Wolterbeek
- Department of Medical Statistics and Bioinformatics; Leiden University Medical Center; Leiden The Netherlands
| | - Simone H. Brand-Schaaf
- Department of Immunohematology and Blood Transfusion; Section Immunogenetics and Transplantation Immunology; Leiden University Medical Center; Leiden The Netherlands
| | - Hein W. Verspaget
- Department of Gastroenterology and Hepatology; Leiden University Medical Center; Leiden The Netherlands
| | | | | | - Herold J. Metselaar
- Department of Gastroenterology and Hepatology; Erasmus MC-University Medical Center; Rotterdam The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology; Leiden University Medical Center; Leiden The Netherlands
| | - Jaap Kwekkeboom
- Department of Gastroenterology and Hepatology; Erasmus MC-University Medical Center; Rotterdam The Netherlands
| | - Dave L. Roelen
- Department of Immunohematology and Blood Transfusion; Section Immunogenetics and Transplantation Immunology; Leiden University Medical Center; Leiden The Netherlands
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Reiling J, Bridle KR, Schaap FG, Jaskowski L, Santrampurwala N, Britton LJ, Campbell CM, Jansen PLM, Damink SWMO, Crawford DHG, Dejong CHC, Fawcett J. The role of macrophages in the development of biliary injury in a lipopolysaccharide-aggravated hepatic ischaemia-reperfusion model. Biochim Biophys Acta Mol Basis Dis 2017; 1864:1284-1292. [PMID: 28709962 DOI: 10.1016/j.bbadis.2017.06.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Endotoxins, in the form of lipopolysaccharides (LPS), are potent inducers of biliary injury. However the mechanism by which injury develops remains unclear. We hypothesized that hepatic macrophages are pivotal in the development of endotoxin-induced biliary injury and that no injury would occur in their absence. MATERIAL AND METHODS Clodronate liposomes were used to deplete macrophages from the liver. Forty-eight rats were equally divided across six study groups: sham operation (sham), liposome treatment and sham operation (liposomes+sham), 1mg/kg LPS i.p. (LPS), liposome treatment and LPS administration (liposomes+LPS), hepatic ischaemia-reperfusion injury with LPS administration (IRI+LPS) and liposome treatment followed by IRI+LPS (liposomes+IRI+LPS). Following 6h of reperfusion, blood, bile, and liver tissue was collected for further analysis. Small bile duct injury was assessed, serum liver tests were performed and bile composition was evaluated. The permeability of the blood-biliary barrier (BBB) was assessed using intravenously administered horseradish peroxidase (HRP). RESULTS The presence of hepatic macrophages was reduced by 90% in LPS and IRI+LPS groups pre-treated with clodronate liposomes (P<0.001). Severe small bile duct injury was not affected by macrophage depletion, and persisted in the liposomes+IRI+LPS group (50% of animals) and liposomes+LPS group (75% of animals). Likewise, BBB impairment persisted following macrophage depletion. LPS-induced elevation of the chemokine Mcp-1 in bile was not affected by macrophage depletion. CONCLUSIONS Depletion of hepatic macrophages did not prevent development of biliary injury following LPS or LPS-enhanced IRI. Cholangiocyte activation rather than macrophage activation may underlie this injury. This article is part of a Special Issue entitled: Cholangiocytes in Health and Diseaseedited by Jesus Banales, Marco Marzioni, Nicholas LaRusso and Peter Jansen.
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Affiliation(s)
- J Reiling
- School of Medicine, The University of Queensland, Brisbane, Australia; Gallipoli Medical Research Institute, Greenslopes Private Hospital, Newdegate Street, Greenslopes, QLD 4120, Australia; PA Research Foundation, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102, Australia; Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands.
| | - K R Bridle
- School of Medicine, The University of Queensland, Brisbane, Australia; Gallipoli Medical Research Institute, Greenslopes Private Hospital, Newdegate Street, Greenslopes, QLD 4120, Australia
| | - F G Schaap
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands; Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - L Jaskowski
- School of Medicine, The University of Queensland, Brisbane, Australia; Gallipoli Medical Research Institute, Greenslopes Private Hospital, Newdegate Street, Greenslopes, QLD 4120, Australia
| | - N Santrampurwala
- School of Medicine, The University of Queensland, Brisbane, Australia; Gallipoli Medical Research Institute, Greenslopes Private Hospital, Newdegate Street, Greenslopes, QLD 4120, Australia
| | - L J Britton
- School of Medicine, The University of Queensland, Brisbane, Australia; Gallipoli Medical Research Institute, Greenslopes Private Hospital, Newdegate Street, Greenslopes, QLD 4120, Australia; Department of Gastroenterology, Princess Alexandra Hospital, 199 Ipswich Road, Wooloongabba, QLD 4102, Australia
| | - C M Campbell
- Envoi Specialist Pathologists, 5/38 Bishop St, Kelvin Grove, QLD 4059, Australia
| | - P L M Jansen
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - S W M Olde Damink
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands; Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - D H G Crawford
- School of Medicine, The University of Queensland, Brisbane, Australia; Gallipoli Medical Research Institute, Greenslopes Private Hospital, Newdegate Street, Greenslopes, QLD 4120, Australia
| | - C H C Dejong
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands; Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - J Fawcett
- School of Medicine, The University of Queensland, Brisbane, Australia; Gallipoli Medical Research Institute, Greenslopes Private Hospital, Newdegate Street, Greenslopes, QLD 4120, Australia; PA Research Foundation, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102, Australia; Queensland Liver Transplant Service, Princess Alexandra Hospital, 199 Ipswich Road, Wooloongabba, QLD 4102, Australia
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de Vries Y, von Meijenfeldt FA, Porte RJ. Post-transplant cholangiopathy: Classification, pathogenesis, and preventive strategies. Biochim Biophys Acta Mol Basis Dis 2017. [PMID: 28645651 DOI: 10.1016/j.bbadis.2017.06.013] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Biliary complications are the most frequent cause of morbidity, re-transplantation, and even mortality after liver transplantation. In general, biliary leakage and anastomotic and non-anastomotic biliary strictures (NAS) can be recognized. There is no consensus on the exact definition of NAS and different names and criteria have been used in literature. We propose to use the term post-transplant cholangiopathy for the spectrum of abnormalities of large donor bile ducts, that includes NAS, but also intraductal casts and intrahepatic biloma formation, in the presence of a patent hepatic artery. Combinations of these manifestations of cholangiopathy are not infrequently found in the same liver and ischemia-reperfusion injury is generally considered the common underlying mechanism. Other factors that contribute to post-transplant cholangiopathy are biliary injury due to bile salt toxicity and immune-mediated injury. This review provides an overview of the various types of post-transplant cholangiopathy, the presumed pathogenesis, clinical implications, and preventive strategies.
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Affiliation(s)
- Yvonne de Vries
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Fien A von Meijenfeldt
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands.
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Reiling J, Bridle KR, Gijbels M, Schaap FG, Jaskowski L, Santrampurwala N, Britton LJ, Campbell CM, Olde Damink SWM, Crawford DHG, Dejong CHC, Fawcett J. Low-Dose Lipopolysaccharide Causes Biliary Injury by Blood Biliary Barrier Impairment in a Rat Hepatic Ischemia/Reperfusion Model. Liver Transpl 2017; 23:194-206. [PMID: 27880979 DOI: 10.1002/lt.24681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 11/10/2016] [Indexed: 02/07/2023]
Abstract
This study explored whether bacterial endotoxins, in the form of lipopolysaccharides (LPS), could have an injurious effect on the biliary tract in conjunction with ischemia. A total of 64 rats were randomly assigned to 4 groups: sham operation (sham group), 1 mg/kg LPS intraperitoneal (LPS group), hepatic ischemia/reperfusion (IR; IR group), and IR combined with LPS (IR+LPS group). Following 1 or 6 hours of reperfusion, serum liver tests, bile duct histology, immunofluorescence microscopy (zonula occludens-1 [ZO-1]), bile composition (bile salts, phospholipids, lactate dehydrogenase), hepatic gene expression (bile salt transporters and inflammatory mediators), as well as serum and biliary cytokine concentrations were quantified and compared between the study groups. In addition, the integrity of the blood biliary barrier (BBB) was assayed in vivo using horseradish peroxidase (HRP). LPS administration induced severe small bile duct injury following 6 hours of reperfusion. Furthermore, total bile salts and bilirubin concentrations in serum were increased in the LPS groups compared with sham controls (LPS, + 3.3-fold and +1.9-fold; IR+LPS, + 3.8-fold and +1.7-fold, respectively). The BBB was impaired in the LPS groups as evidenced by elevated levels of HRP in bile (+4.9-fold), and decreased expression of claudin 1 (-6.7-fold) and claudin 3 (-3.6-fold). LPS was found to be a potent inducer of small bile duct injury following hepatic ischemia and 6 hours of reperfusion. This injury was associated with increased permeability of the BBB and impaired hepatic bile salt clearance. Liver Transplantation 23 194-206 2017 AASLD.
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Affiliation(s)
- Janske Reiling
- School of Medicine, The University of Queensland, Brisbane, Australia.,Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia.,PA Research Foundation, Princess Alexandra Hospital, Brisbane, Australia.,Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Kim R Bridle
- School of Medicine, The University of Queensland, Brisbane, Australia.,Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia
| | - Marion Gijbels
- Departments of Pathology.,Molecular Genetics, Cardiovascular Research Institute Maastricht, the Netherlands.,Department of Medical Biochemistry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Frank G Schaap
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Lesley Jaskowski
- School of Medicine, The University of Queensland, Brisbane, Australia.,Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia
| | - Nishreen Santrampurwala
- School of Medicine, The University of Queensland, Brisbane, Australia.,Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia
| | - Laurence J Britton
- School of Medicine, The University of Queensland, Brisbane, Australia.,Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia
| | | | - Steven W M Olde Damink
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands.,Department of HPB Surgery and Liver Transplantation, Institute for Liver and Digestive Health, Royal Free Hospitals, University College London, London, UK
| | - Darrell H G Crawford
- School of Medicine, The University of Queensland, Brisbane, Australia.,Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia
| | - Cornelius H C Dejong
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands.,Department of Surgery, RWTH Universitätsklinikum Aachen, Aachen, Germany
| | - Jonathan Fawcett
- School of Medicine, The University of Queensland, Brisbane, Australia.,Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia.,PA Research Foundation, Princess Alexandra Hospital, Brisbane, Australia.,Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Australia
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6
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Autoimmune Liver Disease Post-Liver Transplantation: A Summary and Proposed Areas for Future Research. Transplantation 2016; 100:515-24. [PMID: 26447505 PMCID: PMC4764021 DOI: 10.1097/tp.0000000000000922] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Autoimmune liver diseases (AILD) are rare diseases with a reported prevalence of less than 50 per 100 000 population. As the research landscape and our understanding of AILDs and liver transplantation evolves, there remain areas of unmet needs. One of these areas of unmet needs is prevention of disease recurrence after liver transplantation. Disease recurrence is not an insignificant event because allograft loss with the need for retransplantation can occur. Patients transplanted for AILD are more likely to experience acute rejection compared to those transplanted for non-AILD, and the reason(s) behind this observation is unclear. Tasks for the future include a better understanding of the pathogenesis of AILD, definition of the precise pathogenetic mechanisms of recurrent AILD, and development of strategies that can identify recipients at risk for disease recurrence. Importantly, the role of crosstalk between alloimmune responses and autoimmune responses in AILD is an important area that needs further study. This article reviews the relevant literature of de novo autoimmune hepatitis, recurrent autoimmune hepatitis, recurrent primary sclerosing cholangitis, and recurrent primary biliary cirrhosis in terms of the clinical entity, the scientific advancements, and future scientific goals to enhance our understanding of these diseases. A review of the relevant literature of de novo autoimmune hepatitis, recurrent autoimmune hepatitis, recurrent primary sclerosing cholangitis, and recurrent primary biliary cirrhosis in terms of the clinical entity, the scientific advancements and future scientific goals to enhance our understanding of these diseases.
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7
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Change of hepatic arterial systolic/diastolic ratio predicts ischemic type biliary lesion after orthotropic liver transplantation. Clin Imaging 2016; 40:419-24. [PMID: 27133679 DOI: 10.1016/j.clinimag.2016.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/25/2015] [Accepted: 01/26/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND We conducted this prospective nested case-control study for the hepatic artery and portal vein hemodynamic changes after orthotopic liver transplantation. METHODS A total 128 cases of orthotropic liver transplantation were analyzed, including 25 cases of ischemic type biliary lesions (ITBL). The portal vein and hepatic artery flow velocities were detected by ultrasound on days 28, 42, and 84 after liver transplantation. In the GLM analysis of Lg(S/D), the P values of Group Effect, Time Effect, and Time×Group were 0.014, 0.376, and 0.008, respectively. CONCLUSION Our results show a relatively reduced hepatic artery S/D in ITBL, especially in extrahepatic ITBL.
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O'Neill S, Roebuck A, Khoo E, Wigmore SJ, Harrison EM. A meta-analysis and meta-regression of outcomes including biliary complications in donation after cardiac death liver transplantation. Transpl Int 2015; 27:1159-74. [PMID: 25052036 DOI: 10.1111/tri.12403] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/05/2014] [Accepted: 07/12/2014] [Indexed: 12/11/2022]
Abstract
Donation after cardiac death (DCD) liver transplantation is increasingly common but concerns exist over the development of biliary complications and ischemic cholangiopathy (IC). This study aimed to compare outcomes between DCD and donation after brain death (DBD) liver grafts. Studies reporting on post-transplantation outcomes after Maastricht category III DCD liver transplantation were screened for inclusion. Odds ratios (OR) with 95% confidence intervals were produced using random-effects models for the incidence of biliary complications, IC, graft and recipient survival. Meta-regression was undertaken to identify between-study predictors of effect size for biliary complications and IC. PROSPERO Record: CRD42012002113. Twenty-five studies with 62 184 liver transplant recipients (DCD = 2478 and DBD = 59 706) were included. In comparison with DBD, there was a significant increase in biliary complications [OR = 2.4 (1.9, 3.1); P < 0.00001] and IC [OR = 10.5 (5.7, 19.5); P < 0.00001] following DCD liver transplantation. In comparison with DBD, at 1 year [OR = 0.7 (0.5, 0.8); P = 0.0002] and 3 years [OR = 0.6 (0.5, 0.8); P = 0.001], there was a significant decrease in graft survival following DCD liver transplantation. At 1 year, there was also a nonsignificant decrease [OR = 0.8 (0.6, 1.0); P = 0.08] and by 3 years a significant decrease [OR = 0.7 (0.5, 1.0); P = 0.04] found in recipient survival following DCD liver transplantation. Eleven factors were entered into meta-regression models, but none explained the variability in effect size between studies. DCD liver transplantation is associated with an increase in biliary complications, IC, graft loss and mortality. Significant unexplained differences in effect size exist between centers.
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Affiliation(s)
- Stephen O'Neill
- MRC Centre for Inflammation Research, Tissue Injury and Repair Group, University of Edinburgh, Edinburgh, UK
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9
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den Dulk AC, Sebib Korkmaz K, de Rooij BJF, Sutton ME, Braat AE, Inderson A, Dubbeld J, Verspaget HW, Porte RJ, van Hoek B. High peak alanine aminotransferase determines extra risk for nonanastomotic biliary strictures after liver transplantation with donation after circulatory death. Transpl Int 2015; 28:492-501. [PMID: 25601020 DOI: 10.1111/tri.12524] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 09/21/2014] [Accepted: 01/11/2015] [Indexed: 12/11/2022]
Abstract
Orthotopic liver transplantation (OLT) with donation after circulatory death (DCD) often leads to a higher first week peak alanine aminotransferase (ALT) and a higher rate of biliary nonanastomotic strictures (NAS) as compared to donation after brain death (DBD). This retrospective study was to evaluate whether an association exists between peak ALT and the development of NAS in OLT with livers from DBD (n = 399) or DCD (n = 97) from two transplantation centers. Optimal cutoff value of peak ALT for risk of development of NAS post-DCD-OLT was 1300 IU/l. The 4-year cumulative incidence of NAS after DCD-OLT was 49.5% in patients with a high ALT peak post-OLT, compared with 11.3% in patients with a low ALT peak. (P < 0.001). No relation between peak ALT and NAS was observed after DBD-OLT. Multivariate analysis revealed peak ALT ≥1300 IU/l [adjusted hazard ratio (aHR) = 3.71, confidence interval (CI) (1.26-10.91)] and donor age [aHR = 1.04, CI 1.00-1.07] to be independently associated with development of NAS post-DCD-OLT. A peak ALT of <1300 IU/l carries a risk for NAS similar to DBD-OLT. Thus, in DCD-OLT, but not in DBD-OLT, peak ALT discriminates patients at high or low risk for NAS.
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Affiliation(s)
- A Claire den Dulk
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
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10
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Verhoeven CJ, Farid WRR, de Jonge J, Metselaar HJ, Kazemier G, van der Laan LJW. Biomarkers to assess graft quality during conventional and machine preservation in liver transplantation. J Hepatol 2014; 61:672-84. [PMID: 24798616 DOI: 10.1016/j.jhep.2014.04.031] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 04/11/2014] [Accepted: 04/24/2014] [Indexed: 02/08/2023]
Abstract
A global rising organ shortage necessitates the use of extended criteria donors (ECD) for liver transplantation (LT). However, poor preservation and extensive ischemic injury of ECD grafts have been recognized as important factors associated with primary non-function, early allograft dysfunction, and biliary complications after LT. In order to prevent for these ischemia-related complications, machine perfusion (MP) has gained interest as a technique to optimize preservation of grafts and to provide the opportunity to assess graft quality by screening for extensive ischemic injury. For this purpose, however, objective surrogate biomarkers are required which can be easily determined at time of graft preservation and the various techniques of MP. This review provides an overview and evaluation of biomarkers that have been investigated for the assessment of graft quality and viability testing during different types of MP. Moreover, studies regarding conventional graft preservation by static cold storage (SCS) were screened to identify biomarkers that correlated with either allograft dysfunction or biliary complications after LT and which could potentially be applied as predictive markers during MP. The pros and cons of the different biomaterials that are available for biomarker research during graft preservation are discussed, accompanied with suggestions for future research. Though many studies are currently still in the experimental setting or of low evidence level due to small cohort sizes, the biomarkers presented in this review provide a useful handle to monitor recovery of ECD grafts during clinical MP in the near future.
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Affiliation(s)
- Cornelia J Verhoeven
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Waqar R R Farid
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Jeroen de Jonge
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology & Hepatology, Erasmus MC - University Medical Center, Rotterdam, The Netherlands.
| | - Geert Kazemier
- Department of Surgery, VU University Medical Center Amsterdam, The Netherlands
| | - Luc J W van der Laan
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
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11
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Abstract
PURPOSE OF REVIEW The incidence, pathogenesis and management of the most common biliary complications are summarized, with an emphasis on nonanastomotic biliary strictures (NAS) and potential strategies to prevent NAS after liver transplantation. RECENT FINDINGS NAS have variable presentations in time and localization, suggesting various underlying pathogeneses. Early-onset NAS (presentation within 1 year) have shown to be largely related to ischemia-induced bile duct injury, whereas late-onset NAS [>1 year after orthotopic liver transplantation (OLT)] have more immune-mediated causes. Cytotoxic hydrophobic bile salts and impaired biliary HCO3 secretion may also play a role in the occurrence of NAS. Recently, insufficient biliary epithelial regeneration capacity after transplantation has also been suggested to play a major role in the pathogenesis of NAS. A potential strategy to prevent NAS has been proposed to be preservation by machine perfusion instead of classical static cold storage. Although machine perfusion has been shown to be a better preservation method for the liver parenchyma, efficacy in preventing ischemic injury of the biliary epithelium is largely unknown. SUMMARY The potential advantages of machine perfusion are very promising as it may provide better protection of the vulnerable bile ducts against ischemia-reperfusion injury. Clinical trials will be needed to demonstrate the impact of machine perfusion in reducing the incidence of biliary complications, especially NAS, after OLT.
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12
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Autoimmune liver disease, autoimmunity and liver transplantation. J Hepatol 2014; 60:210-23. [PMID: 24084655 DOI: 10.1016/j.jhep.2013.09.020] [Citation(s) in RCA: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 08/13/2013] [Accepted: 09/22/2013] [Indexed: 02/08/2023]
Abstract
Primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH) represent the three major autoimmune liver diseases (AILD). PBC, PSC, and AIH are all complex disorders in that they result from the effects of multiple genes in combination with as yet unidentified environmental factors. Recent genome-wide association studies have identified numerous risk loci for PBC and PSC that host genes involved in innate or acquired immune responses. These loci may provide a clue as to the immune-based pathogenesis of AILD. Moreover, many significant risk loci for PBC and PSC are also risk loci for other autoimmune disorders, such type I diabetes, multiple sclerosis and rheumatoid arthritis, suggesting a shared genetic basis and possibly similar molecular pathways for diverse autoimmune conditions. There is no curative treatment for all three disorders, and a significant number of patients eventually progress to end-stage liver disease requiring liver transplantation (LT). LT in this context has a favourable overall outcome with current patient and graft survival exceeding 80% at 5years. Indications are as for other chronic liver disease although recent data suggest that while lethargy improves after transplantation, the effect is modest and variable so lethargy alone is not an indication. In contrast, pruritus rapidly responds. Cholangiocarcinoma, except under rigorous selection criteria, excludes LT because of the high risk of recurrence. All three conditions may recur after transplantation and are associated with a greater risk of both acute cellular and chronic ductopenic rejection. It is possible that a crosstalk between alloimmune and autoimmune response perpetuate each other. An immunological response toward self- or allo-antigens is well recognised after LT in patients transplanted for non-autoimmune indications and sometimes termed "de novo autoimmune hepatitis". Whether this is part of the spectrum of rejection or an autoimmune process is not clear. In this manuscript, we review novel findings about disease processes and mechanisms that lead to autoimmunity in the liver and their possible involvement in the immune response vs. the graft after LT.
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Haïm-Boukobza S, Balabanian K, Teicher E, Bourgeade M, Perlemuter G, Roque-Afonso AM, Duclos-Vallee JC. Blockade of CCR5 to protect the liver graft in HIV/HCV co-infected patients. J Hepatol 2013; 59:613-5. [PMID: 23583366 DOI: 10.1016/j.jhep.2013.03.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 03/08/2013] [Accepted: 03/27/2013] [Indexed: 12/04/2022]
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Seehofer D, Eurich D, Veltzke-Schlieker W, Neuhaus P. Biliary complications after liver transplantation: old problems and new challenges. Am J Transplant 2013; 13:253-65. [PMID: 23331505 DOI: 10.1111/ajt.12034] [Citation(s) in RCA: 192] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 10/01/2012] [Accepted: 10/23/2012] [Indexed: 01/25/2023]
Abstract
Due to a vulnerable blood supply of the bile ducts, biliary complications are a major source of morbidity after liver transplantation (LT). Manifestation is either seen at the anastomotic region or at multiple locations of the donor biliary system, termed as nonanastomotic biliary strictures. Major risk factors include old donor age, marginal grafts and prolonged ischemia time. Moreover, partial LT or living donor liver transplantation (LDLT) and donation after cardiac death (DCD) bear a markedly higher risk of biliary complications. Especially accumulation of several risk factors is critical and should be avoided. Prophylaxis is still a major issue; however no gold standard is established so far, since many risk factors cannot be influenced directly. The diagnostic workup is mostly started with noninvasive imaging studies namely MRI and MRCP, but direct cholangiography still remains the gold standard. Especially nonanastomotic strictures require a multidisciplinary treatment approach. The primary management of anastomotic strictures is mainly interventional. However, surgical revision is finally indicated in a significant number of cases. Using adequate treatment algorithms, a very high success rate can be achieved in anastomotic complications, but in nonanastomotic strictures a relevant number of graft failures are still inevitable.
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Affiliation(s)
- D Seehofer
- Department of General-, Visceral and Transplantation Surgery, Charité Campus Virchow, Berlin, Germany.
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Iacob S, Cicinnati VR, Dechêne A, Lindemann M, Heinemann FM, Rebmann V, Ferencik S, Sotiropoulos GC, Popescu I, Horn PA, Gerken G, Paul A, Beckebaum S. Genetic, immunological and clinical risk factors for biliary strictures following liver transplantation. Liver Int 2012; 32:1253-61. [PMID: 22550960 DOI: 10.1111/j.1478-3231.2012.02810.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Accepted: 03/19/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND Biliary strictures after liver transplantation (LT) are a major cause of morbidity and reduced graft survival. AIMS The purpose of this study was to investigate genetic, immunological and clinical risk factors for the occurrence of post-LT ischaemic type biliary lesions (ITBLs) and biliary anastomotic strictures (AS). METHODS Clinical and laboratory data, chemokine receptor (CCR) genotypes, chemotactic cytokines and anti-major-histocompatibility complex antibodies in serum were investigated in 162 LT patients. RESULTS In the univariate analysis, older donor and recipient age, partial LT, high peak aspartate aminotransaminase (AST) levels and CC chemokine receptor 5 delta32 loss-of-function mutation (CCR5Δ32) were associated with ITBL, whereas LT for acute liver failure (ALF), ABO-compatible non-identical LT, presence of donor-specific anti-human leucocyte antigen (HLA) class II antibodies and fractalkine receptor (CX3CR1)-249II allele were associated with AS. In the multivariate analysis, CCR5Δ32 was an independent risk factor for ITBL, whereas LT for ALF, ABO-compatible non-identical LT, and CX3CR1-249II allele remained predictive for AS. Serum levels of interferon-gamma and interleukin (IL)-6 as well as IL-10 were significantly increased in patients with biliary strictures. CONCLUSION Specific chemokine receptor polymorphisms of the recipient are associated with development of post-LT biliary strictures. Altered cytokine profile may contribute to enhanced fibrotic tissue remodelling and biliary stricture formation. Screening of anti-HLA antibodies might be useful for early identification of at-risk patients who could benefit from closer surveillance and tailored immunosuppressive regimen. Our findings may have relevance for prediction and management of post-LT biliary strictures.
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Affiliation(s)
- Speranta Iacob
- Department of Gastroenterology, University Hospital Essen, Essen, Germany
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Ischemia-Reperfusion Injury and Ischemic-Type Biliary Lesions following Liver Transplantation. J Transplant 2012; 2012:164329. [PMID: 22530107 PMCID: PMC3316988 DOI: 10.1155/2012/164329] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 12/19/2011] [Accepted: 12/23/2011] [Indexed: 12/14/2022] Open
Abstract
Ischemia-reperfusion (I-R) injury after liver transplantation (LT) induces intra- and/or extrahepatic nonanastomotic ischemic-type biliary lesions (ITBLs). Subsequent bile duct stricture is a significant cause of morbidity and even mortality in patients who underwent LT. Although the pathogenesis of ITBLs is multifactorial, there are three main interconnected mechanisms responsible for their formation: cold and warm I-R injury, injury induced by cytotoxic bile salts, and immunological-mediated injury. Cold and warm ischemic insult can induce direct injury to the cholangiocytes and/or damage to the arterioles of the peribiliary vascular plexus, which in turn leads to apoptosis and necrosis of the cholangiocytes. Liver grafts from suboptimal or extended-criteria donors are more susceptible to cold and warm I-R injury and develop more easily ITBLs than normal livers. This paper, focusing on liver I-R injury, reviews the risk factors and mechanisms leading to ITBLs following LT.
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